Minimizing intraoperative bleeding using a vessel-sealing system and splenic hilum hanging maneuver in laparoscopic splenectomy

LigaSure technique for splenectomy: A systematic review and meta-analysis

BACKGROUND

This study aimed to clarify the optimal management of the LigaSure technique and conventional techniques during splenectomy.

METHODS

All databases, including CBM, CNKI, WFPD, Medline, EMBASE, PubMed, and Cochrane databases up to April 2023, were searched for relevant studies comparing the LigaSure technique with conventional techniques. Six studies, extracted by 2 independent reviewers, were evaluated for blood loss, operative time, conversion, mortality, hospital stay, and transfusion.

RESULTS

The blood loss was significantly higher in the convention group than in the LigaSure group (WMD = -48.98, 95% CI: -62.41 to -35.55, P < .00001). Meanwhile, the mean operative time was significantly shorter in LigaSure group than in convention group (WMD = -10.57; 95% CI: -12.35 to -8.78), P < .00001). No significant differences were found regarding the conversion rate, hospital stay, morbidity, and transfusion.

CONCLUSIONS

The LigaSure technique has comparable effects to conventional techniques, but to some extent reduces blood loss and operative time.

Towards cost saving in surgery without compromising safety: stapleless laparoscopic splenectomy in a developing country-a prospective cohort study

BACKGROUND

Minimally invasive surgery has been steadily growing in popularity. Control of splenic hilar vessels is the most delicate step during laparoscopic splenectomy (LS). In the earlier eras of LS, hilar vessels were controlled using clips and/or ligation. Laparoscopic staples were later introduced and have arguably led to an increase in popularity of LS. They do not abolish potential complications of splenectomy and theoretically represent an added operative cost.In this study, we aimed to assess the safety and efficacy of stapleless LS (using knots, haemostatic devices and clips) compared with the now more conventional stapled LS.

METHODS

A pilot randomised prospective study was conducted in a university hospital between September 2018 and April 2020. It included 40 patients randomly assigned to two equal groups: (1) 20 patients: stapleless LS and (2) 20 patients: LS using laparoscopic staples.We compared operative time, intra and postoperative complications and postoperative recovery.

RESULTS

There was no statistically significant difference between both groups across all comparative outcomes.

CONCLUSION

Both techniques are comparable in terms of safety and operative time. In terms of cost efficiency, we recommend more comprehensive analyses of hospital costs.

The usefulness of modified splenic hilum hanging maneuver in laparoscopic splenectomy, especially for patients with huge spleen: a case-control study with propensity score matching

BACKGROUND

Although Laparoscopic splenectomy (LS) have been proven to the standard operation for removal of spleen, the rate of conversion to open surgery is still higher than those of other laparoscopic surgeries, especially for huge spleen. In order to reduce the rate of conversion to open surgery, we had developed LS using modified splenic hilum hanging (MSHH) maneuver: the splenic pedicle was transected en bloc using a surgical stapler after hanging splenic hilum with an atraumatic penrose drain tube.

METHODS

Between January 2005 and December 2019, we retrospectively assessed 94 patients who underwent LS. MSHH maneuver was performed in 37 patients (39.4%). We compared the intra- and postoperative outcomes between patients with or without MSHH maneuver. To adjust for differences in preoperative characteristics and blood examination, propensity score matching was used at a 1:1 ratio, resulting in a comparison of 29 patients per group. Predictive factors of conversion from LS to open surgery were elucidated using the uni- and multi-variate analyses.

RESULTS

After the propensity score matching, blood loss (268 ml vs. 50 ml), the rate of conversion to open surgery (27.6% vs. 0%), and postoperative hospital stays (15 days vs. 10 days) were significantly decreased in patients with MSHH maneuver, respectively. Among 94 patients, 19 patients (20.2%) underwent conversion to open surgery. In multivariate analysis, spleen volume (SV) and LS without MSHH maneuver were independent predictive factors of conversion to open surgery, respectively. Additionally, cut-off value of SV for conversion to open surgery was 802 ml (sensitivity: 0.684, specificity: 0.827, p < 0.001).

