Laparoscopic splenectomy

Outcome of Laparoscopic Splenectomy for Malignant Hematologic Diseases

Aim

The role of laparoscopic splenectomy in the treatment of hematological diseases is still controversial. The aim of this study was to assess whether the benign or malignant nature of hematological diseases may influence the outcome of laparoscopic splenectomy.

Patients and methods

Between August 1997 and March 2002, 63 unselected patients with hematologic diseases underwent a laparoscopic splenectomy. Patients were divided into two groups according to the benign (Group A, 38 patients) or malignant (Group B, 25 patients) nature of the hematological diseases.

Results

Patients in group B were significantly (a) older, (b) had larger spleens that more frequently needed accessory incisions for specimen retrieval, (c) had greater transfusion requirements, and (d) were fed later than patients in group A. There were no statistically significant differences among the two groups in terms of (a) body-mass index, (b) operative time, (c) conversion rate, (d) blood loss, (e) pain medication requirements, and (f) hospital stay. Two postoperative deaths occurred among patients in group B, but none of them was related to surgery.

Conclusions

The results of the study showed that: a) the nature of the disease does not influence the outcome of laparoscopic splenectomy, b) the size of the spleen might increase the risk of conversion, but it is no longer a contraindication to laparoscopic splenectomy, and c) laparoscopic splenectomy can be effectively performed in the treatment of malignant hematologic diseases.

Comparative treatment and literature review for laparoscopic splenectomy alone versus preoperative splenic artery embolization splenectomy

BACKGROUND

Although laparoscopic splenectomy has been gradually regarded as an acceptable therapeutic approach for patients with massive splenomegaly, intraoperative blood loss remains an important complication. In an effort to evaluate the most effective and safe treatment of splenomegaly, we compared three methods of surgery for treating splenomegaly, including open splenectomy, laparoscopic splenectomy, and a combination of preoperative splenic artery embolization plus laparoscopic splenectomy.

METHODS

From January 2006 to August 2011, 79 patients underwent splenectomy in our hospital. Of them, 20 patients underwent a combined treatment of preoperative splenic artery embolization and laparoscopic splenectomy (group 1), 30 patients had laparoscopic splenectomy alone (group 2), and 29 patients underwent open splenectomy (group 3). Patients' demographics, perioperative data, clinical outcome, and hematological changes were analyzed.

RESULTS

Preoperative splenic artery embolization plus laparoscopic splenectomy was successfully performed in all patients in group 1. One patient in group 2 required an intraoperative conversion to traditional open splenectomy because of severe blood loss. Compared with group 2, significantly shorter operating time, less intraoperative blood loss, and shorter postoperative hospital stay were noted in group 1. No marked significant differences in postoperative complications of either group were observed. Compared with group 3, group 1 had less intraoperative blood loss, shorter postoperative stay, and fewer complications. No significant differences were found in operating time. There was a marked increase in platelet count and white blood count in both groups during the follow-up period.

CONCLUSIONS

Preoperative splenic artery embolization with laparoscopic splenectomy reduced the operating time and decreased intraoperative blood loss when compared with laparoscopic splenectomy alone or open splenectomy. Splenic artery embolization is a useful intraoperative adjunctive procedure for patients with splenomegaly because of the benefit of perioperative outcomes.

Laparoscopic splenectomy in patients of β thalassemia: Our experience

BACKGROUND:

Laparoscopic splenectomy has become a standard treatment of various haematological disorders, but its feasibility in the setting of β thalassemia has not been established.

MATERIALS AND METHODS:

Fifty patients of β thalassemia underwent laparoscopic splenectomy between January 2006 and December 2008. “Anterior approach” method was practiced in all cases, with early ligation of splenic artery and delayed ligation of splenic vein. Specimen was extracted piecemeal via the umbilical port in initial 12 cases, while in 37 cases the specimen was extracted through a 7-8-cm pfannenstiel incision. Twelve patients of β thalassemia having grade IV splenomegaly with hepatomegaly were electively operated by conventional open method.

RESULTS:

The procedure was completed in 49 patients. One (2%) patient required conversion to open surgery. Mean operating time in the first 12 cases was 151 minutes (110-210 minutes), while in 37 cases of splenectomy completed laparoscopically it was 124 minutes (80-190 minutes) [P < 0.05]. Mean intra-operative blood loss was 73.8 ml (30–520 ml). No major intra-operative complications occurred. No patient required per-operative blood transfusion. Mean postoperative hospital stay was 4.7 days (2-11 days). Mean preoperative blood transfusion requirement was 11.98 units per patient per year, while mean postoperative blood transfusion requirement was 4.04 units [P< 0.05].

CONCLUSION:

Laparoscopic splenectomy is feasible and safe even in patients of β thalassemia with massive splenomegaly. Removal of specimen via a pfannenstiel incision significantly saves time, carries low morbidity and is a cosmetically acceptable alternative.

Laparoscopic splenectomy is an effective and safe intervention for hypersplenism secondary to liver cirrhosis

BACKGROUND

Laparoscopic splenectomy has become the standard procedure for the normal to moderately enlarged spleens. We performed this study to investigate the safety, feasibility, and effectiveness of laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis.

METHODS

We performed a retrospective chart review of 24 cases of laparoscopic splenectomy (group 1), 24 cases of open splenectomy (group 2) for hypersplenism secondary to liver cirrhosis, and 68 cases of laparoscopic splenectomy for immune thrombocytopenic purpura (group 3). We performed comparisons between groups 1 and 2 and groups 1 and 3 in terms of demographic, intraoperative, postoperative variables, and changes in blood counts and liver function.

RESULTS

Patients in groups 1 and 2 had comparable demographic characteristics, but those in group 1 had less estimated blood loss, fewer complications, and shorter duration of oral intake, and they required less analgesia and shorter post-hospital stays. In both groups, leukocyte and platelet counts increased significantly and transaminase and total bilirubin decreased postoperatively, but not significantly, and there was no significant difference between the two groups. Compared with group 3, patients in group 1 were older, had lower preoperative hemoglobin levels and leukocyte counts, poorer Child-Pugh class, required more operation time, and suffered more estimated blood loss; however, there were no statistically significant differences in terms of conversion rates, transfusion rates, complication rates, and postoperative course.

