Laparoscopic management of accessory spleens in immune thrombocytopenic purpura

Background: A disparity exists between the incidence of accessory spleens r eported in the open (15-30%) versus the laparoscopic (0-12%) Literature. Th is disparity implies that a percentage of laparoscopic patients will requir e a reoperation for accessory splenectomy. We present our experience with t he laparoscopic management of accessory spleens discovered after primary sp lenectomy for idiopathic thrombocytopenic purpura (ITP), Methods: Seventeen patients who underwent primary splenectomy for ITP were reviewed (1 open, 16 laparoscopic). In the laparoscopic group, the incidenc e of accessory spleens was 3 in 16 (19%) In I of these 3 patients, the acce ssory spleen was found and removed at the initial operation, whereas in 2 o f the 16 patients (13%), the accessory spleens were missed. A third patient , whose initial operation was open, presented with recurrent thrombocytopen ia after primary splenectomy, After recurrent thrombocytopenia developed, r adio nuclide spleen scans were performed showing accessory spleens in all t hree patients. These three patients underwent accessory splenectomy using a four-port laparoscopic approach. Results: Laparoscopic accessory splenectomy was successfully performed in a ll three patients. Location of accessory spleens correlated with the spleen scan in each case. Mean operation time was 180 min. There were no conversi ons to open surgery and no complications. All patients were discharged from the hospital on postoperation day 1. The three patients had a good clinica l response and were weaned effectively from their steroid medications. Conclusions: Patients undergoing a laparoscopic splenectomy for chronic ITP have a higher probability of requiring a reoperation for a missed accessor y spleen. To minimize missing an accessory spleen, a systematic search shou ld be made at the beginning of the laparoscopic operation. We have found th at preoperation imaging with heat-treated erythrocyte scans is valuable for locating accessory spleens before reoperation. When reoperation for access ory splenectomy is necessary, a laparoscopic approach is safe and effective .