CONCLUSIONS

LS using MSHH maneuver seems to be useful surgical technique to improve intraoperative outcomes and reduce the rate of conversion from LS to open surgery resulting in shorten postoperative hospital stay.

Small-for-size graft, small-for-size syndrome and inflow modulation in living donor liver transplantation

The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching called "small-for-size syndrome (SFSS)." The initial trials to resolve this problem involved increasing the procured graft size, from left to right, and even extending to include a right lobe graft. Clinical cases of living right lobe donations have been reported since then, drawing attention to the risks of increasing the liver volume procured from a living donor. However, not only other modes of increasing graft volume (GV) such as auxiliary or dual liver transplantation, but also control of the increased portal pressure caused by a small-for-size graft (SFSG), such as a porto-systemic shunt or splenectomy and optimal outflow reconstruction, have been trialed with some positive results. To establish an effective strategy for transplanting SFSG and preventing SFSS, it is essential to have precise knowledge and tactics to evaluate graft quality and GV, when performing these LDLTs with portal pressure control and good venous outflow. Thus, we reviewed the updated literature on the pathogenesis of and strategies for using SFSG.

Laparoscopic Splenectomy in Children: Safety of Ligasure Usage

Introduction

Laparoscopic splenectomy started to be more popular and nowadays it is the first choice for splenectomy in children. The main advantages of laparoscopic splenectomy over open approach are the shorter hospital stay, low complications and the cosmetic results despite the main concern of long operative time and the intra operative bleeding.

Aim

The aim of this study was to report our experience with laparoscopic splenectomy in children's with hematological diseases using ligasure regarding vascular control safety, efficacy and complications rate.

Methods

A retrospective study was carried out at Queen Rania Al-Abdullah Hospital for Children over the period from January 2017 to February 2019. Total number of 18 patients with hematological diseases underwent laparoscopic splenectomy using ligasure. Demographic data, complications and outcomes were collected to assess the advantages of ligasure usage for vascular control safety.

Results

Out of 18 patients underwent laparoscopic splenectomy using ligasure (10 with spherocytosis, 4 with immune thrombocytopenic purpura [ITP], 3 with sickle cell anemia, 1 with hemangioma), from which number, 8 patients were males and 10 were females. Mean age was 6.7 years (ranges from 4.3 to13.7 years). Mean operative time was 107 minutes (ranges from 70-180 minutes). There was no conversion to open splenectomy and no mortality. Intra operative blood loss was insignificant.

Conclusion

Laparoscopic splenectomy using ligature is safe with excellent results in decreasing operative time, less complications and decrease incidence of intraoperative bleeding.

Safe approach to the splenic hilum by first mobilizing the pancreatic tail in laparoscopic splenectomy

INTRODUCTION

We employed a safe approach during laparoscopic splenectomy by first mobilizing the pancreatic tail and then dissecting the splenic vessels at the splenic hilum before mobilizing the spleen.

MATERIALS AND SURGICAL TECHNIQUE

Patients were placed in the lithotomy position, and only the upper body was twisted to the right side. Five trocars were placed. After the bursa omentalis was opened, an avascular layer was identified behind the pancreas. This avascular layer was bluntly dissected, and the pancreatic tail was isolated from the retroperitoneum. The tissue surrounding the splenic hilum was dissected by a handling tape that was placed around the pancreatic tail. Because the spleen remained connected to the retroperitoneum with the splenorenal ligament, a good operative view of the splenic hilum was obtained with proper extension. After sufficient space was secured between the pancreatic tail and the spleen, the splenic vessels were divided with a linear stapler. The spleen was detached in the final stage.

DISCUSSION

The current standardized procedure is highly recommended for a safe laparoscopic splenectomy.

Laparoscopic splenectomy in children with benign hematological diseases: Leaving nothing behind policy

Context:

Laparoscopic splenectomy (LS) is considered the standard approach for the treatment of children with nonmalignant hematological diseases due to the advances in the minimal invasive surgery over the conventional splenectomy (CS). Different techniques are involved in the operation to secure the hilum.