CONCLUSIONS

Laparoscopic splenectomy is a safe, feasible, and effective procedure for hypersplenism secondary to liver cirrhosis.

Putative predictive parameters for the outcome of laparoscopic splenectomy: a multicenter analysis performed on the Italian Registry of Laparoscopic Surgery of the Spleen

OBJECTIVE

To identify predictive risk factors for conversion to open splenectomy and postoperative complications in patients undergoing elective laparoscopic splenectomy.

BACKGROUND

The laparoscopic approach represents the "gold standard" for splenectomy, but its use in the treatment of splenomegaly and malignant disease is controversial. Factors that influence immediate outcome are clinical, anatomic, and pathologic.

METHODS

Univariate and multivariate analyses of data from the Italian Registry of Laparoscopic Surgery of the Spleen, a multicenter database supported by 25 referral centers. Analysis of data (1993-2007) was performed on a series of patients (n = 676) undergoing elective laparoscopic splenectomy. Demographic data, the operative indications, the surgical technique applied, and any intra- and/or postoperative complications with respect to the patients were assessed. Records were analyzed retrospectively using the Student t test, the chi test, and logistic regression.

RESULTS

Conversion to open splenectomy was necessary in 39 cases (5.8%). Perioperative deaths occurred in 3 cases (0.4%). There were no complications in 560 patients (82.8%), with a mean hospital stay of 5 days (range, 2-54). Overall, morbidity occurred in 116 patients (17.2%). Multivariate analysis found that the body mass index (P = 0.01) and the presence of hematologic malignancy (P < 0.001) were independent predictors for intraoperative complications and surgical conversion. Spleen longitudinal diameter (P = 0.001) and surgical conversion (P = 0.001) were independent predictors for the occurrence of postoperative complications.

CONCLUSIONS

This large multicenter study provides evidence for the significance of predictive risk factors for intra- and postoperative complications in laparoscopic splenic surgery. Besides splenic dimensions, other factors like the patient's habitus and the specific underlying hematologic pathology should be recognized by the surgeon to reduce complications and initiate adequate treatment.

Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

Although laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas still remain controversial. To date, the indications that preclude laparoscopic splenectomy are not clearly defined. In view of this, the European Association for Endoscopic Surgery (EAES) has developed clinical practice guidelines for LS.

METHODS

An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. A consensus development conference using a nominal group process convened in May 2007. Its recommendations were presented at the annual EAES congress in Athens, Greece, on 5 July 2007 for discussion and further input. After a further Delphi process between the experts, the final recommendations were agreed upon.

RESULTS

Laparoscopic splenectomy is indicated for most benign and malignant hematologic diseases independently of the patient's age and body weight. Preoperative investigation is recommended for obtaining information on spleen size and volume as well as the presence of accessory splenic tissue. Preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections is recommended in elective cases. Perioperative anticoagulant prophylaxis with subcutaneous heparin should be administered to all patients and prolonged anticoagulant prophylaxis to high-risk patients. The choice of approach (supine [anterior], semilateral or lateral) is left to the surgeon's preference and concomitant conditions. In cases of massive splenomegaly, the hand-assisted technique should be considered to avoid conversion to open surgery and to reduce complication rates. The expert panel still considered portal hypertension and major medical comorbidities as contraindications to LS.

CONCLUSION

Despite a lack of level 1 evidence, LS is a safe and advantageous procedure in experienced hands that has displaced open surgery for almost all indications. To support the clinical evidence, further randomized controlled trials on different issues are mandatory.

Splenectomy for immune thrombocytopenic purpura: surgery for the 21st century

Although immune thrombocytopenic purpura (ITP) is the most common autoimmune hematological disorder, there is still controversy regarding the optimal management of this condition. Medical therapy may cure a proportion of patients with ITP but there are still a significant number of these individuals who are at risk for bleeding events. Surgery has become the least popular therapeutic option for ITP as other medical therapies have become available that attempt to avoid splenectomy and its morbidity. However, the clinical response to these therapies has not been overwhelming based on the fairly small number of trials conducted to date. With current minimally invasive surgical techniques, splenectomy should be again regarded as a viable therapeutic option in patients with ITP. The laparoscopic approach avoids much of the morbidity and complications seen with the conventional open surgical approach and studies have demonstrated similar, if not better, outcomes. In addition, the risk of infection following splenectomy is not as high as may be suspected, particularly with current vaccination regiments. It should be a priority for both the hematology and medical community to advocate for clinical trials to rationally study alternatives to splenectomy. In the interim, laparoscopic splenectomy should be considered as an additional front line therapeutic option in ITP patients.

Laparoscopic colon surgery in community practice

BACKGROUND

The benefits of laparoscopic colon surgery have been shown in the literature. More recently, the oncologic outcomes have been shown to be similar in the laparoscopic group when compared with open colon surgery for colon cancer. However, most of the published literature is from university/academic institutions. There is limited literature on laparoscopic colon surgery from a community hospital.

METHODS

A retrospective chart review was conducted of 62 laparoscopic colon surgeries from a single surgeon's practice in a community hospital from October 27, 2003, to August 31, 2006. The laparoscopic approach was performed on patients with benign and curative colon cancer. The primary outcome measures were length of operating room times, pathologic results, length of hospital stay, and complication rates.

RESULTS

Of the 62 laparoscopic patients, there were 9 converted patients (14% conversion rate). There were no perioperative deaths, and no anastomotic leaks. The average length of operating room time was 190 minutes (range, 96-295 min). The median length of hospital stay was 4 days (range, 3-17 d). There were 40 laparoscopic patients for colon cancer. The resection margins all were negative, and the mean number of lymph nodes in the resected specimen was 17 (range, 5-37). The overall complication rate was 18%.

CONCLUSIONS

This study showed that laparoscopic colon surgery is technically feasible in a community hospital. The results from this study are similar to the published literature from university/academic institutions.

Laparoscopic splenectomy for hematologic diseases: a preliminary analysis performed on the Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS)

BACKGROUND

The Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS) was developed to provide at the national level an informative tool useful for performing multicenter studies in the field of spleen laparoscopic surgery. In this first study analyzing the IRLSS data, a cohort of patients with hematologic diseases was retrospectively investigated for potential predictive parameters that could affect the outcome of laparoscopic splenectomy.

