Laparoscopic splenectomy

Analysis of the surgical treatment of the patients operated on by using laparoscopic and classic splenectomy due to benign disorders of the spleen

Objectives

Laparoscopic splenectomy became the standard surgical procedure in the 1990s. The goal of this study was to analyze the outcome of the patients who underwent laparoscopic splenectomy for the benign hematologic diseases of the spleen and compare its results with open splenectomy.

Material and Methods

The study was conducted as a retrospective cohort study analyzing and comparing the data obtained from 196 patients' case records in the Clinic for Digestive Surgery, Clinical Center of Serbia, for the benign disorders of the spleen, divided into two groups: patients operated with laparoscopic technique and patients in whom classic splenectomy was performed. The analyzed parameters were divided into three groups as preoperative, intraoperative and postoperative.

Results

In the laparoscopic splenectomy group, less intraoperative blood loss, lower incidental intraoperative complications and a shorter duration of surgery were recorded. The incidence of postoperative complications and reoperations was higher in the group of classically operated patients. Postoperative recovery, expressed by the duration of postoperative abdominal drainage, recovery of intestinal peristalsis and length of postoperative hospitalization, was significantly shorter in the laparoscopic group.

Conclusion

Laparoscopic splenectomy is an effective and safe surgical procedure in the treatment of many benign diseases of the spleen. Improvement of the laparoscopic technique of surgical teams and technical improvement of the laparoscopic equipment can lead to even wider application of laparoscopic splenectomy as standard operative procedure, and thus to safer and better quality treatment of patients with wider spectrum diseases of the spleen.

Current concepts of laparoscopic splenectomy in elective patients

Formerly, open splenectomy represented the conventional surgical treatment for many hematologic diseases. Currently, thanks to permanent technical development and improved skills, also laparoscopic splenectomy (LS) has become a recognized procedure in the treatment of spleen diseases, even in case of splenomegaly. A systematic review was performed with the aim of recalling the proved concepts of this surgical treatment and to browse new devices and techniques and their impact on the surgical outcome. The literature search was initially conducted in PubMed by entering general queries related to LS. The record identified through PubMed searching (n = 1599) was then screened by applying several criteria (study published in English from 1991 to 2013 with abstract available, by excluding systematic/non-systematic reviews, meta-analysis, practice guidelines, case reports, and study involving animals). The articles assessed for eligibility (n = 160) were primarily evaluated by excluding studies that did not report operative time and conversion to open surgery. For articles that treated multiport LS we included only clinical trials with patients > 20. The studies included in qualitative synthesis were 23. The search strategy carried out in PubMed does not allow to obtain an overview of the items returned by the main queries. With this aim we replicated the search in the Web of Science^TM database, only including the studies published in English in the period 1991-2013 with no other filter/selection criteria. The full records (n = 1141) and cited references returned by Web of Science^TM were analyzed with the visualization of similarities (VOS) mapping technique. Maps of title/abstract text corpus and bibliographic coupling of authors obtained by applying the VOS approach were presented. If in normal-size or moderately enlarged spleens the laparoscopic approach is unquestionable, in massive splenomegaly the optimal technique remain to be determined. In this setting, prospective randomized trials to compare open vs LS are needed. Between the new techniques of LS the robotic single port splenectomy has the ability to join all the positive aspects of both techniques. Data about this topic are too initial and need to be confirmed with further studies.

Outcomes of laparoscopic versus open splenectomy

Purpose

Laparoscopic techniques have gained wide clinical acceptance in surgical practice today. The laparoscopic approach has been established as the technique of choice for elective splenectomies performed on normal sized spleens. The purpose of this study was to evaluate the outcome of patients undergoing laparoscopic splenectomy (LS) at the TOBB University of Economics and Technology (ETU) Hospital and Kecioren Training and Research Hospital.

Methods

One hundred and thirty-five patients underwent splenectomy between January 2000 and July 2010. For comparison, the records of 130 patients undergoing splenectomy were evaluated for age, gender, hospital stay, time to start of diet, conversion rate, operation time and wound infection.