Aim:

The use of (Ligasure™) is a safe, effective, less time consuming and with less complications rate.

Materials and Methods:

Sixty children (33 with thalassemia, 20 with immune thrombocytopenic purpura [ITP] and seven with spherocytosis) were operated during the period from June 2007 to December 2014. These children had undergone LS using (Ligasure™). Three ports were used in small-sized spleens while four ports were used in large spleens.

Results:

There were 60 children (37 girls and 23 boys) with a mean age of 10.2 years had LS using Ligasure™ with mean operative time of 85 min for cases of ITP and 120 min for other cases. There was no mortality. Two cases were converted to CS.

Conclusions:

Use of Ligasure™ alone was safe, less time consuming with less complications rates.

Impact of Spleen Size on Outcomes in Laparoscopic Splenectomy in Children

Background. The aim of our study is to compare the efficacy of laparoscopic splenectomy (LS) between enlarged spleens and normal sized spleens. Methods. From June 2006 to September 2012, 50 patients underwent LS. The patients consisted of 24 girls and 26 boys with the mean age of 8.64 years (1–18). The patients are divided into two groups according to spleen's longitudinal length on the ultrasonography. Group I consisted of the normal sized spleens; Group II consisted of spleens that are exceeding the upper limit. Groups are compared in terms of number of ports, operative time, rate of conversion to open procedure, and length of hospital stay. Results. The mean number of ports was 3.27 and 3.46, the mean length of the operation was 116.36 min and 132.17 min, rate of conversion to open procedure was 9.09% and 10.25%, and the mean length of hospital stay was 3.36 days and 3.23 days, respectively, in Group I and Group II. Although there is an increase in the number of the ports, the operative time, rate of conversion to open procedure, and the length of hospital stay, the difference was not significant between groups (P > 0.05). Conclusion. LS is safe and effective in enlarged spleens as well as normal sized spleens.

Decreased Surgical Time with a Vessel Sealing Device Versus a Surgical Stapler in Performance of Canine Splenectomy

The purpose of this retrospective study of 72 dogs was to compare a vessel sealing device with a surgical stapling device for performance of splenectomy. The results of this study demonstrate a statistically significant shorter surgical time for splenectomy, without an adverse effect on outcomes, performed in dogs with the vessel sealing device (mean time, 58.4 min ± 3.3 min; median time, 60 min; range, 22–131 min) compared with a traditional stapling device (mean time, 66.9 min ± 2.4 min; median time, 66 min; range, 40–100 min). No other significant differences were found between the two groups of patients.

Subphrenic hematoma after thoracoscopic discectomy: description of a very rare adverse event and review of the literature on complications

The authors describe a very rare and previously unreported complication of thoracoscopic discectomy. Endoscopic spine surgery has evolved as a safe and effective treatment, and thoracoscopic discectomy, in particular, provides several advantages over open approaches, although it can be associated with intraoperative or postoperative complications. The most frequently observed adverse events are intercostal neuralgia, retained disc fragments, durotomies, atelectasis, extensive bleeding, and emergency conversion to open thoracotomy for vascular injuries. Even rare complications, such as chylorrhea or brain hemorrhagic infarction, have been reported. Nonetheless, a literature review did not reveal any case of postoperative intraabdominal hematoma following thoracoscopic discectomy. A 43-year-old woman, with no history of hematological or vascular disorders or thoracic surgery, underwent a right-sided thoracoscopic discectomy for T11–12 disc herniation. No apparent surgical technique–related complications were encountered, but intermittently repeated difficulties with single-lung ventilation occurred. The resultant dysventilation allowed partial right lung reexpansion, along with increased abdominal pressure. The latter induced an upward ballooning of the right diaphragm with consequent obstruction of the surgical field of view, requiring constant and continuous pressure applied to the thoracic surface of the diaphragm via a metal fan retractor and thus counteracting the increased abdominal pressure. Postoperatively, a large subdiaphragmatic hematoma originating from a bleeding right inferior phrenic artery was diagnosed and required urgent endovascular occlusion. The patient made an uneventful recovery with conservative treatment. A very rare and previously unreported complication—that is, early subdiaphragmatic hematoma after thoracoscopic discectomy—is described here. The authors submit that conversion to an open approach is safer when persistent anesthesia-related complications are encountered in thoracoscopic discectomy.

