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Laparoscopic hand-assisted splenectomy for hydatid cyst

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Laparoscopic hand-assisted splenectomy for hydatid cyst

M.R. Diaconescu, M.R. Diaconescu, M. Glod, I. Costea, C. Ciolpan, St. Georgescu
Cazuri clinice, no. 1, 2008
* IVth Surgical Clinic, University of Medicine and Pharmacy Gr T Popa, Iasi, Romania
* IVth Surgical Clinic
* Ith Surgical Clinic


Hydatid disease (echinococcosis) is endemic in many worldwide zones or countries including also Romania. It is due to the infestation with larval form of the tapeworm Taenia echinococus of which man is an intermediate (1-3). Isolated hydatid cysts of the spleen (HCS) are nevertheless rare even in our country, one of the authors reporting 23 such cases encountered in thirty years (4).
From the first observations open splenectomy was for decades the standard treatment but since 1980 spleen-sparing methods was proposed especially in children to prevent immunological consequences and postoperative sepsis (5-10).
Also attempts to treat hydatid disease with antihelmintic compounds (benzimidamine carbamates) were proposed to decrease the risk of recurrence if spillage occurs introperatively and in inoperable cases with different rates of success (11).
In the last years enlarging the indications of minimal access surgery of the spleen, first reports of successful laparos-copic approach of splenic HC was published (12-19).

Case report
 A 44 year-old male was addressed to our clinic complaining of a painful tender palpable mass in the left upper abdominal quadrant. In rest the physical examination and routine laboratory analyses was normal. Abdominal ultrasonography revealed a well defined cystic aspect of the palpable mass (Fig. 1) being completed by computed tomography which confirmed a large single spherical imagine, measuring 12,5 x 12,5 cm, into the spleen, with a thin contoured regular wall without evidence of daughter vesicles within (Fig. 2). Laboratory analyses were within normal limits. However we suspected a HCS rather a true or secondary cystic lesion.
At operation under general anesthesia the patient was placed in a decubit position turned 15o on the right combined with a reverse Trendelenburg tilting of the table. After creation of CO2 pneumoperitoneum, four trocars (5 to 10 mm) are inserted and the great omentum is removed from the left subphrenic space showing an enlarged spleen but not the roof of the cyst. (Fig. 3)
Figure 1
Figure 2
Figure 3
Figure 4

Lifting laterally and upward the inferior pole of the spleen the lower fibrous peritoneal splenocolic structures are dissected, clipped and sectioned. (Fig. 4) Dissection is continued upward to expose the anterior peritoneal aspect of the tail of the pancreas and the secondary subhilar vessels which are gradually divided.
With a "fan" retractor the spleen is pushed medially and the lateral and retroperitoneal bindings (splenorenal ligament) are dissected pursuing the delivery of the posterior aspect of the organ in cranial sense, so clearing all of the hilum.
The adequate exposure of the main splenic vein and artery permit their double clipping and section. (Fig. 5).
Convenable weighting the stomach from the spleen, the short gastric vessels are progressively dissected, clipped and sectioned.
However the spleen remains wide and strong attached to the diaphragm by its superior pole where is also the roof of the cyst which must be liberated by gentle and economic dissection even in proper muscle structure. (Fig. 6)
The whole organ being so delivered is placed over the neighboring viscera and an intraabdominal puncture of the cyst at the most proeminent zone with aspiration of a little quantity of patognomonic crystal clear liquid is done. The restant content is neutralized with hypertonic saline solution followed by reaspiration of majority of hydatid fluid (cca 300 ml).
Enlarging one port incision, a longitudinal mini-laparatomy of 5 cm, allowed an instrumental and "digital lever" moving out the entire spleen without incidents. It measured about 14 x 10 x 8 cm (total weight 600 gm). The bulky upper half of the opened spleen appears with a flattened wall harboring the univesicular collapsed cystic membrane.
Control and drainage for 48 h of the splenic loge.
The operation duration was 200 min. Recovery was uneventful, the patient being discharged in the 5th postoperative day under treatment with albendazol (20 ml/24h) for three months. He is still well at 12 and 24 months respectively after surgery and the CT do not revealed recurrence.
Figure 5
Figure 6

Discussion
 The splenic location of hydatid disease was first signaled by Berthelot (1791) and Morgagni (1821) and splenectomy which was proposed and performed by Brocq (1852) and Quenu (1889) remains for more than a century the gold standard treatment. (quoted by 4)
Even in 2002 Dar proclaim splenic removal as the main and safest method of therapy of HCS (2).
Nevertheless in time more conservative surgical approaches as cyst enucleation or partial cystectomy with omentoplasty, partial splenectomy, cystojejunal Roux-en-Y jejunostomy and percutaneous aspiration injection together with reaspiration (PAIR) was considered. (5-10)
Also after the first successful laparoscopic splenectomies, the growing experience and new developments of the technique allows the enlargement of its indications. (12-13) In 1994 Kuminsky introduced the artifice of "hand-assisted" minimal access encouraging Ballaux to perform in 1997 the first hand-assisted splenectomy. (14-15) His attempt was followed by another surgeons (Khoury 2000, Gharabieh 2001, Bickel 2001) some of them using the "Kuminsky's hand" and performing total splenectomies or conservative procedures. (16-18) Sargsyan (2005) presenting his own case search the literature on Medline and found seven reports about laparos-copic techniques in splenic hydatidosis (in two cases total splenectomies were performed and in five cases spleen preserving operations were done). (19)
So our case seems to be the third laparoscopic total splenectomy (imposed by the topography and volume of the cyst).
Owing to the location of the parasite we performed a "blind" abord of the spleen after the initial local exploration do not objectived the presence of the cyst showing only the splenomegaly.
Also the steps of dissection and vessels control was adapted beginning with the lower pole and splenocolic ligament and continued upward with the subhilar vessels. The interception of the main hilar vein and artery is achieved after the complete delivery of the hilum the releasing of the spleen being pursued in cranial sense.
The superior unhooking of the spleen imposed attentive gesture conserving the integrity of the cystic roof and avoiding spillage of hydatic content. Also the intrabdominal puncture decompression, sterilisation and aspiration of the cystic fluid and finally the potential contaminating extraction of the spleen constituted delicate steps of the operation. No any supplementary precautions to prevent intraoperative spillage of hydatid contents was taken
After minilaparatomy, our "finger-assisted extraction" was in fact a combination between catching the spleen with a soft forceps and a two fingers lever maneuver.
The favorable immediate and late (two years) postoperative evolution encourage us to affirm that laparoscopic approach of splenic hydatidosis can be performed by skilled surgeons in well selected cases (univesicular, uncomplicated), constituting a safe and challenging therapeutic alternative. The actual tendency of spleen sparing methods also sustain further minimal invasive access of this disease even with robotic techniques. (20)

Aknowledgements
 The first author acknowledge and underline the contribution of prof. St. Georgescu in the performance of this operation.

References
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