METHODS

A total of 309 patients who underwent laparoscopic splenectomy for hematologic diseases in 17 Italian centers (between February 1, 1993, and September 30, 2004) were entered in the IRLSS. Their records were analyzed retrospectively by the Student's t-test, chi-square, and logistic regression.

RESULTS

The mean operative time was 141 min (range, 30-420 min). Conversion was necessary in 21 cases (7%), and approximately 1 accessory spleen in 25 patients (9%) was found. The mean spleen weight was 1191 g (range, 85-4,500 g). Perioperative death occurred in two cases (0.6%). No complications were experienced by 253 patients (81.9%), who had a mean hospital stay of 5.4 days (range, 2-30 days). Overall morbidity occurred in 56 patients (18.1%), mainly associated with transient fever (n = 22), pleural effusion (n = 13), and actual or suspected hemorrhage (n = 12), requiring a reintervention for 7 patients. Multivariate analysis found that body mass index (p = 0.024) and clinical indication (p = 0.004) were independent predictors for surgical conversion. The clinical indication was almost significant as an independent predictor for the occurrence of postoperative complication (p = 0.05).

CONCLUSIONS

This first study analyzing the IRLSS data shows that laparoscopic splenectomy may represent the gold standard treatment for hematologic diseases with normal-size spleen. The low morbidity and mortality rate suggests that laparoscopic splenectomy can be successfully proposed also for splenomegaly in hematologic malignancies.

Splenic artery embolization before laparoscopic splenectomy in children

BACKGROUND

This study assessed the safety and utility of preoperative splenic artery embolization before laparoscopic splenectomy in children.

METHODS

Five young girls with a mean age of 13.2 years underwent laparoscopic splenectomies at the authors' institution from August 1998 to April 2003. Three of the patients had idiopathic thrombocytopenic purpura, and two had hereditary spherocytosis. Preoperative splenic artery embolization was performed the day before the surgery in all cases. The laparoscopic splenectomy was performed using traditional laparoscopic procedures and standard laparoscopic instruments with the patient in the right semilateral position.

RESULTS

The mean spleen weight was 252.6 g, and the mean length was 11.6 cm. All the patients reported postembolic pain, but not to a level unmanageable by intravascular narcotics. There were no severe complications in the splenic artery embolization. The laparoscopic splenectomies were completed in a mean of 211 min, with a mean estimated blood loss of 9 ml. None of the operations required conversion to traditional open laparotomy, and none of the patients died or experienced operative complications.

CONCLUSION

The authors concluded that splenic artery embolization is safe and useful as an adjuvant procedure performed before elective laparoscopic splenectomy in children.

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura

BACKGROUND

Laparoscopic splenectomy (LS) has become the treatment of choice for patients with idiopathic thrombocytopenic purpura (ITP) who do not respond to medical treatment. Long-term follow-up data of LS for ITP are scarce.

METHODS

From May 1997 to December 2002, we performed 67 LS for patients with ITP. Data were assessed retrospectively.

RESULTS

LS was successfully attempted in all 67 patients. There was no surgical mortality. Three postoperative complications (5%) were encountered. The mean operative time decreased significantly from 176.2 minutes in the first 41 cases to 125.2 minutes in the last 26 cases. The mean postoperative hospital stay was 3.2 days. Accessory spleens were found in 3 patients (5%) during the LS. The mean follow-up interval was 23.3 months. The initial response to LS was 83%, and overall remission of ITP was 74%. The preoperative effect of steroid therapy had no significant influence on postoperative remission rate. More significant indicators of LS effectiveness were either an immediate postoperative platelet count surge or an immediate postoperative platelet count >or=100000/microL.

CONCLUSIONS

LS can be performed safely with a satisfactory remission rate for patients with ITP who do not respond to medical treatment. Our results indicated that an immediate postoperative platelet count surge and/or an immediate postoperative platelet count >or=100000/microL were positive predictors of long-term remission after LS for ITP.

Esplenectomia laparoscópica

OBJETIVO: O objetivo do presente estudo é avaliar a segurança e as complicações relacionadas à esplenectomia laparoscópica. MÉTODO: Análise retrospectiva dos pacientes submetidos à esplenectomia laparoscópica entre janeiro de 1998 e março de 2003. RESULTADOS: Trinta e cinco pacientes (22 mulheres e 13 homens) foram submetidos a esplenectomia laparoscópica. As indicações cirúrgicas para esplenectomia foram: púrpura trombocitopênica idiopática (29 pacientes), linfoma (3), anemia hemolítica (2) e esferocitose (1). O tamanho médio do baço foi de 12cm (entre 7 e 27cm) e o peso médio 262gr (entre 30 e 1850gr). Baço acessório foi encontrado em seis pacientes (17%). O tempo cirúrgico médio foi de 195 minutos (entre 120 e 270 minutos). Houve três casos (8%) de sangramento intra-operatório, resultando em dois casos de conversão. Outros dois casos de conversão ocorreram por espaço inadequado em pacientes com baço gigante, 24 e 27cm. Complicações pós-operatórias ocorreram em três pacientes (8%). O tempo médio de internação hospitalar foi de 1,7 dia (entre 1 e 7dias). CONCLUSÕES: A esplenectomia laparoscópica é segura e está associada à baixa taxa de complicações e curto período de hospitalização. Fatores limitantes são a experiência do cirurgião, obesidade do paciente e esplenomegalia.

Does the Early Ligation of the Splenic Artery Reduce Hemorrhage During Laparoscopic Splenectomy?

The aim of this study was to investigate whether early ligation of the splenic artery before splenic lysis has an effect on the amount of intraoperative bleeding and conversion rate during laparoscopic splenectomy. Laparoscopic splenectomy was performed in 34 patients with hematological diseases or splenic cysts between January 1993 and January 2003. The splenic artery was ligated before manipulation of the spleen in 22 patients (group 1) and laparoscopic splenectomy was performed with no previous ligation of the splenic artery in 12 patients (group 2). Prospective data was collected and the groups compared regarding intraoperative blood loss, platelet count, operative time, hospital stay, and conversion rate. Laparoscopic splenectomy was successfully completed in 30 (88%) patients. One patient in group 1 (5%) and 3 patients in group 2 (25%) required conversion due to bleeding. Estimated average blood loss was 161 mL (range 70-450 mL) in group 1, and 292 mL (range 100-700 mL) in group 2 (P < 0.001). The average operative time was 140 minutes (range 80-240) in group 1, and 155 minutes (range 80-200) in group 2 (P > 0.05). There were no statistically significant differences between the two groups comparing splenic size, conversion rate, hospital length of stay and platelet count. Early ligation of the splenic artery is feasible, safe and effective and may provide easy dissection and manipulation of the spleen during laparoscopic splenectomy with decreased intraoperative blood loss and no extension of the operative time.

