Laparoendoscopic single site surgery (LESS) is a promising alternative to conventional laparoscopic surgery and has redirected attention from natural orifice transluminal endoscopic surgery (NOTES). Its popularity has led to the development of novel instruments and techniques to facilitate LESS procedures, which may offer advantages, but are not absolutely necessary.^1–4 LESS operations have been reported for urological, gastrointestinal, gynecologic, and endocrine procedures.^5–8 For general surgical procedures, LESS cholecystectomy and appendectomy have been increasingly reported, with only several published reports of LESS splenectomy. We present 2 cases of LESS splenectomy performed with a conventional laparoscope and instruments, and the use of a novel internal retraction device.

A 25-year-old female with a longstanding history of idiopathic thrombocytopenia purpura (ITP) presented with spontaneous gingival bleeding and hemotympanum. Her initial platelet count was 3000 which increased to 75 000 with prednisone and intravenous gamma globulin. The patient was referred for minimally invasive splenectomy. Triple vaccination was administered in preparation for surgery.

The second patient was a 17-year-old female with sickle cell disease, who presented with left upper quadrant and right upper quadrant pain. She had an enlarged spleen measuring 15.4cm on ultrasound, and multiple large gallstones. After triple vaccination, she underwent simultaneous LESS splenectomy and cholecystectomy.

Laparoscopic splenectomy was first described in 1992, and is now well established for the treatment of multiple hematologic diseases, primary splenic tumors, and metastatic disease involving the spleen.^9–11 Even more so than appendectomy, laparoscopic splenectomy decreases length of stay and recovery compared to an open procedure.^12,13

LESS procedures are still in evolution, and the majority of published literature describes cholecystectomy and appendectomy. Our initial experience with LESS also began with cholecystectomy and appendectomy, and after 25 such procedures, we embarked on a LESS splenectomy. While we performed LESS cholecystectomy and appendectomy with low-profile 5-mm trocars, we elected to use a single port access device (SILS port) for our LESS splenectomy, primarily to facilitate exchange between a 5-mm and 12-mm trocar, which would be necessary for a laparoscopic stapler to secure the splenic hilum. Another consideration was to minimize air leakage around individual 5-mm trocars, which can develop during lengthier cases, and repetitive torque on the trocars leads to enlargement of the fascial opening. The SILS port creates a tighter fascial seal to prevent air leakage.

In the pediatric population, Dutta¹⁴ successfully performed multiple LESS procedures including splenectomy. His technique uses articulating instruments (Realhand High Dexterity Instruments, Novare Surgical, Cupertino, CA), with comparable outcomes to those of standard laparoscopic surgery. Another report of LESS splenectomy by Targarona et al¹⁵ incorporated a flexible laparoscope and flexible instruments. This equipment is not readily available to many centers due to cost constraints, and we chose to develop a technique where additional instrumentation was kept to a minimum. Rottman et al¹⁶ described LESS splenectomy using 5-mm trocars and conventional instruments within an umbilical incision.

In our cases, an intracorporeal retractor was used to anchor the specimen bag to the abdominal wall and also to retract the gallbladder, which avoided the need for a fourth trocar. This retractor is easily made by attaching a small metal hook to a laparoscopic bulldog clamp. An alternative technique is the use of extracorporeal sutures passed through the abdominal wall, which we used for LESS cholecystectomy in our earlier experience. We have found that either technique is an effective substitute for a fourth trocar and instrument.

LESS splenectomy is a feasible procedure that can be performed safely and may lead to higher patient satisfaction compared to laparoscopic splenectomy by avoiding multiple incisions (Figure 3). Operative time is clearly increased with LESS splenectomy compared to laparoscopic splenectomy, but as the learning curve improves, this will likely decrease. While articulating instruments and laparoscopes may offer technical advantages, they are not necessary for performing LESS splenectomy. Comparative studies will be necessary to demonstrate whether LESS splenectomy confers other benefits, such as decreased pain and faster recovery, compared to laparoscopic splenectomy.