Shinshu M ed J, 62⑹ :441〜446, 2014

Laparoscopic Splenectomy Using a Low‑pressure Pneumoperitoneum for
the Treatment of Immune Thrombocytopenic Purpura During Pregnancy:
A Case Report
Koji KUBOTA , Akira KOBAYASHI ＊, Takahide YOKOYAMA , Norihiko KIKUCHI
Noriyuki KITAGAWA , Norihiko FURUSAWA , Hiroaki MOTOYAMA
Akira SHIMIZU , Tanri SHIOZAWA and Shin‑ichi MIYAGAWA
1) Department of Surgery, Shinshu University School of Medicine
2) Department of Obstetrics and Gynecology, Shinshu University School of Medicine

We report the case of a 21‑year‑old pregnant woman who underwent a laparoscopic splenectomy for thetreatment of immune thrombocytopenic purpura (ITP) because of severe thrombocytopenia refractory to
medical therapy using steroids.The operation was performed during the 24 week of pregnancy using a rigid
10‑mm scope with adjustable viewing angles and limiting the abdominal insuﬄation pressure to 8 mmHg.The
operating time was 204 minutes,and the amount of intraoperative blood loss was 200 mL.Her postoperative
course was uneventful,and her platelet count rapidlyincreased postoperatively.No additional treatments wererequired. Shinshu Med J 62 : 441―446, 2014
(Received for publication May 14, 2014;accepted in revised form August 1, 2014)
Key words:pregnancy, immune thrombocytopenic purpura, laparoscopic splenectomy,
low‑pressure pneumoperitoneum

become a standard operative procedure because of

Introduction

its low degree of invasiveness. Previous studies

Idiopathic thrombocytopenic purpura (ITP) dur-

have shown that a laparoscopic splenectomy can be

ing pregnancy is a rare condition that occurs insuccessfully applied for the treatment of ITP during

0.1% to 0.2% of all pregnancies but can lead topregnancy with an insuﬄation pressure of morehemorrhagic complications, which are potentiallythan 12 mmHg

hazardous for both the mother and fetus .Although

Endoscopic Surgery guidelines deﬁne normal and

ITP during pregnancy can usually be managed

low laparoscopic insuﬄation pressure as 12‑15 andmedically using corticosteroids or the intravenous

5‑7 mmHg, respectively, and recommends that the

injection of immunoglobulin,a splenectomyis some-intraabdominal pressure for pregnant patientstimes required when thrombocytopenia is severe

should be kept as low as possible during a laparos-

and fails to respond to medical treatment.

copy because an increased intraabdominal pres-Since laparoscopic splenectomy provides a com-

. The European Association forsure may decrease maternal respiratory compli-

parably safe and eﬀective alternative to an open

ance

splenectomy for the treatment of ITP

the case of a 21‑year‑old pregnant woman who, it hasand uterine blood ﬂow . Here, we reportunderwent a laparoscopic splenectomyfor ITP with
Corresponding author:Akira Kobayashi
Department of Surgery, Shinshu University School of
Medicine, 3‑1‑1 Asahi, M atsumoto, Nagano 390‑8621,

a limited abdominal insuﬄation pressure of 8mmHg of carbon dioxide (CO ).

Japan
E‑mail:kbys＠shinshu‑u.ac.jp

No. 6, 2014441

Kubota.Kobayashi.Yokoyama et al.

Fig. 1 Preoperative platelet count and medical treatment for thrombocytopenia.

Case Report
Case

Surgical Technique
Adequate perioperative hydration was ensured,and the fetal heart rate monitoring results were

A 21‑year‑old pregnant woman was referred toreassuring. While the patient was under general

our hospital at 8 weeks of pregnancy with a 3‑year

anesthesia, she was placed in a 45°right lateral

history of ITP diagnosed on the basis of a bone

decubitus position. A direct incision was made atmarrow biopsy. Her baseline platelet count was

the midline above the umbilicus,and a 12‑mm port

around 50,000/mm . Clinical examinations revealed

was secured. After the establishment of a COno coagulation disorders.Although she tested nega-pneumoperitoneum with an insuﬄation pressure oftive for serum antibody against Helicobacter pylori,

8 mmHg, three additional ports were placed under

the serum autoantibody level against platelets was

direct visualization as follows:two 10‑mm ports atslightly elevated.

