Laparoscopic splenectomy is most commonly performed for those with hereditary red cell membrane disorders such as spherocytosis causing hemolysis. The hemoglobinopathies such as sickle cell and thalassemia causing sequestration or hypersplenism are increasingly common indications. Chronic immune thrombocytopenia (ITP) is a good indication but less effective. Tumors, abscesses, or cysts are rare indications. Nonparasitic splenic cysts should be completely excised by partial splenectomy. Torsion of a wandering spleen is similarly rare.

A preoperative ultrasound is essential to identify the size of the spleen and any accessory splenunculi or gallstones. If concomitant cholecystectomy is indicated, it is usually best performed after the splenectomy. Reliable vessel sealing is the key element of the procedure and can be achieved in various ways. Early splenic artery sealing is recommended to allow the spleen to be emptied of blood. The use of a stapler is less desirable for the hilar vessels because it requires a 12-mm port and may be difficult to deploy in the small patient; therefore it is best used as a backup for troublesome bleeding. Retrieval may be problematic in small patients, and a suprapubic port or pfannenstiel incision to extract the spleen may be necessary.

Risks include recurrent disease from a missed spleneculus or splenosis from an intra-abdominal or port site implantation of tissue. Perforation of the colon or stomach is possible. Diaphragmatic hernia is a recognized complication. Portal vein thrombosis is a potential risk or more recent concern. Pancreatitis seems not to be a significant risk. The risk of overwhelming postsplenectomy sepsis is small but real, and therefore prophylactic daily oral penicillin is recommended.

The patient is placed in a semilateral position with the left flank raised, the table head up 30°, and the right side of the table tilted down 15°. A 12- or 15-mm umbilical port is inserted by open technique with a vertical umbilical incision through the umbilicus. Ideally this would be a port that is easily replaced like a balloon port or a multiple instrument port (e.g., SILS type port) that allows use of a 12-mm stapler if used and a 15-mm retrieval bag. Two or three working instruments are placed as shown in Fig. 25.1. In cases of simultaneous cholecystectomy, the splenectomy ports are positioned first and any additional ports are placed later. The left-hand working port is placed in the midline just below or through the falciform ligament, and the right-hand port is placed in the midclavicular line above the level of the umbilicus. A further port may be placed in the anterior axillary line above the umbilicus for retraction if necessary. The surgeon, assistant, and nurse all stand on the patient’s right-hand side, with the table lowered to a comfortable height.