Perioperative outcomes of laparoscopic versus open splenectomy: a meta-analysis with an emphasis on complications

BACKGROUND

The purpose of this study was to analyze the published perioperative results of laparoscopic splenectomy (LS) compared to open splenectomy (OS), and to determine the impact of LS on the incidence and type of splenectomy-related complications.

METHODS

Perioperative results and complications were tabulated from all English-language reports of LS from 1991 through 2002, and complications were analyzed further by type. Data were taken from 26 series that compared OS to LS within an institution (paired analysis) and from an additional 25 series of only LS (unpaired analysis), and a meta-analysis was performed.

RESULTS

A total of 2940 patients from 51 published series were included (LS, 2119 patients; OS, 821 patients). Age, gender, and American Society of Anesthesiologists class were similar. In the analysis of paired OS and LS studies, the mean operative time for LS was significantly longer (LS, 180 minutes; OS, 114 minutes; P<.0001,) but the postoperative hospital stay was shorter (LS, 3.6 days; OS, 7.2 days; P<.001). Accessory spleens were identified in 11% of cases in both groups. The total complication rate for LS was 15.5%, compared with 26.6% for OS (P<.0001). LS was associated with significantly fewer pulmonary, wound, and infectious complications (P<.001 for all) but with more hemorrhagic complications, when conversions for bleeding were included. Mortality rates for LS and OS were similar (OS, 1.1%; LS, 0.6%; P=not significant). Comparable results were obtained when the unpaired LS series were added to the analysis.

CONCLUSIONS

Although operative times are longer for LS than OS, LS is associated with a significant reduction in splenectomy-related morbidity, primarily as a function of fewer pulmonary, wound, and infectious complications.

Accuracy of laparoscopy in the diagnosis and staging of lymphoproliferative diseases

Laparoscopy seems to be playing an emerging role in the management of lymphoproliferative diseases. The aim of this study was to prospectively analyze personal experience evaluating the role and limits of laparoscopy in the management of lymphomas. From July 1993 to December 2000, 131 consecutive patients were referred to our institution for primary diagnosis (group A, n = 70), suspected relapse (reassessment) (group B, n = 54), or staging/restaging of lymphoproliferative diseases (group C, n = 7). Diagnostic and/or operative laparoscopy was performed in all patients. To assess the accuracy of laparoscopy, the results were analyzed according to the indications for surgery. In all, 128 procedures were completed laparoscopically (95.5%). Conversion was required in 7 cases (5.1%). Causes of the conversions were severe obesity (body mass index 62.5), uncontrolled intraoperative bleeding (HIV+), nondiagnostic tissue sampling (2 cases), perisplenic inflammation and perisplenic abscesses (3 cases). The results of this study highlight the safety of diagnostic and staging laparoscopy and laparoscopic splenectomy in patients with lymphoproliferative diseases (major complications 2.9%, perioperative mortality 0%). In all, 96.4% of patients from group A and 100% of patients from group B were treated on the basis of laparoscopic findings. No false negative diagnosis occurred. Laparoscopy may become the "gold standard" in the management of lymphoproliferative disease in the following settings: for the differential diagnosis of hepatic and/or splenic focal lesions; when percutaneous needle biopsy fails and/or genetic analysis is needed for therapeutic decision; for the primary diagnosis and abdominal staging of patients with diffuse retroperitoneal lymphadenopathy in the absence of peripheral lymphadenopathy; for cases of abdominal restaging after concurrent chemoradiotherapy and in cases of suspected relapse when percutaneous biopsy is not technically possible; and for patients with lymphoproliferative disease when splenectomy is required. Marked splenomegaly with perisplenic inflammatory reaction and lymphadenopathy in HIV+ patients should be considered possible causes of failure of the laparoscopic approach.

Technical developments and a team approach leads to an improved outcome: lessons learnt implementing laparoscopic splenectomy

BACKGROUND

To document the technical aspects, outcome and lessons learnt during the learning curve phase of implementing laparoscopic splenectomy, by comparing the results before and after the introduction of a standardized technique.

METHODS

We present a retrospective and prospective review of laparoscopic splenectomies over a 4-year period. Two chronological periods were studied, before and after the implementation of a standardized technique of a laparoscopic splenectomy involving: (i) hilar dissection with ultrasonic shears; (ii) two experienced laparoscopic surgeons; and (iii) trained dedicated equipment and staff using a checklist approach in the preparation and conduct of the operation. Two groups of patients were studied relating to the periods before and after the implementation of a standardized technique. Statistical methods used were the Wilcoxon's rank sum test and the two-sample test.

RESULTS

Thirty-one laparoscopic splenectomies were attempted. The most common indication was for idiopathic thrombocytopenic purpura. When comparing the early phase (n = 15) with the standardized technique phase (n = 16), there was a significant reduction in conversion rates (40% vs 6%), operating times (218 min vs 171 min), complication rates (6 cases including 1 death vs none) and length of stay (11 days vs 4 days). The results were significant for reduction in hospital stay, conversion rates and complications rates.

CONCLUSIONS

A reduction in conversion rates, operating time, morbidity and length of stay was realized during the learning curve of implementing laparoscopic splenectomy by adopting a standardized technique. This technique involved hilar dissection using the ultrasonic shears, two experienced laparoscopic surgeons performing the surgery, dedicated equipment and trained staff using the checklist approach. We recommend such a standardized technique in performing laparoscopic splenectomy.

