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He Z, Ren J, Tang X, Li W, Zhang X, Liao W, Lin J, Wang J, Ao L, Xie J, Li H, Yi X, Lu X, Feng X, Diao D. Innovative pancreas-guided technique for splenic flexure mobilization in laparoscopic left hemicolectomy. Surg Endosc 2024:10.1007/s00464-024-11009-0. [PMID: 39060624 DOI: 10.1007/s00464-024-11009-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 06/22/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVE Splenic flexure mobilization (SFM) is a major challenge in laparoscopic left hemicolectomy. This study aims to assess the safety and effectiveness of the pancreas-guided SFM technique during laparoscopic left hemicolectomy. METHODS From January 2018 to December 2023, 352 patients with left-sided colon cancer underwent laparoscopic left hemicolectomy. Based on the SFM method used, the patients were divided into the pancreas-guided group (167 cases) or the "Three Approaches Roundabout"/classic group (185 cases). Clinicopathologic characteristics and intraoperative and postoperative variables were compared between the two groups. RESULTS The two groups had no significant differences in baseline indicators (P > 0.05). All surgeries were successful without needing to convert to laparotomy, and there were no combined organ resections involving the spleen or pancreas in either group. The mean duration of surgery was significantly lower in the pancreas-guided group than in the classic group (P < 0.01). The median volume of intraoperative blood loss in the pancreas-guided group was lower than that in the classic group (P < 0.01). Through video playback, it was found that the retro-pancreatic space had been entered during operation in 8 cases (4.3%) in the classic group, while there were no such occurrences in the pancreas-guided group. This difference was statistically significant (P < 0.05). The difference in the number of lymph nodes cleared, postoperative hospital stays, and incidence of complications were not statistically significant (all P > 0.05) between the groups. CONCLUSION The pancreas-guided SFM technique is a safe and feasible option for laparoscopic left hemicolectomy. Our study's findings suggest that this approach facilitates accurate access to the correct anatomic plane, potentially improving surgical efficiency.
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Affiliation(s)
- Ziyan He
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiaqi Ren
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xin Tang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wenjuan Li
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xueyang Zhang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Weilin Liao
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Jiaxin Lin
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Jiahao Wang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lin Ao
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Jiaxin Xie
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Hongming Li
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Xiaojiang Yi
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - XinQuan Lu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - XiaoChuang Feng
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Dechang Diao
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China.
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Emile SH, Dourado J, Rogers P, Horesh N, Garoufalia Z, Gefen R, Wexner SD. Splenic flexure mobilization in left-sided colonic and rectal resections: A meta-analysis and meta-regression of factors associated with anastomotic leak and complications. Colorectal Dis 2024; 26:1332-1345. [PMID: 38757843 DOI: 10.1111/codi.16983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/06/2024] [Accepted: 03/16/2024] [Indexed: 05/18/2024]
Abstract
AIM Splenic flexure mobilization (SFM) is commonly performed during left-sided colon and rectal resections. The aim of the present systematic review was to assess the outcomes of SFM in left-sided colon and rectal resections and the risk factors for complications and anastomotic leak (AL). METHOD This study was a PRISMA-compliant systematic review. PubMed, Scopus and Web of Science were searched for studies that assessed the outcomes of sigmoid and rectal resections with or without SFM. The primary outcomes were AL and total complications, and the secondary outcomes were individual complications, operating time, conversion to open surgery, length of hospital stay (LOS) and pathological and oncological outcomes. RESULTS Nineteen studies including data on 81 116 patients (49.1% male) were reviewed. SFM was undertaken in 40.7% of patients. SFM was associated with a longer operating time (weighted mean difference 24.50, 95% CI 14.47-34.52, p < 0.0001) and higher odds of AL (OR 1.19, 95% CI 1.06-1.33, p = 0.002). Both groups had similar odds of total complications, splenic injury, anastomotic stricture, conversion to open surgery, (LOS), local recurrence, and overall survival. A secondary analysis of rectal cancer cases only showed similar outcomes for SFM and the control group. CONCLUSIONS SFM was associated with a longer operating time and higher odds of AL, yet a similar likelihood of total complications, splenic injury, anastomotic stricture, conversion to open surgery, LOS, local recurrence, and overall survival. These conclusions must be cautiously interpreted considering the numerous study limitations. SFM may have only been selectively undertaken in cases in which anastomotic tension was suspected. Therefore, the suboptimal anastomoses may have been the reason for SFM rather than the SFM being causative of the anastomotic insufficiencies.