Results

Mean operation time means the time interval between surgeon commencing operation to end of operation. Mean operation time in patients treated by LS was 132 minutes and 121 minutes in open splenectomy (OS). Mean hospital stay was 5.65 days in patients undergoing LS and starting of diet was 1.21 days. In patients treated by OS, mean hospital stay was 9.17 days, starting of diet was 2.37 days. Four patients were converted to open surgery. Conversion rate was 6.4 percent. In the early post operative period (within 10 days of surgery) 9.2%, LS group had lower incidences of wound infection rate after surgery than OS group (4.8%, 7.4%, respectively; P = 0.06).

Conclusion

LS is a safe and effective alternative to OS for treatment of splenic diseases in patients of all ages.

Rigid and flexible endoscopic rendezvous in spatium peritonealis may be an effective tactic for laparoscopic megasplenectomy: significant implications for pure natural orifice translumenal endoscopic surgery

BACKGROUND

We recently experienced 10 patients with cirrhosis who underwent laparoscopic splenectomy. A portion of these patients underwent dissection with a flexible endoscope in the peritoneal cavity. This pilot study mainly focused on the technical aspects and immediate results.

METHODS

From November 2009 to September 2010, 10 patients with cirrhosis and hypersplenism were entered into this pilot study. They were indicated to undergo laparoscopic splenectomy to treat portal hypertension and to facilitate initiation and completion of either interferon therapy for liver cirrhosis or anticancer therapy for hepatocellular carcinoma. To dissect the upper end of the gastrosplenic ligament and the marginal region between the left diaphragm and upper pole of the spleen, a flexible single-channel endoscope was introduced into the peritoneal cavity simultaneously with the use of a rigid laparoscope. Dissection with the flexible endoscope in the peritoneal cavity was performed using an insulation-tipped electrosurgical knife through the channel of the flexible endoscope.

RESULTS

The flexible endoscope offered a magnified operative view, a water-jet lens cleaner, and a powerful lavage and suction capability. The upper end of the gastrosplenic ligament and the marginal region between the left diaphragm and upper pole of the spleen were easily seen, and dissection of these critical regions was smoothly conducted with articulation of the tip of the flexible endoscope, even in patients with splenomegaly. No patient experienced major intraoperative complications or required conversion to open surgery.

CONCLUSIONS

Dissection with a flexible endoscope in the peritoneal cavity may be an effective tactic for laparoscopic megasplenectomy, and significant implications for pure natural orifice translumenal endoscopic surgery have been raised. Although future randomized controlled prospective studies are needed to confirm these findings, surgeons might find this to be a typical example of an appropriate strategy for high-risk patients.

[Laparoscopic splenectomy: indications, techniques, outcomes]

Laparoscopic splenectomy (LS) has become the standard approach to splenectomy for benign and malignant hematologic diseases despite a paucity of high-level evidence. The procedure requires expertise in laparoscopic surgical techniques and meticulous dissection of the spleen. Management should include a preoperative radiologic assessment to measure splenic volume and to detect the presence of accessory splenic tissue; the patient should undergo preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections. Prophylactic antibiotics are used in the perioperative period as well as prophylactic anticoagulation therapy which may be continued long-term in high-risk patients. LS is associated with a low morbidity and mortality; when compared to laparotomy, it reduces the length of hospital stay and improves the quality of life by decreasing postoperative ileus and pain. There are a variety of laparoscopic approaches; the hand-assisted technique and newer coagulating devices have facilitated the operative technique leading to increasing acceptance of laparoscopy as the preferred approach - even in patients with malignant hematologic disease and/or massive splenomegaly.

Technical standardization of laparoscopic splenectomy harmonized with hand-assisted laparoscopic surgery for patients with liver cirrhosis and hypersplenism

BACKGROUND/PURPOSE

The aims of this study were to standardize the techniques of laparoscopic splenectomy (LS) to improve safety in liver cirrhosis patients with portal hypertension.

METHODS

From 1993 to 2008, 265 cirrhotic patients underwent LS. Child-Pugh class was A in 112 patients, B in 124, and C in 29. Since January 2005, we have adopted the standardized LS including the following three points: hand-assisted laparoscopic surgery (HALS) should be performed in patients with splenomegaly (> or =1,000 mL), perisplenic collateral vessels, or Child-Pugh score 9 or more; complete division and sufficient elevation of the upper pole of the spleen should be performed before the splenic hilar division; and when surgeons feel the division of the upper pole of the spleen is too difficult, conversion to HALS should be performed.