3 cm below the xiphoid process and on the left

Prednisolone was administered at a daily dose ofanterior axillary line 3 cm below the costal margin

20 mg from her 10th week of pregnancy,with a dose

(Fig. 2), and a 5‑mm port on the left midclavicularincrease to 30 mg/day at the 14th week of preg-line 3 cm below the costal margin. A rigid 10‑mm

nancy. However, her platelet count level did not

scope(EndoCAMeleon ;KARL STORZ Gmbh & Co.

respond to the steroid therapy and remained low

KG, Tuttlingen Germany) that allows adjustablethroughout the treatment (Fig. 1). Because of on-

viewing angles was used. The splenocolic, gastros-

going gingival bleeding and subcutaneous hemor-

plenic,and splenophrenic ligaments were sequential-

rhage, a laparoscopic splenectomy was planned atly divided (Fig. 3), followed by transection of thethe 24th week of pregnancy after gamma‑globulin

splenic hilar vessels using an Echeron ﬂex 60(white)

infusion therapy (400 mg/kg/day) had been perfor-(ETHICHON, Tokyo, Japan). The spleen was thenmed for 7 days. Her platelet count increased toplaced into a large EZ purse (HAKKO, Nagano,

141,000/mm before surgery (Fig. 1)

Japan)and retrieved through the incision above the442

Shinshu Med J Vol.62

Laparoscopic splenectomy for ITP during pregnancy

Fig. 2

Laparoscopic view of the uterus (arrows) and a 10‑mm port on the left anterior
axillary line 3 cm below the costal margin.

Fig. 3 The splenophrenic ligament was divided using ultrasonic laparoscopic coagulation shears.

umbilicus after morcellation of the specimen using

100,000/mm during pregnancy.She delivered a 2,850

ring forceps. The operating time was 204 minutes,

g healthy baby during her 40 week of pregnancy

urinary output was 110 mL, and intraoperative

via a low transverse caesarean section because of ablood loss was 200 mL. During anesthesia, therotational anomaly and obstructed labor.

maternal oxygen saturation, end‑tidal CO , heartrate, and mean arterial blood pressure were well

Discussion

maintained within the ranges of 99 ‑100%, 32‑36

The major consideration during laparoscopic sur-mmHg, 70‑80 beats per minute, and 80‑90 mmHg,

gery for pregnant women is the possible adverse

respectively.There was no need for platelet transfu-

eﬀects of an increased intraabdominal pressure,sion.

which has been reported to compromise maternal

The patientʼs postoperative course was unevent-pulmonary and circulatory conditions, such as aful,and her platelet count was maintained at arounddecreased venous return, culminating in hypoten-

No. 6, 2014443

Kubota.Kobayashi.Yokoyama et al.

sion and hypoxia;decreased respiratory compli-

lower intraabdominal pressure, which might beance ;decreased uterine blood ﬂow ;and reduced

associated with a smaller space, seems to make it

renal blood ﬂow, resulting in a decreased urinarydiﬃcult to obtain a good surgical view and hence tooutput . Although most of these concerns are

perform surgical procedures . Indeed, previous

based on experimental studies, a low insuﬄation

studies have argued that an insuﬄation pressure ofpressure is likely to be beneﬁcial. However, previ-

less than 12 mmHg may not provide adequate visu-

ous randomized clinical trials comparing the use of

alization of the intraabdominal cavity

low‑pressure and high‑pressure pneumoperitoneumsidering the above mentioned comparable short‑

for laparoscopic cholecystectomy have yielded

term outcomes between the use of a low‑pressure

conﬂicting results.Wallace and colleagues revealed

and a standard pressure pneumoperitoneum, thethat a low ‑pressure group (7.5 mmHg) had

application of a standard pressure pneumoper-

signiﬁcantly less postoperative pain,compared withitoneum in the present case might have allowed aa high ‑pressure group (15 mmHg), while nowider surgical view, leading to a shorter operation

signiﬁcant diﬀerence was observed in cardiopul-

time.However,we believe that the well‑maintainedmonary parameters between the two groups . In

cardiopulmonary condition observed in the present

contrast, Dexter et al.showed that a high‑pressurecase was achieved,at least in part,as a result of thepneumoperitoneum (15 mmHg) reduced the stroke

lower‑pressure pneumoperitoneum.