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Affiliation(s)
- Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Justin Dourado
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Peter Rogers
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
- Department of Surgery and Transplantation, Sheba Medical Center, Ramat-Gan, Israel
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
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Zhang X, Wei Z, Fu H, Hu Z, Wang W, Yan R. Predictors of iatrogenic splenic injury in radical gastrectomy for gastric cancer. Front Oncol 2024; 14:1361185. [PMID: 38601758 PMCID: PMC11005098 DOI: 10.3389/fonc.2024.1361185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 03/14/2024] [Indexed: 04/12/2024] Open
Abstract
Background Iatrogenic splenic injury (ISI) is a recognized complication in radical gastrectomy that may result in incidental splenectomy (IS). However, the predictors of such events remain largely unknown. Methods Medical records of the patients who underwent radical gastrectomy at our institution between January 2015 and December 2022 were retrospectively reviewed. Potential predictors of ISI and IS were collected and analyzed by multivariate logistic regression. Results were reported as an odds ratio (OR) with 95% confidence intervals (CI). Results A total of 2916 patients were included, of whom 211 patients (7.2%) suffered from ISI and 75 patients (2.6%) underwent IS. Multivariate analysis demonstrated that BMI≥25 (OR: 3.198 (2.356-4.326), p<0.001), total gastrectomy (OR: 2.201 (1.601-3.025), p<0.001), and the existence of "criminal fold" (OR: 13.899 (2.824-251.597), p=0.011) were independent predictive risk factors for ISI; whereas laparoscopic surgical approach (OR: 0.048 (0.007-0.172), p<0.001) was a protective factor for ISI. Moreover, the existence of "criminal fold" (OR: 15.745 (3.106-288.470), p=0.008) and BMI≥25 (OR: 2.498 (1.002-6.046), p=0.044) were identified as independent risk factors of ISI under laparoscopic gastrectomy. There was no association between sex, age, previous abdominal surgery, neoadjuvant therapy, outlet obstruction, tumor stage, nodal stage, and total lymph node retrieved and ISI. Conclusions BMI≥25 and total gastrectomy can predict high risk of ISI during radical gastrectomy. Laparoscopic surgery is superior to open gastrectomy in lowing the risk of ISI.
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Affiliation(s)
| | | | | | | | - Weijun Wang
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Ronglin Yan
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
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Miftari R, Gazzetta J. Splenic Capsule Injury: A Rare Complication of Sigmoid Volvulus. Cureus 2023; 15:e41118. [PMID: 37519610 PMCID: PMC10382788 DOI: 10.7759/cureus.41118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Sigmoid volvulus can lead to life-threatening complications. We report a splenic capsule avulsion injury requiring laparotomy as a complication of sigmoid volvulus. A 73-year-old woman was admitted with abdominal distension, rigidity, and tenderness. CT abdomen revealed a splenic injury and hemoperitoneum along with possible sigmoid volvulus. The patient required an emergent exploratory laparotomy due to an acute abdomen and hemodynamic instability. A left colectomy, on-table sigmoidoscopy, hemostasis of the spleen, and temporary abdominal closure were performed. She required subsequent operations for end colostomy and abdominal closure. We establish that splenic lacerations are rare but life-threatening complications of sigmoid volvulus. Careful assessment of the spleen on abdominal imaging and clear visualization of the spleen during sigmoid volvulus surgery is recommended for early recognition and prompt management of splenic injury.
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Affiliation(s)
- Rrezane Miftari
- General Surgery, Saba University School of Medicine, The Bottom, BES
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Vargas HD. Gaining Mesenteric Length following Colorectal Resection: Essential Maneuvers to Avoid Anastomotic Tension. Clin Colon Rectal Surg 2023; 36:37-46. [PMID: 36643828 PMCID: PMC9839430 DOI: 10.1055/s-0042-1758776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
A surgeon must possess the knowledge and technical skill to obtain length following a left-sided colorectal resection to perform a tension free anastomosis. The distal target organ - either rectum or anus - is fixed in location, and therefore requires surgeons to acquire mastery of proximal mobilization of the colonic conduit. Generally, splenic flexure mobilization (SFM) provides adequate length. Surgeons benefit from clearer understanding of the multiple steps involved in SFM as a result of improved visualization and demonstration of the relevant anatomy - adjacent organs and the attachments, embryologic planes, and mesenteric structures. Much may be attributed to laparoscopic and robotic platforms which provided improved exposure and as a result, development or refinement of novel approaches for SFM with potential advantages. Complete mobilization draws upon the sum or combination of the varied approaches to accomplish the goal. However, in the situation where extended resection is necessary or in the case of re-operative surgery sacrificing either more proximal or distal large intestine often occurs, the transverse colon or even the ascending colon represents the proximal conduit for anastomosis. This challenging situation requires familiarity with special maneuvers to achieve colorectal or coloanal anastomosis using these more proximal conduits. In such instances, operative techniques such as either ileal mesenteric window with retroileal anastomosis or de-rotation of the right colon (Deloyer's procedure) enable the intestinal surgeon to construct such anastomoses and thereby avoid stoma creation or loss of additional large intestine.