Postoperative outcomes after laparoscopic splenectomy compared with open splenectomy

OBJECTIVE

To evaluate 30-day postoperative outcomes in laparoscopic (LS) versus open splenectomy (OS).

SUMMARY BACKGROUND DATA

LS has generally been associated with lower rates of postoperative complications than OS. However, evidence mainly comes from small studies that failed to adjust for the confounding effects of the underlying indication or clinical condition that may have favored the use of one technique over the other.

METHODS

A retrospective cohort study of patients undergoing splenectomy in 2008 and 2009 using data from the American College of Surgeons National Surgical Quality Improvement Program database (n = 1781). Retrieved data included 30-day mortality and morbidity (cardiac, respiratory, central nervous system, renal, wound, sepsis, venous thromboembolism, and major bleeding outcomes), demographics, indication, and preoperative risk factors. We used multivariate logistic regression to assess the adjusted effect of the splenectomy technique on outcomes.

RESULTS

A total of 874 (49.1%) cases had LS and 907 (50.9%) had OS. After adjusting for all potential confounders including the indication and preoperative risk factors, LS was associated with decreased 30-day mortality [OR (odds ratio): 0.39, 95% CI: 0.18-0.84] and postoperative respiratory occurrences (OR: 0.46, 95% CI: 0.27-0.76), wound occurrences (OR: 0.37, 95% CI: 0.11-0.79), and sepsis (OR: 0.52, 95% CI: 0.26-0.89) when compared with OS. Patients who underwent LS also had a significantly shorter total length of hospital stay and were less likely to receive intraoperative transfusions compared with patients who underwent OS.

CONCLUSIONS

LS is associated with more favorable postoperative outcomes than OS, irrespective of the indication for splenectomy or the patient's clinical status.

Anterior versus posterolateral approach for total laparoscopic splenectomy: a comparative study

OBJECTIVE

Although the anterior approach is normally used for elective laparoscopic splenectomy (LS), the posterolateral approach may be superior. We have retrospectively compared the effectiveness and safety of these approaches in patients with non-severe splenomegaly scheduled for elective total LS.

METHODS

Patients with surgical spleen disorders scheduled for elective LS between March 2005 and June 2011 underwent laparoscopic splenic mobilization via the posterolateral or anterior approach. Main outcome measures included operation time, intraoperative blood loss, frequency of postoperative pancreatic leakage, and length of hospital stay.

RESULTS

During the study period, 203 patients underwent LS, 58 (28.6%) via the posterolateral and 145 (71.4%) via the anterior approach. Three patients (1.5%) required conversion to laparotomy due to extensive perisplenic adhesions. The posterolateral approach was associated with significantly shorter operation time (65.0 ± 12.3 min vs. 95.0 ± 21.3 min, P < 0.01), reduced intraoperative blood loss (200.0 ± 23.4 mL vs. 350.0 ± 45.2 mL, P < 0.01), and shorter hospital stay (5.0 ± 2.0 d vs. 9.0 ± 3.0 d, P < 0.01) than the anterior approach. The frequency of pancreatic leakage was slightly lower in patients undergoing LS via the posterolateral than the anterior approach (0.0% vs. 3.4%, P > 0.05).

CONCLUSIONS

The posterolateral approach is more effective and safer than the anterior approach in patients without severe splenomegaly (< 30 cm).