RESULTS

There were no deaths related to LS in this study. After the standardization, conversion to open surgery significantly reduced from 11 (10.3%) of 106 to 3 (1.9%) of 159 patients (P < 0.05). The average operation time and blood loss significantly reduced from 259 to 234 min (P < 0.01) and from 506 to 171 g (P < 0.01), respectively.

CONCLUSIONS

With the technical standardization, LS becomes a feasible and safe approach in the setting of liver cirrhosis and portal hypertension.

Laparoscopic splenectomy in goats

OBJECTIVE

To report laparoscopic splenectomy in goats.

STUDY DESIGN

Experimental study.

ANIMALS

Healthy female goats (n=9); aged, 10-18 months; weighing, 22-30 kg.

METHODS

Food was withheld for 24 hours and water for 10 hours. Anesthetized right laterally recumbent goats had a laparoscopic portal and 3 instrumental portals created in the left flank. Splenic attachments were dissected with monopolar electrocautery and blunt dissection through 2 instrument portals. Exposure and isolation of splenic vessels was performed with laparoscopic "right-angle" preparation forceps. Vessels were ligated with a medium-titanium clip and 2 silk sutures and then transected between the silk sutures. The detached spleen was manipulated into a specimen retrieval bag, morcellated, and the bag retrieved through an enlarged portal. Repeat laparoscopic examination was performed at 1 month.

RESULTS

Laparoscopic splenectomy required 70 minutes (range, 52-88 minutes) and was successful without major intraoperative and postoperative complications. Postoperatively, all goats had signs of mild abdominal discomfort. On repeat laparoscopy, with the exception of 1 goat that had a focal omental adhesion to the enlarged portal site, no other abnormalities were identified.

CONCLUSIONS

Laparoscopic splenectomy can be accomplished in goats using 4 portals in the left flank and a combination of monopolar cautery dissection of splenic attachments, ligation of vessels using metal clips and intracorporeal ligatures, and intra-abdominal morcellation of the detached spleen in a specimen retrieval bag.

CLINICAL RELEVANCE

Laparoscopic splenectomy is an effective and safe technique in goats.

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.

Laparoscopic splenectomy is a better treatment for adult ITP than steroids — it should be used earlier in patient management. Conclusions of a ten-year follow-up study

BACKGROUND

Laparoscopic splenectomy (LS) has rapidly become the preferred surgical treatment for immune thrombocytopaenic purpura (ITP). The aim of this study was to assess the long-term outcome of laparoscopic splenectomy for adult ITP performed in a single unit.

METHODS

Between 1992 and 2002, 55 patients underwent LS for ITP refractory to medical therapy. These were performed by one surgeon. Long-term outcome data was obtained by case note review and telephone-based questionnaire. Complete remission was defined as a sustained platelet count of >100 x 10(9)/L without further requirement for medical therapy.

RESULTS

Follow-up information was obtained for 40 (73%) out of 55 patients. Overall, 35 (88%) of 40 patients were in complete remission at five-year median follow-up. Five (13%) patients required continued steroid therapy despite LS. Seven (18%) patients reported bleeding problems, in particular bruising. Thirty-five (88%) of 40 patients considered their operation a success. Of these, 16 (46%) patients wished that the operation had been performed earlier in the course of their disease.

CONCLUSIONS

This ten-year experience demonstrates that LS is safe, effective, and yields excellent long-term results for adult ITP, equivalent to results after open splenectomy. Patients' views suggest that laparoscopic splenectomy should be considered sooner in the management of adult ITP, reducing the duration and morbidity of medical treatment.

Analysis of risk factors for massive intraoperative bleeding during laparoscopic splenectomy

BACKGROUND/PURPOSE

Laparoscopic splenectomy is occasionally converted to open surgery due to massive intraoperative bleeding. The aim of this study was to identify the risk factors for massive bleeding during laparoscopic splenectomy.