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Affiliation(s)
- Herschel David Vargas
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
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Polovinkin VV, Pryn PS. [Mobilization of splenic flexure - routine or selective (results of a single-center randomized study)]. Khirurgiia (Mosk) 2022:33-44. [PMID: 35775843 DOI: 10.17116/hirurgia202207133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate safety and effectiveness of routine splenic flexure mobilization (SFM) in surgical treatment of rectal cancer (RC). MATERIAL AND METHODS A single-center randomized study was performed between 2016 and 2019. Patients were randomized into 2 groups (SFM (+), n=156, SFM(-), n=67). Standard anterior and low anterior rectal resection was used. We used a combination of medial, lateral, and anterior approaches for SFM. Intraoperative, early and late postoperative complications, histological data, local recurrence, overall 3-year, relapse-free and cancer-specific survival were analyzed. RESULTS Surgery time was 253.2±72.8 and 252.0±78.0 min in the SFM(+) and SFM(-) groups, respectively (p=0.98). Blood loss was 53.3±53.6 and 67.0±108.8 ml, respectively (p=0.85), length of specimen - 28.6 (95% CI 27.2-29.9) and 24.0 cm (95% CI 22.2-25.7) (p<0.0001). Length of residual fragment of sigmoid colon was 5.0 (95% CI 3.9-6.1) and 9.1 cm (95% CI 7.2-11.1) (p<0.0001), respectively. The number of examined lymph nodes was 15.5 (95% CI 14.2-16.8) and 16.1 (95% CI 14.2-18.1) (p=0.52), number of affected lymph nodes - 1.5 (95% CI 0.9-2.1) and 1.5 (95% CI 0.9-2.2), respectively (p=0.38). Spleen damage was more common in the SFM (-) group (4.5% vs. 1.3%, p=0.12). Logistic regression analysis indicates that SFM does not affect the incidence of spleen damage. Severity of postoperative complications was similar (p=0.63). Anastomotic leak (AL) was more common in the SFM group (-) (17.9% vs. 9.6%, p=0.04). AL grade B was more common in the SFM(-) group (p=0.0001). Logistic regression analysis revealed the following predictors of anastomotic leakage: length of specimen and length of residual sigmoid colon. There was no significant relationship between SFM and incidence of local and systemic recurrences. Overall, cancer-specific and relapse-free 3-year survival was similar. CONCLUSION SFM is a safe procedure with various advantages. However, this approach does not improve intraoperative, early and long-term postoperative outcomes that does not allow us to recommend this approach for routine application.
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Affiliation(s)
- V V Polovinkin
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russian Federation
| | - P S Pryn
- Research Institute - Ochapovsky Regional Clinical Hospital No. 1, Krasnodar, Russian Federation
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Carrano FM, Spinelli A. Management of intraoperative complications during laparoscopic left colectomy. Minerva Surg 2021; 76:316-323. [PMID: 33855373 DOI: 10.23736/s2724-5691.21.08644-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Minimally invasive surgery has gained a major role in the current management of colorectal disease since the introduction of laparoscopy in the early 1990s for colorectal procedures. The laparoscopic approach, in fact, is not exempt from the risk of intraoperative complications, some of which can occur outside the field of view. Aim of this chapter is to review the different types of complications that can happen during left colectomy, analyzing the causes, how to prevent them and what to do in case they occur. EVIDENCE ACQUISITION A literature search was carried out using the MEDLINE and PubMed databases for studies published between January 1980 and October 2020. The following terms were used for the search: complications, risk factors, colorectal surgery, colorectal resection, laparoscopy, left colectomy, intraoperative complications, splenic injury, intraoperative bleeding. EVIDENCE SYNTHESIS From our literature search we identified twenty-four studies, including two systematic reviews and metanalyses, that were the most pertinent to the subject. CONCLUSIONS Many different complications can occur during laparoscopic left colectomy. Maintaining control of the situation is important to provide a prompt solution to the occurred injury. Increasing the reporting rate of complications may help, in the future, to analyze the causes and improve management strategies, keeping in mind that the only surgeon who does not have complications is the one who does not operate.