. Con-

volume as well as the cardiac output to a greater

We performed a laparoscopic splenectomy in theextent than a low‑pressure pneumoperitoneum .

present patient without anydiﬃculties in visualizing

Other previous prospective randomized studies havethe intraabdominal cavity or performing the surgi-

shown no signiﬁcant diﬀerences between a low‑

cal procedures. In line with a previous study , thepressure (7‑9 mmHg) and a standard‑pressure (12‑patient was placed in a right lateral decubitus

15 mmHg)pneumoperitoneum in terms of the short‑position according to the results of a previous study,

term outcomes, such as operation time, the length

which showed that no signiﬁcant hemodynamicof the hospital stay, or the morbidity rate, except

change was observed between the left and rightfor a lower incidence of shoulder tip pain in the low‑

positions . A rigid 10‑mm scope with adjustablepressure pneumoperitoneum group. The car-viewing angles was used in the present case.

diopulmonary parameters in the present case were

Because this scope can provide a viewing angle thatwell maintained during surgery. The low urine

can be adjusted between 0°and 110°, it might be

output could have raised concerns regarding pos-

useful for obtaining an adequate view of the intraab-sible impairment of renal function,but the postoper-

dominal cavity even under conditions of spatial

ative blood urea nitrogen and serum creatinine

restriction.Its usefulness in gastrointestinal surgery

levels did not increase beyond the preoperative

has been previously reported .

values.

In conclusion,we successfully performed a lapar-

Since the purpose of a pneumoperitoneum is tooscopic splenectomy for ITP in a pregnant patientobtain enough space between the abdominal wall

while limiting the abdominal insuﬄation pressure toand the viscera to perform surgical procedures, a

8 mmHg of CO .

References
1) Gill KK,Kelton JG :Management of idiopathic thrombocytopenic purpura in pregnancy.Semin Hematol 37:275‑
289, 2000
2) Webert KE, Mittal R, Sigouin C, Heddle NM, Kelton JG :A retrospective 11‑year analysis of obstetric patientswith idiopathic thrombocytopenic purpura. Blood 102:4306‑4311, 2003
3) Lozano‑Salazar RR, Herrera M F, Vargas‑Vorackova F, Lopez‑Karpovitch X : Laparoscopic versus open
444