[Latest indications for hanging manoeuvre in liver surgery]

By definition the liver hanging manoeuvre (LHM) means that a slip is passed between the liver parenchyma and the inferior vena cava. It was first published by Belghiti in 200l, and several changes in the indication as well as in the method have been published since then. In parallel, the anatomical and histological basis has been clarified for LHM, too. According to general consensus LHM increases safety and radicality of liver surgery. Initially LHM was applied for removal of huge tumours infiltrating the diaphragm. Authors worked out two modifications for LHM. Tumours / primary or secondary / in segment IVA are sometimes located in close proximity to the median hepatic vein and inferior vena cava , and the resectability of these tumors can determined by the hanging manoeuvre. Tumors in segment VII can be removed by partial resection of vena cava facilitated by LHM. Four patients with LHM are discussed, and based on this limited experience as well as the latest observations from relevant literature the authors claim that LHM increases the safety of resections from segment IVA and VII. Vascular infiltration of the vena cava is always a technical challenge, which can be suspected on preoperative imaging modalities, but in borderline cases only the intraoperative ultrasound and surgical judgment together with LHM would lead to the exact diagnosis and makes the resection possible.

Laparoscopic splenectomy: ligasure or clip ligation?

Laparoscopic splenectomy (LS) is frequently performed for spleen removal under pathologic conditions. The aim of this study was to evaluate whether ligasure is superior to clip ligation during LS. In a simple randomized prospective study, 40 patients who were candidates for splenectomy were randomly assigned to 2 groups of clip and ligasure. Operating time, need for transfusion, intraoperative and postoperative bleeding, open conversion, and postoperative complications were evaluated. Operating time was 115.4 min (SD 15.24) in the clip group and 100.6 min (SD 16.05) in the ligasure group (P=0.005). Bleeding volume was 150.9 mL (SD 26.2) in the clip group and 131.7 mL (SD 25.1) in the ligasure group (P=0.025). In both groups, there was no need for transfusion and no conversion to the open approach. Although both clip and ligasure can be used for vascular control in LS, hemostasis is simply and easily achieved with little dissection using the ligasure method. Therefore, ligasure is superior to clip in cases of LS.

Is expertise in pediatric surgery necessary to perform laparoscopic splenectomy in children? An experience from a department of general surgery

Splenectomy is frequently required in children for various hematologic pathologic findings. Because of progress in minimally invasive techniques, laparoscopic splenectomy (LS) has become feasible. The objective of this report is to present a monocentric experience and to evaluate the efficacy of and complications observed after laparoscopic splenic procedures in a department of general surgery. 57 consecutive LSs have been performed in a pediatric population between January 2000 and October 2010. There were 33 females and 24 males with a median age of 12 years (range 4-17). Indications were: hereditary spherocytosis 38 cases, idiopathic thrombocytopenic purpura 10, sickle cell disease (SCD) 6, thrombocytopenic thrombotic purpura 2 and non-hodgkin lymphoma 1 case. Patients were operated on using right semilateral position, employing Atlas Ligasure vessel sealing system in 49 cases (86%) and Harmonic Scalpel + EndoGIA in 8. In 24 patients (42.1%), a cholecystectomy was associated. Two patients required conversion to open splenectomy (3.5%). In three cases, a minilaparotomy was performed for spleen removal (5.2%). Accessory spleens were identified in three patients (5.2%). Complications (8.8%) included bleeding (two), abdominal collection (one) and pleural effusion (two). There was no mortality. Average operative time was 128 min (range 80-220). Average length of stay was 3 days (range 2-7). Mean blood loss was 80 ml (range 30-500) with a transfusion rate of 1.7% (one patient). Laparoscopic spleen surgery is safe, reliable and effective in the pediatric population with hematologic disorders and is associated with minimal morbidity, zero mortality, and a short length of stay. Ligasure vessel sealing system shortened operative time and blood loss. On the basis of the results, we consider laparoscopic approach the gold standard for the treatment of these patients even in a department of general surgery.