METHODS

Fifty-three patients underwent laparoscopic splenectomy. The indications were hematologic disease in 25 patients, liver cirrhosis in 17 patients, and other conditions in 11 patients. Univariate analysis was conducted with Fisher's exact test, and multivariate analysis was conducted with a stepwise logistic regression model.

RESULTS

None of the patients required open surgery. Blood loss of more than 800 ml was defined as massive intraoperative bleeding. Univariate analysis showed significant risk factors for massive bleeding to be liver cirrhosis, portal hypertension, splenomegaly, Child class, and preoperative platelet count. Independent risk factors in the multivariate analysis were portal hypertension and Child class.

CONCLUSIONS

Careful attention to intraoperative bleeding during laparoscopic splenectomy is necessary for patients with portal hypertension and/or deteriorated liver function.

Does open surgery continue to have a role in elective splenectomy?

BACKGROUND

Since it was first reported in 1991, laparoscopic splenectomy has become the procedure of choice for elective splenectomy. However, doubts have been raised regarding the suitability of patients with splenomegaly (>1 kg) for laparoscopic resection because there have been reports of greater morbidity and higher conversion rates in this group of patients. Since 2000, patients referred to the authors' center for splenectomy with an estimated spleen weight exceeding 1 kg have undergone splenectomy by the open approach.

METHODS

Between September 1995 and April 2005, 95 elective splenectomies were performed by a single surgeon. Operative data were collected prospectively.

RESULTS

A comparison between the operations that took place before 2001 (n = 47) and those performed after 2000 (n = 48) for all sizes of spleen showed significant reductions in conversion rate, operative time, and hospital stay in the later group. As compared with laparoscopic splenectomy (n = 11), open splenectomy (n = 18) for cases of splenomegaly resulted in a significantly shorter operative time, less operative blood loss, and no significant difference in hospital stay.

CONCLUSION

Although laparoscopic splenectomy is the treatment of choice for the majority of patients requiring elective splenectomy, the procedure for patients with significant splenomegaly requires caution and common sense. This study shows that an open splenectomy for these patients significantly reduces operative time and blood loss without increasing morbidity or hospital stay.

Imaging findings of biliary and nonbiliary complications following laparoscopic surgery

Laparoscopic techniques are evolving for a wide range of surgical procedures although they were initially confined to cholecystectomy and exploratory laparoscopy. Recently, surgical procedures performed with a laparoscope include splenectomy, adrenalectomy, gastrectomy, and myomectomy. In this article, we review the spectrum of complications and illustrate imaging features of biliary and nonbiliary complications after various laparoscopic surgeries. Biliary complications following laparoscopic cholecystectomy include bile ductal obstruction, bile leak with bile duct injury, dropped stones in the peritoneal cavity, retained CBD stone, and port-site metastasis. Nonbiliary complications are anastomotic leakage after partial gastrectomy, gangrenous cholecystitis after gastrectomy, hematoma at the anastomotic site following gastrectomy, gastric infarction after gastrectomy, port-site metastasis after gastrectomy, hematoma after splenectomy, renal infarction after adrenalectomy, and active bleeding after myomectomy of the uterus.

Staple line bleeding following laparoscopic splenectomy: intraoperative prevention and postoperative management with splenic artery embolization

Laparoscopic splenectomy (LS) has become the procedure of choice for a variety of hematologic disorders and non-traumatic splenic pathology. Perioperative hemorrhage remains one of the most feared complications. We report 2 cases of postoperative splenic artery hemorrhage following vascular division using 2.5-mm Endo-GIA stapling cartridges. In this paper we identify and discuss important technical aspects of obtaining hilar vascular control during LS and report the first use of postoperative splenic artery embolization to control staple line bleeding following LS.