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Affiliation(s)
- Francesco M Carrano
- Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy.,University of Rome Tor Vergata, Rome, Italy
| | - Antonino Spinelli
- Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy - .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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Manatakis DK, Piagkou M, Loukas M, Tsiaoussis J, Delis SG, Antonopoulos I, Chytas D, Natsis K. A systematic review of splenic artery variants based on cadaveric studies. Surg Radiol Anat 2021; 43:1337-1347. [PMID: 33481130 DOI: 10.1007/s00276-020-02675-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/30/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The splenic artery (SA) is the largest and most tortuous branch of the celiac trunk with a wide spectrum of variants, particularly in its terminal branches. METHODS The current study presents a systematic review of the English literature on the SA variations, with emphasis on its terminal branching patterns. RESULTS Thirty cadaveric studies (3132 specimens) were included in the analysis. The SA originated from the celiac trunk in 97.2%, from the abdominal aorta in 2.1% and from the superior mesenteric or the common hepatic artery in 0.7% of cases. A suprapancreatic course was observed in 77.4%, retropancreatic course in 17.8%, anteropancreatic course in 3.4% and intrapancreatic course in 1.3%. In the majority of cases, the SA bifurcated into superior and inferior lobar arteries (83.4%), with trifurcation and quadrifurcation in 11.3% and 2.7%, respectively. Five or more lobar branches (1.4%) and a single lobar artery (1.2%) were rarely identified. The distributed branching pattern was found in 72.7%, whereas the magistral pattern in 26.9%. The inferior and superior polar arteries (IPA and SPA) were found in 47.7% and 41.7% of cases, respectively, while polar artery agenesis was recorded in 28.2%. The SPA usually originated from the SA main trunk (53.6%) or from the superior lobar artery (33.1%). The IPA emanated mainly from the left gastroepiploic artery (53%), from the SA (23.5%) or the inferior lobar artery (21.9%). Intersegmental anastomoses between adjacent arterial segments were identified in 14.2%. CONCLUSION Knowledge of the SA aberrations is important for surgeons and radiologists involved in angiographic interventions.
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Affiliation(s)
- Dimitrios K Manatakis
- Department of Surgery, Athens Naval and Veterans Hospital, 70 Deinokratous Str., 11521, Athens, Greece.
| | - Maria Piagkou
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - John Tsiaoussis
- Laboratory of Anatomy, School of Medicine, University of Crete, Heraklion, Greece
| | - Spiridon G Delis
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, Athens, Greece
| | - Ioannis Antonopoulos
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Konstantinos Natsis
- Department of Anatomy and Surgical Anatomy, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloníki, Greece
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Pryn PS, Polovinkin VV. [Splenic flexure mobilization in surgery for rectal cancer]. Khirurgiia (Mosk) 2020:94-99. [PMID: 31994507 DOI: 10.17116/hirurgia202001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Nowadays, the issue of splenic flexure mobilization (SFM) in anterior and low anterior rectal resection for rectal cancer is still debatable. This stage is important because dissection results tension-free anastomosis and excision of specimen of enough length with adequate number of harvested lymph nodes. However, literature review confirmed the absence of agreement regarding reduced incidence of colorectal anastomotic leakage and improved long-term oncologic outcomes after SFM. Opinion about selective approach to this procedure is becoming more common. Therefore, randomized trials are necessary to determine a need for routine SFM or indications for selective approach to SFM in anterior rectal resection for rectal cancer.