Laparoscopic splenectomy for hematological diseases

BACKGROUND

We reviewed retrospectively the records of all patients who underwent laparoscopic splenectomy (LS) at our institution for a wide range of hematological disorders. We compared our experience to those reported in the literature and analyzed various aspects of the treatment that are still under discussion and in need of confirmation, such as the treatment of malignant blood diseases, the indication in case of splenomegaly, and the adequacy of the detection of accessory spleens.

METHODS

Between June 1997 and June 2001, we performed 43 LS. The patients were classified into three groups according to clinical diagnosis: idiopathic thrombocytopenic purpura (ITP) (n = 23), hemolytic anemia (HA) (n = 5), and hematological malignancy (HM) (n = 15). Statistical analyses were done to compare the three groups.

RESULTS

LS was completed in 41 patients, with a conversion rate of 5%. Splenomegaly was present in 37% of all patients (73% of HM). Mean operative time was 128 min. The incidence of accessory spleens was 20%. A concomitant laparoscopic procedure was done in three cases (cholecystectomy). Postoperative complications occurred in eight patients (18%). Duration of surgery, length of hospital stay, transfusions rate, and some demographics features, such as age and spleen weight and length, were significantly different in each group. No deaths were attributed to the procedure.

CONCLUSIONS

The statistical analysis of our series shows that, the laparoscopic approach reliable even in the management of malignant and nonmalignant blood diseases.

Laparoscopic splenectomy

PURPOSE

To study the safety and efficacy of laparoscopic splenectomy (LS) in patients with hematologic disorders requiring surgical intervention.

PATIENTS AND METHODS

A series of 103 consecutive adult patients underwent LS between 1992 and 1997 at our teaching hospital. Data were collected prospectively. The indications for splenectomy included idiopathic thrombocytopenic purpura (ITP), hereditary spherocytosis, autoimmune hemolytic anemia, and thrombotic thrombocytopenic purpura.

RESULTS

The mean spleen size was 14 cm (range 8.5-24 cm) and the mean weight was 263 g (range 40-210 g). Accessory spleens were detected in 12 patients with ITP and 17 patients in the study overall. In 12 patients, LS was combined with a laparoscopic cholecystectomy for gallstones. There were four conversions to open splenectomy, all for hemorrhage and all occurred in the first 50 patients. We have not converted a single patient in the last 2 years. The mean operative time was 161 minutes and was greater in the first 10 cases than the last 10. There were no deaths. Postoperative complications occurred in six patients, one necessitating a second procedure for a small-bowel obstruction. The average length of stay in the hospital was 2.5 days. After surgery, thrombocytopenia resolved in 84% of patients with ITP and anemia resolved in 92% of the patients with hereditary spherocytosis. After a mean follow-up of 38 months (range 2-565 months), four patients (6%) showed a relapse of ITP, three within 12 months of surgery.

CONCLUSIONS

Laparoscopic splenectomy can be performed safely and effectively in a teaching institution. LS in comparison with open surgery offers the same efficacy in the control of hematologic disease with the additional benefits of a minimally invasive approach. Laparoscopic splenectomy should therefore be considered the technique of choice and should prompt earlier consideration of surgery for patients with selected hematologic disorders.

Mini-laparoscopic splenectomy

BACKGROUND AND PURPOSE

Since the introduction of mini-laparoscopic instruments (2- to 3-mm diameter), their utility and safety have been questioned. Their application in cholecystectomy has recently been documented. This study determined the adequacy and safety of these minimally invasive instruments in laparoscopic splenectomy.

METHODS

Retrospective review of all 16 mini-laparoscopic splenectomies performed by the authors was carried out. Diagnoses included immune thrombocytopenia (5), spherocytosis (6), and beta-thalassemia, sickle-cell disease, splenic mass, cyst, and splenomegaly in 1 case each. The average age of the patients was 20.1 years (range 4-70 years); seven patients were adults. Ten of the patients were female. The patients' body mass index ranged from 17 to 25 kg/m2. Splenomegaly (at least two times normal size: 100-200 g for children, 400-600 g for adults) was present in each case. A three-trocar technique was used in 15 patients, and a fourth trocar was required in only one case.

RESULTS

The average operative time and blood loss were 114 minutes (range 60-195 minutes) and 44 mL (range 10-150 mL), respectively. There were no intraoperative complications, and no patient required transfusion. Conversion to standard laparoscopy or laparotomy did not occur. The mean hospital stay was 1.4 days (range 1-2 days). With an average 20-month follow-up, no wound, septic, or other complications have been identified. All patients or their families (in the case of children) graded the cosmetic outcome as excellent.

CONCLUSION

The use of mini-laparoscopic instruments for splenectomy is safe and effective in children and adults with a normal body mass index, even in the case of splenomegaly. Operative times are reasonable, and hospital stays are brief. The postoperative cosmetic appearance is excellent.

Safety of Laparoscopic Splenectomy in Elderly Patients with Idiopathic Thrombocytopenic Purpura

Laparoscopic splenectomy (LS) for immune thrombocytopenic purpura (ITP) is very successful. However, the safety of LS in older patients who have less cardiac and pulmonary reserve has not been studied. Our objective was to compare results of LS in elderly and younger patients with ITP. LS performed for ITP between 1992 and 1999 were studied. Perioperative data were collected concurrently. Follow-up was obtained by chart review and phone interview. Groups were arbitrarily divided: Group A, age ≥70; group B, age <70. Main outcome measures were platelet response, duration of operation, hospitalization, blood loss, and complications were compared using t test and Chi-square analyses. Group A had more comorbid conditions (80% vs 28%, P = 0.04). Operative time (80 vs 119 minutes, P = 0.23), estimated blood loss (156 vs 189 cm3, P = 0.62), and hospitalization (3.6 vs 2.8 days, P = 0.23) were similar for both groups. Although group B had significantly more patients with an early platelet response (70% vs 97%, P = 0.02), there was no difference in platelet response at long-term follow-up (70% vs 84%, P = 0.22). Long-term follow-up was completed on 87 per cent of patients at an average of 43 months postoperatively. We conclude that LS is safe and effective in elderly patients with ITP.

Laparoscopic splenectomy

Laparoscopic splenectomy can be taught and performed safely. It presents less significant morbidity than does open surgery, and efficacy in the control of hematologic disease is comparable while offering the proven benefits of the minimally invasive approach. Laparoscopic splenectomy for selected hematologic disorders should replace open splenectomy as the technique of choice and prompt earlier consideration of surgery when it is indicated.