Shinshu Med J Vol.62

Laparoscopic splenectomy for ITP during pregnancy
splenectomy for immune thrombocytopenic purpura. Am J Surg 176:366‑369, 1998
4) Watson DI, Coventry BJ, Chin T, Gill PG, M alycha P : Laparoscopic versus open splenectomy for immune
thrombocytopenic purpura. Surgery 121:18‑22, 1997
5) Anglin BV, Rutherford C, Ramus R,Lieser M ,Jones DB :Immune thrombocytopenic purpura during pregnancy:
laparoscopic treatment. JSLS 5:63‑67, 2001
6) Griﬃths J,Sia W,Shapiro AM,Tataryn I,Turner AR :Laparoscopic splenectomy for the treatment of refractory
immune thrombocytopenia in pregnancy. J Obstet Gynaecol Can 27:771‑774, 2005
7) Felbinger TW,Posner M,Eltzschig HK,Kodali BS :Laparoscopic splenectomy in a pregnant patient with immune
thrombocytopenic purpura. Int J Obstet Anesth 16:281‑283, 2007
8) Neudecker J, Sauerland S, Neugebauer E, Bergamaschi R, Bonjer HJ, Cuschieri A, Fuchs KH, Jacobi C, Jansen
FW, Koivusalo AM, Lacy A, McM ahon M J, M illat B, Schwenk W :The European Association for Endoscopic
Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery.Surg Endosc 16:1121‑1143,
2002
9) Curet M J,Vogt DA,Schob O,Qualls C,Izquierdo LA,Zucker KA :Eﬀects of CO2 pneumoperitoneum in pregnant
ewes. J Surg Res 63:339 ‑344, 1996
10) Andreoli M,Servakov M,Meyers P,Mann WJ Jr:Laparoscopic surgery during pregnancy.J Am Assoc Gynecol
Laparosc 6:229 ‑233, 1999
11) Kammerer WS :Nonobstetric surgery during pregnancy. Med Clin North Am 63:1157‑1164, 197912) Hume RF,Killiam AP :Maternal Physiology.In :Scott JR,KiSaia J,DB Hammon,(eds),Obstetrics and gynecology, pp 93‑100, JB Lippincott, Philadelphia, 1990
13) M cDougall EM,Monk TG,Wolf JS Jr,Hicks M ,Clayman RV,Gardner S,HumphreyPA,Sharp T,M artin K :Theeﬀect of prolonged pneumoperitoneum on renal function in an animal model. J Am Coll Surg 182:317‑328, 1996
14) Wallace DH, Serpell MG, Baxter JN, Oʼ
Dwyer PJ : Randomized trial of diﬀerent insuﬄation pressures forlaparoscopic cholecystectomy. Br J Surg 84:455‑458, 1997
15) Dexter SP,Vucevic M,Gibson J,McMahon M J :Hemodynamic consequences ofhigh‑and low‑pressure capnoperitoneum during laparoscopic cholecystectomy. Surg Endosc 13:376‑381, 199916) Sarli L, Costi R, Sansebastiano G, Trivelli M, Roncoroni L : Prospective randomized trial of low‑pressure
pneumoperitoneum for reduction of shoulder‑tip pain following laparoscopy. Br J Surg 87:1161‑1165, 2000
17) Barczynski M, Herman RM :A prospective randomized trial on comparison of low‑pressure (LP)and standard‑pressure (SP)pneumoperitoneum for laparoscopic cholecystectomy. Surg Endosc 17:533‑538, 2003
18) Perrakis E,Vezakis A,Velimezis G,Savanis G,Deverakis S,Antoniades J,Sagkana E :Randomized comparison
between diﬀerent insuﬄation pressures for laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech
13:245‑249, 2003
19) Sefr R, Puszkailer K, Jagos F :Randomized trial of diﬀerent intraabdominal pressures and acid‑base balancealterations during laparoscopic cholecystectomy. Surg Endosc 17:947‑950, 2003
20) Chok KS, Yuen WK, Lau H, Fan ST :Prospective randomized trial on low‑pressure versus standard‑pressure
pneumoperitoneum in outpatient laparoscopic cholecystectomy.Surg Laparosc Endosc Percutan Tech 16:383‑386,
200621) Sandhu T,Yamada S,Ariyakachon V,Chakrabandhu T,Chongruksut W,Ko‑iam W :Low‑pressure pneumoperitoneum versus standard pneumoperitoneum in laparoscopic cholecystectomy, a prospective randomized clinical
trial. Surg Endosc 23:1044‑1047, 200922) Joshipura VP, Haribhakti SP, Patel NR, Naik RP, Soni HN, Patel B, Bhavsar MS, Narwaria MB, Thakker R :A prospective randomized, controlled study comparing low pressure versus high pressure pneumoperitoneum
during laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 19 :234‑240, 2009
No. 6, 2014445

Kubota.Kobayashi.Yokoyama et al.
23) Aﬄeck DG,Handrahan DL,Egger MJ,Price RR :The laparoscopic management of appendicitis and cholelithiasis
during pregnancy. Am J Surg 178:523‑529, 1999
24) Rollins M D, Chan KJ, Price RR : Laparoscopy for appendicitis and cholelithiasis during pregnancy: a new
standard of care. Surg Endosc 18:237‑241, 2004
25) Friedman RL, Fallas MJ, Carroll BJ, Hiatt JR, Phillips EH : Laparoscopic splenectomy for ITP. The gold
standard. Surg Endosc 10:991‑995, 1996
26) Clark SL, Cotton DB, Pivarnik JM, Lee W, Hankins GD, Benedetti TJ, Phelan JP :Position change and central
hemodynamic proﬁle during normal third‑trimester pregnancy and post partum. Am J Obstet Gynecol 164:883‑
887, 1991
27) Yoshikawa T,Hayashi T,Aoyama T,Cho H,Fujikawa H,Shirai J,Hasegawa S,Yamada T,Oshima T,Yukawa
N, Rino Y, Masuda M, Ogata T, Tsuburaya A :Laparoscopic esophagojejunostomy using the EndoStitch and acircular stapler under a direct view created by the ENDOCAMELEON. Gastric Cancer 16:609 ‑614, 2013（2014. 5.14 received ; 2014. 8. 1 accepted）

446

Shinshu Med J Vol.62