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Affiliation(s)
- P S Pryn
- Research Institute - Ochapovsky Regional Clinical Hospital No.1 of the Ministry of Health of the Krasnodar Region, Krasnodar, Russia
| | - V V Polovinkin
- Research Institute - Ochapovsky Regional Clinical Hospital No.1 of the Ministry of Health of the Krasnodar Region, Krasnodar, Russia
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10
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Popeskou SG, Ris F, Buchs NC, Meyer J, Liot E, Toso C. Laparoscopic splenectomy in the armamentarium of the colorectal surgeon - a video vignette. Colorectal Dis 2019; 21:1342-1343. [PMID: 31373154 DOI: 10.1111/codi.14802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 07/23/2019] [Indexed: 02/08/2023]
Affiliation(s)
- S G Popeskou
- Departement de Chirurgie, Visceral Surgery Department, Hopitaux Universitaires de Geneve, Geneva, Switzerland
| | - F Ris
- Departement de Chirurgie, Visceral Surgery Department, Hopitaux Universitaires de Geneve, Geneva, Switzerland.,Colorectal Surgery, John Radcliffe Hospital, Oxford, UK
| | - N C Buchs
- Departement de Chirurgie, Visceral Surgery Department, Hopitaux Universitaires de Geneve, Geneva, Switzerland
| | - J Meyer
- Departement de Chirurgie, Visceral Surgery Department, Hopitaux Universitaires de Geneve, Geneva, Switzerland
| | - E Liot
- Departement de Chirurgie, Visceral Surgery Department, Hopitaux Universitaires de Geneve, Geneva, Switzerland
| | - C Toso
- Departement de Chirurgie, Visceral Surgery Department, Hopitaux Universitaires de Geneve, Geneva, Switzerland
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Dilday JC, Gilligan TC, Merritt CM, Nelson DW, Walker AS. Examining Utility of Routine Splenic Flexure Mobilization during Colectomy and Impact on Anastomotic Complications. Am J Surg 2019; 219:998-1005. [PMID: 31375246 DOI: 10.1016/j.amjsurg.2019.07.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/16/2019] [Accepted: 07/22/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Despite a lack of supporting data, routine splenic flexure mobilization (SFM) during colectomy has been thought to reduce anastomotic leak (AL). We evaluated the impact of SFM on outcomes in distal colectomy. STUDY DESIGN The 2005-2016 NSQIP database identified 66,068 patients undergoing distal colectomy with anastomosis. Cohorts were stratified by addition of SFM. Postoperative outcomes were compared between groups. Regression analysis identified factors affecting odds of developing AL. RESULTS SFM was performed in 27,475 patients (41.6%). There was no difference in overall complications between cases with SFM and those without (p = 0.55). SFM had longer operative times (220 min vs. 184 min; p < 0.0001). SFM was not associated with any difference in AL rate (3.6% vs. 3.7%; p = 0.86). Factors most associated with AL were lack of oral antibiotic preparation (OR 1.93; p < 0.001), chemotherapy (OR 1.91; p < 0.001), and weight loss (OR 1.68; p = 0.0005). Operative indication and approach did not affect leak. CONCLUSIONS SFM in distal colectomy increased operative time without decreasing overall complications or AL. Routine splenic flexure mobilization may add risk without significant benefit.
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Affiliation(s)
- Joshua C Dilday
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Timothy C Gilligan
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Clay M Merritt
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Daniel W Nelson
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Avery S Walker
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA.
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Delafontaine JL, Moreci R, Samra NS. Acute splenic rupture following laparoscopic pneumoperitoneum: A case report. Trauma Case Rep 2019; 22:100211. [PMID: 31338406 PMCID: PMC6620620 DOI: 10.1016/j.tcr.2019.100211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction Splenic rupture after laparoscopic surgery is a very rare complication. In this study, we report a case of a splenic laceration that occurred during a laparoscopic gastrostomy tube placement. The theorized mechanism in this case was acute disruption of a peri-splenic hematoma. Case report A 64-year-old African-American male presented after a motor vehicle accident with multiple injuries and was admitted to a surgical intensive care unit, where he declined from ICU days 6 through 11. The patient underwent tracheostomy and laparoscopic gastrostomy tube placement given his significant neurologic deficits. Intraoperatively, the patient developed hypotension, leading to the discovery of hemoperitoneum and necessitating an emergent open splenectomy. Conclusion Splenic rupture following laparoscopic procedures is a very rare phenomenon. In this case, we believe the splenic rupture was secondary to an acute disruption of a previously hemostatic splenic hematoma involving the abdominal wall during creation of capnoperitoneum.