Laparoscopic versus open splenectomy in children

BACKGROUND

The authors have reviewed their initial experience with laparoscopic splenectomy (LS) to identify the indications, success rate, and complications associated with this procedure compared with a series of children undergoing open splenectomy (OS) during the same time period.

METHODS

The records of 51 children who underwent splenectomy from 1993 through 1998 were reviewed retrospectively.

RESULTS

Thirty-five patients aged 1 to 17 years (mean, 9.4 years) underwent LS for the following indications: ITP (n = 20), sickle cell disease or thalassemia (n = 6), hereditary spherocytosis (n = 5), other hematologic disorders (n = 4). Seventeen patients aged 2 to 17 years (mean, 11.8 years) underwent OS during the same time period for ITP (n = 4), sickle cell disease or thalassemia (n = 4), hereditary spherocytosis (n = 5), and other indications (n = 4). Concomitant cholecystectomy was performed in 4 of 35 LS and 4 of 17 OS. Accessory spleens were identified in 10 of 35 LS and 2 of 17 OS cases. Eleven spleens were enlarged in the LS group, and 8 were enlarged in the OS group. One LS required conversion to an open procedure because the spleen did not fit in the bag. No other cases were converted. Median estimated blood loss was 50 mL for both the LS and OS groups. The only intraoperative complication in the LS group was a splenic capsular tear, which had no effect on the successful laparoscopic removal of the spleen. No patient in either group required a blood transfusion. The LS patients had a shorter length of hospital stay (1.8 +/- 1 versus 4.0 +/- 1 day, P = .0001). Total hospital charges were not significantly different. Follow-up ranged from 6 to 40 months. One LS patient died 47 days postoperatively from unrelated causes. Two LS patients had recurrent ITP; accessory spleens were found in one and resected laparoscopically.

CONCLUSION

LS in children can be performed safely with a low conversion rate (2.9%) and is associated with a shorter hospital stay and comparable total hospital cost when compared with OS.

Laparoscopic splenectomies for idiopathic thrombocytopenic purpura: experience of sixty cases

We performed a laparoscopic splenectomy (LS) in 60 patients (age 9-83, 45 females) with idiopathic thrombocytopenic purpura (ITP) who did not achieve sustained remission on steroid therapy. Using a modified procedure, the mean duration of LS was 78 min (range 25-240 min) and surgery was associated with only 5% major and 5% minor complications. Ten patients had a platelet count less than 50 x 10(9)/l during surgery despite the administration of immune globulin (0.4 g/kg x 3-5 days) or pulsed oral dexamethasone (40 mg/day x 4 days). Three patients were refractory to these therapies and underwent LS with a platelet count less than 5 x 10(9)/l. Bleeding complications during or after surgery were rare (5%). Accessory spleens were removed in eight patients. Convalescence was rapid and the mean hospital stay was 2.3 days (range 1-7 days). The patients were followed for a mean of 16 months (range 1-36 months), and 49 patients (84%) are in complete remission. Seven patients (12.5%) relapsed despite an initial good response in 6 of them. Two patients underwent laparoscopic removal of accessory spleens with excellent response. We conclude that LS for ITP is safe and effective and associated with low morbidity and fast recovery. Thus, LS may be considered earlier in the course of ITP.

A learning curve for laparoscopic splenectomy at an academic institution

BACKGROUND

Laparoscopic splenectomy is emerging as the standard for treatment of benign splenic disorders. Since splenectomy is indicated relatively infrequently, issues arise concerning training of surgeons to perform laparoscopic splenectomy. Our experience with 50 laparoscopic splenic procedures is reported with emphasis on the learning curve at an academic institution.

MATERIALS AND METHODS

Data were prospectively collected on 50 consecutive patients undergoing attempted or successful laparoscopic surgical procedures on the spleen at Northwestern Memorial Hospital or The Chicago Health Care System, Lakeside Division, from April 1993 to April 1998, and on 5 patients undergoing open splenectomy from April 1993 to October 1995. Outcomes including conversion rate, operative time, day feedings were tolerated, and length of hospital stay was examined and correlated with the number of attempted cases.

RESULTS

Laparoscopic splenectomy progressed from an operation requiring two advanced laparoscopic surgeons to one performed by carefully supervised senior residents. Success rates increased from 60% initially to greater than 95% recently. Likewise, operative time decreased significantly from 195 to 97 min, while length of stay declined from 2.5 to 1.5 days. High success rates, low operative times, and short length of stays were achieved during the last 20 patients while surgical residents were taught to perform the procedures. The reasons for improvement are multifactorial including use of the harmonic scalpel, a change to the lateral position, and increasing experience with the procedure.

CONCLUSIONS

Laparoscopic splenectomy is a safe and effective procedure that reduces postoperative length of hospital stay. It can be performed successfully in most patients with operative times comparable to those of open splenectomy. Moreover, the procedure can (and should) be taught to residents once they master basic and advanced laparoscopic skills.

Laparoscopic versus open splenectomy in the management of splenomegaly: our preliminary experience

BACKGROUND

Laparoscopic splenectomy for normal-sized spleens has several advantages compared with laparotomy. Only a few cases of splenomegaly done by laparoscopy are reported in the literature. The purpose of this study is to show that laparoscopy for splenomegaly is feasible and has several advantages over the open operation.

METHODS

We performed retrospective chart review of 8 cases of splenomegaly managed by laparoscopy (group 1), 15 cases of open splenomegaly (group 2), and 27 cases of laparoscopic splenectomy for normal-sized spleens (group 3). Comparison has been done between groups 1 and 2 and groups 1 and 3 in terms of operative time, intraoperative estimated blood loss, need for blood transfusion, postoperative ileus, postoperative stay, and mortality and morbidity rates.

RESULTS

Patients in group 1 required longer operative time and significantly less intraoperative blood transfusion compared with group 2. The postoperative course was less complicated and shorter in group 1 than in group 2. Operative time was longer in group 1 compared with group 3. No significant differences in terms of postoperative course have been found between groups 1 and 3.

CONCLUSIONS

Laparoscopy for splenomegaly is a feasible, effective, and safe technique for experienced laparoscopic surgeons. This approach seems to have several advantages over the open operation. Prospective, randomized trials would be required for a proper quantitative evaluation.

