Because the navel is a natural scar, single incision laparoscopic surgery (SILS) is attractive in that it results in a virtually scarless operation. Scarless surgery has been the appeal of natural orifice transluminal endoscopic surgery (NOTES) as well. Currently, both of these new approaches are mostly performed in the adult population, and a state-of-the-art review of SILS and NOTES for cholecystectomy was published recently.2
Pediatric surgeons have performed laparoscopic splenectomy for well over a decade3
and have developed extensive experience, resulting in a conversion rate of around 2% and a total complication rate of around 11%.4
This is the standard against which newer operative approaches, including SILS splenectomies in children, should be compared.
The previously described SILS splenectomies were in young adult females (22 and 28 years of age) with idiopathic thrombocytopenic purpura.1
The initial trocar placement was similar to what we used, with three 5-mm trocars in a 2-cm vertical umbilical incision. In contrast to this report, we did not use reticulating graspers or instruments except for the endosurgical stapler, because we have not found a clear advantage over straight instruments in our single-site laparoscopic approach to appendectomy, cholecystectomy, and pyloromyotomy. Our operative time of 84 minutes was shorter than the previously reported adult cases (110 and 150 minutes, respectively).
SILS poses significant ergonomic challenges. Grouping all 3 trocars into the same incision leads to spatial interference of the camera and working instruments. The freedom of motion can be improved by spacing the ports in the periumbilical fascia as far away from each other as possible. Furthermore, the trocars should be introduced at different depths, so that collision of the valve heads is minimized. Additionally, using instruments and a camera of different lengths, minimizes interference of the surgeon's and assistant's hands. An angled scope is essential. Compared with our standard laparoscopic approach, no special instruments were required for the SILS procedure. Using a tissue sealing electrosurgery device and a vascular stapler for the splenic hilum minimized the operative blood loss, which was recorded as <10 mL.
We recommend that during a SILS procedure, the surgeons are ready to introduce additional trocars to aid in visualization, dissection, or reconstruction if they perceive that a maneuver cannot be performed safely for the patient through a single incision. In our practice, we always have additional trocars ready to convert to dual incision laparoscopic surgery (DILS) or standard laparoscopy anytime.
Although some dissection of the splenic attachments was slightly more cumbersome than during the standard laparoscopic procedure, we did not encounter any moment where we perceived an increased risk to the patient because of the SILS approach. Using a tissue sealing electrosurgery device and a vascular stapler for the splenic hilum minimized the endovascular blood loss, which was recorded as <10 mL. The splenic hilum was well dissected before the endostapler was applied, and only one 4.5-cm vascular load was required. The SILS approach did not seem to compromise our visualization or the ability to identify accessory spleens.
Compared with our standard laparoscopic approach, no special instruments were required for the SILS procedure, so that there is no economic disadvantage using SILS. Subjectively though, operating time may have been increased by placing all trocars in the umbilicus, although this remains to be shown once we have a larger series for comparison.
Our report shows that single-incision splenectomy is feasible even in young children. Further experience with this evolving technique is needed to determine specific risks and benefits.