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Affiliation(s)
- Jean-Luc Delafontaine
- Department of Surgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, USA
| | - Rebecca Moreci
- Louisiana State University School of Medicine, Shreveport, LA, USA
| | - Navdeep S Samra
- Department of Trauma, Acute Care Surgery, and Surgical Critical Care, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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Laparoscopy reduces iatrogenic splenic injuries during colorectal surgery. Tech Coloproctol 2018; 22:767-771. [PMID: 30460619 DOI: 10.1007/s10151-018-1861-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 09/24/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Splenic injury can occur during colorectal surgery especially in cases, where the splenic flexure is mobilized. The aim of this study was to analyze whether the operative approach (laparoscopic vs. open) was associated with an increased risk for splenic injury during colorectal surgery and to compare the outcomes of different management options. METHODS All accidental injuries that occurred during colorectal resections performed in our department between January 2010 and June 2013 were identified from an administrative database. All patients with iatrogenic splenic injuries were classified into two groups according to the operative approach. Only procedures that required splenic flexure mobilization were included. Splenic injury management options and outcomes were compared. RESULTS There were 2336 colorectal resections (1520 open, 816 laparoscopic) performed during the study period. There were 25 (1.1%) iatrogenic splenic injuries. 23 out of 25 splenic injuries occurred during open colorectal surgery. Overall, 16 (64%) patients were managed with topical hemostatic methods, 5 (20%) with splenectomy, and 4 (16%) with splenorrhaphy. It was possible to salvage the spleen in both laparoscopic patients. The laparoscopic approach was associated with a lower splenic injury rate (0.25% vs. 1.5%, p = 0.005) and a lower need for splenectomy/splenorrhaphy (p = 0.03). CONCLUSIONS Our data suggest that laparoscopic colorectal surgery may be associated with a lower risk of iatrogenic splenic injury, and that most splenic injuries can be managed with spleen-preserving approaches.
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Mangano A, Gheza F, Giulianotti PC. Iatrogenic spleen injury during minimally invasive left colonic flexure mobilization: the quest for evidence-based results. MINERVA CHIR 2018; 73:512-519. [DOI: 10.23736/s0026-4733.18.07737-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mangano A, Fernandes E, Valle V, Bustos R, Gheza F, Giulianotti PC. Iatrogenic spleen injury risk during robotic left colonic and rectal resections by routine left flexure mobilization technique: a retrospective study. MINERVA CHIR 2018; 73:451-459. [PMID: 29806761 DOI: 10.23736/s0026-4733.18.07806-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The routine mobilization of the left colonic flexure as a standard procedure during left colonic/rectal resection is a controversial topic in open and minimally invasive surgery. According to some authors, this maneuver may increase the risk of iatrogenic spleen damage; for others this does not change the odds. Ligaments over-traction is the most frequent injury mechanism. Some documented risk factors are reported: laparotomic approach, male gender, vascular disease, cancer, diverticulitis, surgery performed in emergency-setting. The type of procedure influences the associated risk: transverse colectomy is the riskiest, followed by left colonic resection and pancolectomy. METHODS Retrospective original paper. Sample size - a total of 125 patients have been considered. 75 robotic left colonic resections (60%), 40 robotic rectal resections (32%) and 10 robotic pancolectomy (8%). Primary outcomes - 1) percentage of iatrogenic splenic injuries; 2) conversion rate. Secondary outcomes - 1) intra-/postoperative complications; 2) anastomotic leakage rate; 3) mortality. In order to avoid potential confounding factors and technical/expertise heterogeneity, all the procedures included have been performed using the same standardized operative technique and by the same experienced surgeon (P.C.G.). RESULTS We retrospectively analyzed 125 procedures. Primary outcomes - 1) iatrogenic splenic injuries: 0%; 2) conversion rate: 1.6%. Secondary outcomes - 1) intraoperative complications: 0%; 2) anastomotic leakage rate: 1 case of leakage out of 125 cases (1.3% of the left colectomy sub-sample); in this case the leakage was probably due to an infectious process rather than a vascular deficit; 3) mortality: 0%; 4) miscellanea postoperatory complications (small bowel obstructions, wound infection, pelvic collections, pneumonia and acute kidney injury) are detailed in the manuscript. CONCLUSIONS In our experience, and according to some of the literature data as well, during robotic left colonic/rectal resections the routine mobilization of the left flexure as a standard procedure is not a risk factor in terms of iatrogenic spleen injury rate. Conversely, this technique may be beneficial as it does not excessively extend the operative time, increases the surgical skills acquirement, and reduces the tension-related anastomotic ischemia. It also allows a better oncological dissection. Standard laparoscopic approach reduces the rate of spleen by almost 3.5 times in comparison to open surgery. The improved technical accuracy provided by the robotic platform may decrease the rate of splenic injury. More studies are needed on the topic to confirm our findings.