Laparoscopic splenectomy: outcome and efficacy in 103 consecutive patients

OBJECTIVE

To study the safety and efficacy of laparoscopic splenectomy (LS) in patients with predominantly benign hematologic disorders.

SUMMARY BACKGROUND DATA

The technical feasibility of LS has been recently established. However, data regarding the efficacy of the procedure in a large cohort of patients are scarce.

METHODS

One hundred three consecutive patients underwent LS between June 1992 and October 1997. Data were collected prospectively on all patients.

RESULTS

Indications were idiopathic thrombocytopenic purpura (ITP), hereditary spherocytosis, autoimmune hemolytic anemia, thrombotic thrombocytopenic purpura, and others. Mean spleen size was 14 cm and mean weight was 263 g. Accessory spleens were found in 12 patients with ITP and in 5 patients without ITP. There were no deaths. Complications occurred in six patients, one requiring a second procedure for small bowel obstruction. Six patients received transfusions, and four procedures were converted to open splenectomy for bleeding. Mean surgical time was 161 minutes and was greater in the first 10 cases than the last 10. Mean postsurgical stay was 2.5 days. Thrombocytopenia resolved after surgery in 84% of patients with ITP, and hematocrit levels increased significantly in 70% of patients with chronic hemolytic anemias. A positive response was noted in 92% of patients with hereditary spherocytosis, without relapse for the duration of the observation. ITP relapsed in four patients during follow-up, three within 12 months.

CONCLUSIONS

LS can be performed safely and effectively in a teaching institution. Rigorous technique will minimize capsular fractures, reducing the risk of splenosis. Accessory spleens can be successfully localized, thus improving response and limiting recurrence of ITP. LS should become the technique of choice for treatment of intractable benign hematologic disease.

Laparoscopic or open splenectomy for hematologic disease: which approach is superior?

BACKGROUND

This study was undertaken to compare safety, outcome, and costs of laparoscopic (LS) and open splenectomy (OS) for a variety of hematologic diseases.

STUDY DESIGN

The records of 137 patients who underwent splenectomy (63 LS and 74 OS) at a large private teaching hospital between March 1991 and April 1996 were reviewed retrospectively. Diagnosis, age, gender, operative time, blood loss, splenic weight, time to resumption of oral diet, postoperative hospital stay, morbidity, mortality, and costs (direct and operative) were analyzed by multivariate statistical analysis.

RESULTS

Laparoscopic splenectomy patients had significantly shorter hospitalization and time to resumption of an oral diet (p < 0.01); although operative costs were higher, total direct costs were not. Idiopathic thrombocytopenic purpura patients had earlier resumption of an oral diet after LS, shorter postoperative stay, and comparable OR time. Five patients (7%) were converted, with outcomes similar to OS except for greater operative time and cost. Grade II complications occurred in three LS and four OS patients; Grade III in three OS patients; and Grade IV in two OS patients. There were two major complications of LS and eight of OS, with two deaths. Multivariate analysis showed that operative time and time to resumption of oral intake were significantly related to age, diagnosis, operative technique, and splenic weight. Duration of postoperative hospitalization was related to operative technique, splenic weight, and major complications. Costs (direct and operative) were related to age, splenic weight, and major complications, but not to operative technique.

CONCLUSIONS

LS results are influenced by splenic weight, disease, and age. Splenic weight appears to be the crucial determinant of operative time and length of hospitalization. LS is a superior treatment for patients with idiopathic thrombocytopenic purpura and patients with small spleens.

Comparison of laparoscopic and open splenectomy in children with hematologic disorders

OBJECTIVE

To compare laparoscopic and traditional open splenectomy in children with nonmalignant hematologic disorders.

STUDY DESIGN

Retrospective review of 36 consecutive nonrandomized splenectomies (16 laparoscopic and 20 open) performed for hematologic disorders at a single pediatric institution during the past 3 years. The two-sided Mann-Whitney U test for non-parametric variables was used for statistical analysis.

RESULTS

An open procedure was performed on 20 patients (mean age, 9.7 years), five of whom had a concomitant cholecystectomy. A laparoscopic splenectomy was performed on 16 children (mean age, 10.3 years), seven of whom had a concomitant cholecystectomy. The mean anesthesia and operative times were longer in the laparoscopic than in the open group (p < 0.001). However, the mean number of hours of postoperative analgesia was less in the laparoscopic group (p < 0.005). Patients who had laparoscopic splenectomy were also discharged home earlier (p < 0.01) and resumed a regular diet sooner. Mean operating room charges were higher in the laparoscopic group (p < 0.001), but total hospitalization costs were not significantly different. Postoperative complication rates were similar. The hematologic response was comparable.

CONCLUSIONS

laparoscopic splenectomy is feasible and safe in children with hematologic disorders. Although it currently requires more operative time than the open approach, it is superior with regard to duration of postoperative analgesia, duration of hospital stay, and recovery of bowel function.

The lateral approach to laparoscopic splenectomy

BACKGROUND

Laparoscopic splenectomy has been shown to result in shorter hospital stays and a quicker return to work than conventional splenectomy. Having tried the anterior 5 trocar approach, we developed a 4 trocar lateral approach and now present our experience with 22 cases.

METHODS

All patients were placed in the right lateral decubitus position. A 10-mm trocar was inserted in the left subcostal region, 2 in the flank, and a 5-mm trocar dorsally. A 30 degrees laparoscope was used. Splenectomy was performed for varying pathologies.

RESULTS

Operating room (OR) time averaged 169 minutes, spleen weight 513 grams, and postoperative (post-op) stays 5.4 days (median 3 days). One patient was converted to laparotomy. There were no deaths, post-op abscesses, pancreatic injuries, or bleeding complications.

CONCLUSIONS

The lateral approach affords superior exposure, allowing easier dissection of splenic hilar structures. Over varying patient habitus and spleen size it has been demonstrated to be the approach of choice for laparoscopic splenectomy.

Laparoscopic splenectomy by the lateral approach: a safe and effective alternative to open splenectomy for hematologic diseases

BACKGROUND

The purpose of this study was to compare the clinical outcomes and expense of laparoscopic splenectomy by the lateral approach with open splenectomy for the treatment of hematologic diseases.

