History |
N |
% |
Diabetics |
4 |
14.3 |
Allergy to Penicillin |
3 |
10.7 |
Pulmonary Tuberculosis |
1 |
3.6 |
Hematologic Tuberculosis |
1 |
3.6 |
Abdominal Surgery |
2 |
7.2 |
Chronic Renal Failure |
1 |
3.6 |
HIV |
1 |
3.6 |
Symptoms |
% |
Purpura |
46.4 |
Ecchymosis |
51.4 |
Hematochezia |
7.2 |
Epistaxis |
7.2 |
Gingivorrhagia |
29.6 |
Metrorrhagia |
18.5 |
Hematuria |
3.7 |
Anemic syndrome |
22.2 |
Splenomegaly |
29.6 |
Upper left Quadrant Tenderness |
14.8 |
Abdominal ultrasonography and computed tomography were performed in 17 (60.7%) and 5 patients (17.8%) respectively. Splenomegaly was present in 35.3% of the cases (6patients/17). The average size of splenomegaly was 19 cm with a maximum size of 28cm. Two accessory spleens were identified. Laboratory findings identified thrombocytopenia in 78.5% of cases (22 patients), and it was severe (platelet levels <20000/mm3) in 50% of patients. The median platelet count was 9000/mm3. One of our patients received a platelet transfusion for a preoperatively platelet count of<1000/mm3. The mean operative time was 195 ± 68.3 minutes. The mean estimated blood loss was 127.8 ± 250 ml. Intraoperative transfusions were necessary in 4 patients. The conversion rate was 14.3% (4cas), 3 cases following uncontrollable hemorrhage and a case for significant splenomegaly impeding dissection. Accidental small bowel injury occurred during specimen extraction in one patient which required end to end resection and anastomosis. An accessory spleen was found and removed in 4 patients. In six patients with splenomegaly, the mean operative time was 225 ± 30 minutes, the average length of hospital stay was 6.6 ± 2.6 days. Three of our patients required ICU stay. The first case was for intraoperative bleeding with blood loss requiring intraoperative transfusion of 8 platelet units (initial platelets count of 2000/mm3). The 2 others were in the ICU for postoperative monitoring, the LS had lasted 210 minutes for one of the patients and the other had a platelet count of<1000/mm3 preoperatively and had required platelet transfusion. Immediate postoperative complications (10.8%) included hemorrhage requiring surgery 6 hours after the initial operation. A second patient had a subphrenic abscess, treated with antibiotics and maintenance of drainage with favorable outcome, a third patient had a surgical wound infection treated by local antiseptics. The mortality rate in our series was 3.5%. This involved the patient who required reoperation but died the same day at the ICU due to hemorrhagic shock. The average length of postoperative stay was 4.9 ± 2 days. Two cases of recurrence were noted in our series, the first at one month, and the second at 11 months after surgery. Both were given corticosteroid therapy with favorable outcome.
Discussion
Laparoscopic splenectomy for benign hematological disease has become a gold standard. Described by Delaitre in 1992 [1], its major indication is for ITP [2-3] after failure of medical treatment. This indication may vary between 47% and 88% depending on the series [2-4]. Patients with ITP have spleens of normal or slightly increased size and the results appear to be better than for other indications [5-14]. In 2004, Napoli et al. [15] published a study in which a high performance abdominal CT was performed in 22 patients preoperatively and it was noted intraoperatively that the imagery examinations provided a sensitivity of 100% when it came to the number and location of accessory spleens. In our series, CT scan was performed in only 5 patients. It identified an accessory spleen in 2 patients. Intraoperatively, LS has reduced operative time, bleeding, and duration of postoperative hospitalization [8-9-16]. However in the case of splenomegaly, there is increased operative time, increased blood loss, an increase in postoperative complications and a longer length of hospital stay [9-10-11]. Intra and Post-operative hemorrhage can occur in 3% to 25% of cases [2, 3]. Age and the indication of the splenectomy are the most incriminating factors in the occurrence of complications [17]. Prophylaxis with antibiotics should be started at the induction of anesthesia. Postoperatively, it is continued by a twice-daily intake of Oracilline (Penicillin V) for at least two years in adults and five years in children to reduce the risk of serious infections. [17]. In our series, all patients were started on antibiotic prophylaxis based on Oracilline.
Conclusion
LS has become a safe and feasible approach for ITP through the standardization of the surgical techniques and the development of new materials for dissection and hemostasis.
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- Knauer EM, Ailawadi G, Yahanda A, et al. 101 laparoscopic splenectomies for the treatment of benign and malignant. Am J Surg 2003; 186:500-4.
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