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Affiliation(s)
- Alberto Mangano
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA -
| | - Eduardo Fernandes
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Valentina Valle
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Roberto Bustos
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Federico Gheza
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Pier Cristoforo Giulianotti
- Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
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Inadvertent Splenectomy During Resection for Colorectal Cancer Does Not Increase Long-term Mortality in a Propensity Score Model: A Nationwide Cohort Study. Dis Colon Rectum 2016; 59:1150-1159. [PMID: 27824700 DOI: 10.1097/dcr.0000000000000712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous studies suggest that long-term mortality is increased in patients who undergo splenectomy during surgery for colorectal cancer. The reason for this association remains unclear. OBJECTIVE The purpose of this study was to investigate the association between inadvertent splenectomy attributed to iatrogenic lesion to the spleen during colorectal cancer resections and long-term mortality in a national cohort of unselected patients. DESIGN This was a retrospective, nationwide cohort study. SETTINGS Data were collected from the database of the Danish Colorectal Cancer Group and merged with data from the National Patient Registry and the National Pathology Databank. PATIENTS Danish patients with colorectal cancer undergoing curatively intended resection between 2001 and 2011 were included in the study. MAIN OUTCOME MEASURES The primary outcome was long-term mortality for patients surviving 30 days after surgery. Secondary outcomes were 30-day mortality and risk factors for inadvertent splenectomy. Multivariable and propensity-score matched Cox regression analyses were used to adjust for potential confounding. RESULTS In total, 23,727 patients were included, of which 277 (1.2%) underwent inadvertent splenectomy. There was no association between inadvertent splenectomy and long-term mortality (adjusted HR = 1.15 (95% CI, 0.95-1.40); p = 0.16) in the propensity score-matched model, whereas 30-day mortality was significantly increased (adjusted HR = 2.31 (95% CI, 1.71-3.11); p < 0.001). Inadvertent splenectomy was most often seen during left hemicolectomy (left hemicolectomy vs right hemicolectomy: OR = 24.76 (95% CI, 15.30-40.06); p < 0.001). LIMITATIONS This study was limited by its retrospective study design and lack of detailed information on postoperative complications. CONCLUSIONS Inadvertent splenectomy during resection for colorectal cancer does not seem to increase long-term mortality. The previously reported reduced overall survival after inadvertent splenectomy may be explained by excess mortality in the immediate postoperative period.
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Feola A, Niola M, Conti A, Delbon P, Graziano V, Paternoster M, Pietra BD. Iatrogenic splenic injury: review of the literature and medico-legal issues. Open Med (Wars) 2016; 11:307-315. [PMID: 28352813 PMCID: PMC5329846 DOI: 10.1515/med-2016-0059] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 06/27/2016] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Iatrogenic splenic injury is a recognized complication in abdominal surgery. The aim of this paper is to understand the medico-legal issues of iatrogenic splenic injuries. We performed a literature review on PubMed and Scopus using iatrogenic splenic or spleen injury and iatrogenic splenic rupture as keywords. Iatrogenic splenic injury cases were identified. Most cases were related to colonoscopy, but we also identified cases related to upper gastrointestinal procedures, colonic surgery, ERCP, left nephrectomy and/or adrenalectomy, percutaneous nephrolithotomy, vascular operations involving the abdominal aorta, gynecological operation, left lung biopsy, chest drain, very rarely spinal surgery and even cardiopulmonary resuscitation. There are several surgical procedures that can lead to a splenic injury. However, from a medico-legal point of view, it is important to assess whether the cause can be attributed to a technical error of the operator rather than being an unpredictable and unpreventable complication. It is important for the medico-legal expert to have great knowledge on iatrogenic splenic injuries because it is important to evaluate every step of the first procedure performed, how a splenic injury is produced, and whether the correct treatment for the splenic injury was administered in a judgment.
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Affiliation(s)
- Alessandro Feola
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Massimo Niola
- Department of Advanced Biome-dical Sciences, University of Naples “Federico II”, Naples, Italy
| | - Adelaide Conti
- Department of Surgery, Radiology and Public Health, Public Health and Humanities Section, University of Brescia - Centre of Bioethics Research, Italy
| | - Paola Delbon
- Department of Surgery, Radiology and Public Health, Public Health and Humanities Section, University of Brescia - Centre of Bioethics Research, Italy
| | - Vincenzo Graziano
- Department of Advanced Biome-dical Sciences, University of Naples “Federico II”, Naples, Italy
| | | | - Bruno Della Pietra
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
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[Intraoperative complications of the lower gastrointestinal tract : Prevention, recognition and therapy]. Chirurg 2015; 86:319-25. [PMID: 25687814 DOI: 10.1007/s00104-014-2849-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Every surgical intervention is associated with the risk of intraoperative complications. These occur in approximately 2-12% of patients but significantly influence the postoperative outcome, overall complication and mortality rates. This article presents the treatment of typical intraoperative complications during surgery of the lower gastrointestinal tract with a focus on the prevention and identification of risk factors. Especially changes in the regular anatomy caused by previous surgery, inflammation, tumors and emergency situations carry the risk of iatrogenic injuries to the bowels, spleen, ureter and blood vessels. These risk factors must be considered when choosing a surgical procedure, a surgical approach or an appropriate surgeon. The early detection of complications with a definitive restoration is the essential step for a successful treatment without long-term sequelae. Every delay in therapy is associated with an increased morbidity and mortality and should be avoided.