METHODS

Medical records of 20 matched patients undergoing open splenectomy and lateral approach laparoscopic splenectomy were retrospectively reviewed detailing perioperative course, clinical outcome, and hospital charges.

RESULTS

Patients undergoing laparoscopic splenectomy (n = 10) experienced longer anesthesia (324 versus 176 minutes; p < 0.05) and operative times (261 versus 131 minutes; p < 0.05) than those undergoing open splenectomy (n = 10). No difference was noted in both intraoperative and postoperative packed red blood cells transfused. Laparoscopic splenectomy resulted in a shorter duration of nasogastric decompression (1.2 versus 2.6 days), more rapid resumption of normal oral intake (1.9 versus 4.4 days), and earlier hospital dismissal (3.0 versus 5.8 days). Although hospital charges were not significantly higher in the laparoscopic group ($17,071.00 versus $13,196.00; p > 0.05), operative charges were always significantly higher.

CONCLUSIONS

When compared with open splenectomy, lateral approach laparoscopic splenectomy allows a more rapid return of normal gastrointestinal function and shorter hospital stay. The operative expense of laparoscopic splenectomy is significantly higher; however, the overall hospital expense is not. If costs can be decreased, the lateral approach laparoscopic splenectomy will be the preferred operative approach.

Laparoscopic splenectomy for immune thrombocytopenic purpura

Splenectomy is an effective treatment for immune thrombocytopenic purpura (ITP). The recent advances in laparoscopic technique and technology have made laparoscopic splenectomy a viable option. Over 36 months we performed a total of 17 laparoscopic splenectomies, 15 of them for ITP and 2 for familial spherocytosis. We present our initial experience with laparoscopic splenectomy in 15 patients (age 16-71 years) with ITP. Operations were performed 2-24 months after the establishment of the diagnosis and initiation of appropriate therapy. Technically, the splenic artery was clipped first; the lower pole of the spleen and its posterolateral attachments were dissected using endoclips and electrocautery; the hilum and short gastric vessels were separated using an endostapler; the spleen was placed in a plastic bag, its opening pulled out through the umbilical incision, and the spleen fragmented and aspirated out of the bag. Operations lasted 100-300 min (mean 170 min). No patient required blood transfusion. The postoperative course was uneventful in all patients with minimal requirement of analgesia and early return to normal activity. Platelet counts returned to normal in all patients in a follow-up period of 2-36 months. Laparoscopic splenectomy is safe and effective for patients with ITP because of reduced operative trauma, less postoperative pain, cosmetic advantage, and possibly less postoperative complications.

Pediatric laparoscopic splenectomy using the lateral approach

Laparoscopic splenectomy in children has been shown to be safe, to reduce postoperative pain and hospital stay, and to accelerate return to full activities. We describe our experience with a four-port "lateral" approach in 18 patients. Patients were placed in the lateral decubitus position and the table was flexed to separate the left subcostal margin and iliac crest. The camera port was inserted at the umbilicus and additional ports were placed in the epigastrium and left lower quadrant. After mobilization of the splenic flexure a port was inserted in the left flank below the 12th rib for elevation of the spleen. A 30 degrees laparoscope was used and the splenic vessels were controlled with an endo-GIA and/or clips. The spleens were placed in a bag, morcellated, and extracted through a port site. Eight females and 10 males with a median age of 12.5 years (5-17 years) and weight of 55.5 kg (17-124 kg) underwent splenectomy of idiopathic thrombocytopenia purpora (10), spherocytosis (6), elliptocytosis (1), and Hodgkin's disease (1). The median operating time was 160 min (90-300 min) and median blood loss was 105 ml (5-350 ml). Accessory spleens were removed in four cases. Three patients required extensions of a port site to remove large spleens which could not be placed in a bag. The sole complication was a transient pancreatitis with associated pleural effusion. The median postoperative hospital stay was 2 days (1-11 days) and time to full activities was 8 days (3-25 days). The lateral approach affords excellent visualization of the splenic vessels, pancreas, and accessory spleens. This approach is safe and reliable and is our preferred approach for laparoscopic splenectomy in children.

Laparoscopic splenectomy

Dramatic decreases in length of hospital stay and time to complete recovery with laparoscopic cholecystectomy have led to the development of more advanced laparoscopic procedures. The rationale, technique, and early results with laparoscopic splenectomy are described in this article. Laparoscopic splenectomy is a complex procedure with a real potential for significant operative bleeding, but it can be accomplished successfully in greater than 80% of selected patients with minimal blood loss. If successful, length of stay is reduced in most patients to 1 to 3 days, but this benefit is not always seen in patients with complicated medical problems or with massive splenomegaly. The effects of increased blood loss in patients whose operations are converted to open operations are also not yet clear. Laparoscopic splenectomy is a procedure with great potential, but it is still in evolution.

Laparoscopic splenectomy in adults and children: experience with 31 patients

BACKGROUND

Open surgery is the standard approach for splenectomy in hematologic disorders, but a few cases of successful laparoscopic splenectomy have been reported.

METHODS

Thirty-one patients (18 adults, group 1; and 13 children, group 2) underwent laparoscopic splenectomy. Indications for surgery included idiopathic thrombocytopenic purpura (25 patients), congenital spherocytosis (4 patients), and hemolytic anemia (2 patients). In 97% of the patients the diameter of the spleen was less than 15 cm.

RESULTS

Laparoscopic splenectomy was successful in 94% of the patients; conversion to open surgery was mainly related to hemorrhage. Accessory spleen was found in 39% in group 1 and 8% in group 2. Two adults received intraoperative autotransfusion. Postoperative morbidity was minimal. The median postoperative stay was 3 days (range, 2 to 12 days) in group 1 and 2 days (range, 2 to 5 days) in group 2.

CONCLUSIONS

Laparoscopic splenectomy is safe in both adults and children. Adequate selection of patients (small-size spleen, splenic destruction on preoperative scanning of platelets), appropriate preparation in patients with idiopathic thrombocytopenic purpura (immunoglobulin G), and meticulous surgical technique (with routine opening of the gastrocolic ligament to search for accessory spleen) are key factors in obtaining the same long-term results as with open surgery.