Splenic hilum management during laparoscopic splenectomy

BACKGROUND

The division of the splenic hilum is the most delicate step during laparoscopic splenectomy. An incorrect approach could lead to a series of related complications. Aim of the study was to report authors' personal experience in a series of 107 laparoscopic splenectomies where the splenic hilum was approached by means of stapling device. A possible relationship between instruments used to divide the splenic artery and vein and complications was analyzed.

METHODS

Laparoscopic splenectomy was performed in 107 cases at authors' institution between 1998 and January 2011. In all the patients, splenic hilum was approached by means of vascular stapler.

RESULTS

Indications for the spleen removal mainly were hematologic disorders. Associated surgical procedures were performed in 32 cases. Among the 13 patients who required a conversion to open splenectomy, only in 3 cases the reason was related to the hilum management. Postoperative complications included portal vein thrombosis in 3 cases, pancreatic fistula in 1 case, and bleeding, requiring reintervention, in 2 cases.

CONCLUSIONS

The use of the stapling device is a safe and effective method to approach the splenic hilum during laparoscopic splenectomy. In experienced hands it showed a low rate of related complications.

Laparoscopic Splenectomy Using LigaSure

BACKGROUND

Laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases. Bleeding is the main complication and cause for conversion. We present our experience with the LigaSure and discuss its advantage as a vessel sealing system in achieving safe vascular control.

METHOD

Over a 3-year period, we performed 12 consecutive LS using LigaSure at a single center. A literature review of all the patients who had undergone laparoscopic splenectomy with of the LigaSure to achieve vascular control at the hilum was carried out, assessing its advantages and outcome.

RESULTS

Twelve LS were performed. Eleven of these patients had ITP, and one patient had sickle cell disease. The mean blood loss was 70mL (range, 50 to 460), and operating time was 126 minutes (range, 110 to 240). Two postoperative complications occurred: portal vein thrombosis in one case and subphrenic collection in the other. The literature review revealed 8 studies with 231 cases in which the LigaSure was used to perform laparoscopic splenectomy. A significant reduction in operating time (average 102 minutes) and intraabdominal blood loss (66mL) was observed with the LigaSure compared with endostaplers.

CONCLUSION

The use of LigaSure and the semilateral position results in a gain of time and safety in addition to low intraoperative bleeding, need for transfusion, minimal complications and a low conversion rate.

Single-incision laparoscopic splenectomy using the "tug-exposure technique" in adults: results of ten initial cases

BACKGROUND

The application of single-incision laparoscopic surgery (SILS) to splenectomy is still challenging with much room for technical improvement. The purpose of this study was to describe the tug-exposure technique, an innovative technique for performing safe single-incision laparoscopic splenectomy (SILS-Sp).

METHODS

We performed SILS-Sp in ten consecutive adult patients with a variety of pathology requiring total splenectomy. A SILS™ Port with three 5-mm trocars was placed in the umbilicus as a single-access site. A flexible 5-mm laparoscope and an articulating grasper were used in addition to standard laparoscopic equipment. A cloth tape was introduced intraperitoneally to encircle and tug the splenic hilum. Both ends of the tape were extracted through an extra needle hole in the skin. Pulling the tape in appropriate directions provided excellent exposure of the splenic hilum (the tug-exposure technique). Under sufficient tension and exposure by tugging the spleen, a linear stapler was introduced for stapling and dividing the splenic hilum and the splenic artery and vein. The spleen was extracted through the umbilical wound within a retrieval bag. The umbilical wound was closed with subcutaneous sutures.

RESULTS

The tug-exposure technique was successfully used in all patients and markedly improved the exposure of the splenic hilum during SILS-Sp. The median intraoperative blood loss was 15 (range 0-1,000) ml. Only one patient (10%) required conversion to open surgery. Median operative time was 230 (range, 150-378) min, the median extracted spleen weight was 260 (range, 100-580) g, and the median postoperative hospital stay was 7 (range, 4-9) days. All patients were discharged uneventfully. The umbilical incision was nearly invisible at the 1-month follow-up.

CONCLUSIONS

The tug-exposure technique is an innovative technique that enables easy and safe SILS splenectomy by experienced surgeons.