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Isik O, Aytac E, Ashburn J, Ozuner G, Remzi F, Costedio M, Gorgun E. Does laparoscopy reduce splenic injuries during colorectal resections? An assessment from the ACS-NSQIP database. Surg Endosc 2014; 29:1039-44. [PMID: 25159632 DOI: 10.1007/s00464-014-3774-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 07/26/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Nearly half of all incidental splenectomies caused by iatrogenic splenic injury occur during colorectal surgery. This study evaluates factors associated with incidental splenic procedures during colorectal surgery and their impact on short-term outcomes using a nationwide database. METHODS Patients who underwent colorectal resections between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database according to Current Procedural Terminology codes. Patients were classified into two groups based on whether they underwent a concurrent incidental splenic procedure at the time of the colorectal procedure. All splenic procedures except a preoperatively intended splenectomy performed in conjunction with colon or rectal resections were considered as incidental. Perioperative and short-term (30 day) outcomes were compared between the groups. RESULTS In total, 93633 patients who underwent colon and/or rectal resection were identified. Among these, 215 patients had incidental splenic procedures (153 open splenectomy, 17 laparoscopic splenectomy, 36 splenorraphy, and 9 partial splenectomy). Open colorectal resections were associated with a significantly increased likelihood of incidental splenic procedures (OR 6.58, p < 0.001) compared to laparoscopic surgery. Incidental splenic procedures were associated with increased length of total hospital stay (OR 1.25, p < 0.001), mechanical ventilation dependency (OR 1.62, p = 0.02), transfusion requirement (OR: 3.84, p < 0.001), re-operation requirement (OR 1.7, p = 0.005), and sepsis (OR: 2.03, p = 0.001). Short-term advantages of splenic salvage (splenorraphy or partial splenectomy) included shorter length of total hospital stay (p = 0.001) and decreased need for re-operation (p < 0.001). CONCLUSIONS Incidental splenic procedures during colorectal resections are associated with worse short-term outcomes. Use of the laparoscopic technique decreases the need for incidental splenic procedures.
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Affiliation(s)
- Ozgen Isik
- Department of Colorectal Surgery, Digestive Disease Institute, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Van Koughnett JAM, Kalaskar SN, Wexner SD. Pitfalls of laparoscopic colorectal surgery and how to avoid them. COLORECTAL CANCER 2013. [DOI: 10.2217/crc.13.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY Laparoscopic surgery is commonly used for colorectal diseases. Recently, laparoscopy for colorectal carcinoma has increased in use, especially by colorectal surgeons. Laparoscopy is associated with potential pitfalls that pose challenges to the surgeon and team. The identification and management of these pitfalls may not directly parallel those during an open approach. As such, it is essential for the surgeon to have a good working knowledge of how to avoid potential problems and how to best manage them when they do occur. This review highlights common pitfalls of laparoscopic colorectal surgery, as well as offering practical approaches to their management. Technical, patient and surgeon factors are all discussed.
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Affiliation(s)
- Julie Ann M Van Koughnett
- Department of Colorectal Surgery, Cleveland Clinic FL, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
| | - Sudhir N Kalaskar
- Department of Colorectal Surgery, Cleveland Clinic FL, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic FL, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.
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Wang JK, Tollefson MK, Kim SP, Boorjian SA, Leibovich BC, Lohse CM, Cheville JC, Thompson RH. Iatrogenic splenectomy during nephrectomy for renal tumors. Int J Urol 2013; 20:896-902. [DOI: 10.1111/iju.12065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 11/28/2012] [Indexed: 12/01/2022]
Affiliation(s)
- Jeffrey K Wang
- Department of Urology; Mayo Clinic; Rochester; Minnesota; USA
| | | | - Simon P Kim
- Department of Urology; Mayo Clinic; Rochester; Minnesota; USA
| | | | | | - Christine M Lohse
- Department of Health Sciences Research; Mayo Clinic; Rochester; Minnesota; USA
| | - John C Cheville
- Department of Anatomic Pathology; Mayo Clinic; Rochester; Minnesota; USA
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Kosuta M, Cosola D, de Manzini N. Intraoperative Accidents. Updates Surg 2013. [DOI: 10.1007/978-88-470-2670-4_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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