Modelo experimental de esplenectomia laparoscópica em ratos

OBJETIVO: Desenvolver um modelo de esplenectomia laparoscópica em ratos. MÉTODOS: Foram utilizados trinta e cinco ratos machos ( Rattus Norvegicus Albinus, linhagem Wistar),pesando 250 +/- 50 g .Os animais foram anestesiados com cetamina e xylazina e foi estabelecido pneumoperitônio de CO2 com pressão de 7 mmHg, através da agulha de Veress. Após pneumoperitônio, dois trocateres de 5 mm e um de 11mm foram alocados na parade abdominal obedecendo a triangulação. O ligamento gastroesplênico foi dissecado para mobilização do baço. Os vasos hilares foram dissecados e eletrocoagulados utilizando a pinça "Maryland" e o gancho "HooK". Um "endobag" adaptado, foi utilizado para retirar o orgão da cavidade abdominal. RESULTADOS: Um animal (2,86%) morreu na indução anestésica. Após um período de observação de oito dias, trinta animais sobreviveram (85,7 %) e quatro (11,42%) Morreram no pós-operatório imediato. Em relação às complicações, Aderências intra-abdominais foram encontradas em 25,71% dos animais (n=9). CONCLUSÃO: A esplenectomia laparoscópica é um modelo factível por conta da baixa taxa de mortalidade além do baixo custo para treinamento da técnica.

Laparoscopic splenectomy: the latest technical evaluation

AIM: To introduce our latest innovation on technical manipulation of laparoscopic splenectomy.

METHODS: Under general anesthesia and carbon dioxide (CO₂) pneumoperitoneum, 86 cases of laparoscopic splenectomy (LS) were performed. The patients were placed in three different operative positions: 7 cases in the lithotomic position, 31 cases in the right recumbent position and 48 cases in the right lateral position. An ultrasonic scissors was used to dissect the pancreaticosplenic ligament, the splenocolicum ligament, lienorenal ligament and the lienophrenic ligament, respectively. Lastly, the gastrosplenic ligament and short gastric vessels were dissected. The splenic artery and vein were resected at splenic hilum with Endo-GIA. The impact of different operative positions, spleen size and other events during the operation were studied.

RESULTS: The laparoscopic splenectomy was successfully performed on all 86 patients from August 1997 to August 2002. No operative complications, such as peritoneal cavity infection, massive bleeding after operation and adjacent organs injured were observed. There was no death related to the operation. The study showed that different operative positions could significantly influence the manipulation of LS. The right lateral position had more advantages than the lithotomic position and the right recumbent position in LS.

CONCLUSION: Most cases of LS could be accomplished successfully when patients are placed in the right lateral position. The right lateral position has more advantages than the conventional supine approach by providing a more direct view of the splenic hilum as well as other important anatomies. Regardless of operation positions, the major axis of spleen exceeding 15 cm by B-ultrasound in vitro will surely increase the difficulties of LS and therefore prolong the duration of operation. LS is a safe and feasible modality for splenectomy.

Use of laparoscopic splenectomy in developing countries: analysis of cost and strategies for reducing cost

BACKGROUND

In general, laparoscopic surgery is more expensive than open surgery. However, recent reports showed lower overall cost.

PATIENT AND METHODS

Fourteen patients underwent laparoscopic splenectomy (LS) and 15 patients open splenectomy (OS). Patients were evaluated with regard to blood loss, complication rate, length of hospital stay, operative time, presence of accessory spleens, hospital cost, and total cost. For the OS group, there was no laparoscopic instrument cost, and the total cost was equal to the hospital cost. In the LS group, total cost was calculated by adding the hospital cost to the cost of laparoscopic instruments.

RESULTS

The postoperative hospitalization was shorter in the LS group than the OS group (3.4 vs. 7.5 days), but the operating time was significantly longer for the LS group. The mean hospital cost was calculated as US $1,055 in the LS group and $1,664 in the OS group. The overall total cost was $1,664 for the OS group and $2,064 for the LS group. In the LS group, less morbidity and shorter postoperative hospital stay resulted in lower hospital cost.

CONCLUSION

The cost for laparoscopic instruments is the main factor responsible for the high total cost of LS. Resterilization of disposable laparoscopic instruments is feasible and a more economic way of treatment compared with splenectomy with totally disposable laparoscopic instruments and has costs comparable to those of open surgery.

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 massive splenomegaly using a Lahey bag

BACKGROUND

Although the recent development of hand-assisted laparoscopic surgery (HALS) has made the laparoscopic retraction of large spleens feasible, the laparoscopic removal of massively enlarged spleens (>1,000 g) remains a significant problem because these spleens do not fit into endoscopic bags. Consequently, in order to remove massive spleens either a large abdominal incision or morcellation of the spleen outside of an endoscopy bag is required.

METHODS

Two patients, with spleens weighing 2,510 g and 1,720 g, underwent laparoscopic splenectomy using a hand port to ensure safe retraction. The massive spleen was placed into a Lahey bag that was inserted into the abdomen through the hand port site. While in the Lahey bag, the spleen was removed piecemeal through the hand port site.

RESULTS

Both operations were completed laparoscopically without complications. The patients were discharged on postoperative day 2 and experienced minimal morbidity.

CONCLUSIONS

The Lahey bag facilitates laparoscopic splenectomy for massive splenomegaly as even the most massive spleens will fit into a Lahey bag. A massive spleen may be removed piecemeal from the Lahey bag through the small hand port incision without risking a large abdominal incision, splenosis, or the insertion of a morcellator.

The Ascendance of Laparoscopic Splenectomy

The application of laparoscopic techniques for abdominal procedures has been achieved with varying success. The general acceptance of laparoscopic splenectomy (LS) may be hindered by its infrequent performance and difficulty in manipulating the spleen. A retrospective review of splenectomies performed for primary splenic pathology was done to assess the role and outcome of LS. One hundred fifty LSs were performed from July 1995 through September 1999. Over that time period the proportion of LS performed increased steadily from 17 to 75 per cent of all splenectomies. The primary indications for splenectomy included immune thrombocytopenic purpura in 75 (50%), lymphoma/leukemia 36 (24%), and splenomegaly 19 (13%). There were 86 females and 64 males. Immediately before operation 36 patients (4%) had a platelet count <50,000/mL, and 24 patients (16%) a hemoglobin <10 mg per cent. The mean operative time was 161 minutes with an average blood loss of 138 cm3 (<50–800). The mean morcellated weight of the entire group was 411 g (33–3300) indicating generally large splenic size. In the 37 patients with splenomegaly the mean weight was 735 g (293–3300). There were two conversions to open splenectomy. Two patients with hematologic malignancy, splenomegaly, and cytopenias died from overwhelming post-splenectomy sepsis (1.3%). Morbidity occurred in 14 (9%) with the most common complication being pancreatitis in seven (5%). The median length of postoperative stay was 2.4 days (range 1–5). In summary LS has rapidly replaced the open approach for nearly all elective splenectomies in adults and children. When performed with the patient in the lateral position it can be accomplished with minimal morbidity, even in complex patients, including those with splenomegaly.

Surgeon predictions on growth of minimal invasive therapy: the difficulty of estimating technologic diffusion

OBJECTIVE

To compare five-year predictions made in 1992 by academic surgeon leaders in UK, US and Canada, with actual experiences in 1997, of increased rates of minimal invasive therapy (MIT) for surgical operations.

METHOD

We compared 1992 predictions of percent of operations done by minimal invasive therapy and length of stay in the US with actual 1997 percents found by literature searches.

RESULTS

We found sufficient data on 12 operations done by MIT in 1997 of the original 34 operations predicted in 1992 by surgeon experts to be to be amenable to this technique. These 12 operations were among the top 20 most commonly performed procedures in 1992 and 1997. Of these 12 operations, ten had 40-60% lower 1997 percentages than predicted, one had about 10% lower rate, and two had 18% and 100% higher rates of MIT than predicted. Overall mean length of stay (LOS) for all 34 study operations fell from 6.8 days in 1992 to 5.2 days in 1997. Mean LOS in 1997 was 2.5 days by MIT and 6.7 days by open technique (OT).

CONCLUSION

Most of the predictions made in 1992 by surgical leaders in Canada, US and UK were incorrect when examined 5 years later. The rate of MIT diffusion and its effect on length of stay were overestimated for most operations, while for two procedures the predictions underestimated extent of diffusion. Also, much of the declines of LOS for surgical care paralleled declines in length of stay for all care, supplemented by the individual contributions of MIT specifically. Relying on expert opinion alone to predict the acceptability, rapidity, scope and extent of technological change is fraught with uncertainty. Unexpected consequences occur when one or a few parts of complex systems are changed. This is a particular problem when predictions are a main basis for informed decision making in the absence of any supporting data from appropriately designed empirical or controlled study.