A comparison of laparoscopic and traditional open splenectomy in childhood

Twenty-Five-Year Experience with Minimally Invasive Splenectomy in Children: From Minilaparotomy to Use of Sealing Devices and Indocyanine Green Fluorescence Technology: Tips and Tricks and Technical Considerations

Background: This study aimed to review our 25-year experience with pediatric laparoscopic splenectomy (LS) and describe tips, tricks, and technical considerations. Methods: The records of 121 children, undergoing minimally invasive splenectomy in the last 25 years (1996-2021), were retrospectively reviewed. Median patient age was 10.2 years (range 7-17). The patients were grouped according to the period: G1 (1996-2005) included 31 patients undergoing open splenectomy using left subcostal minilaparotomy (G1a) and 28 receiving LS using supine position (G1b); G2 (2006-2021) included 62 patients undergoing LS using lateral decubitus. A five-trocar technique was adopted in G1b, with the spleen removed through a Pfannenstiel incision. In G2, we preferred to use lateral decubitus, 10-mm 30° optic, only four trocars, and sealing devices. In such cases, the spleen was placed in an endobag, finger-fragmented, and extracted through the umbilicus. Furthermore, indocyanine green (ICG) fluorescence was used in the last 4 G2 patients to clearly identify the vascular anatomy. Results: The median operative time was 65 minutes in G1a, 125 in G1b, and 95 in G2. Complications occurred intraoperatively in 14 cases (11.5%): 5 bleedings during dissection (G1b), 4 endobag breakages during spleen removal (G2); 3 spleen capsule breakages during removal (G1a); and 2 instrumentation failures (G2). No conversions to open occurred. Median hospital stay was 6 days in G1a and 4 days in G1b and G2. Conclusions: LS is a standardized and effective procedure in children and is preferable to mini- or conventional open splenectomy. Our 25-year experience showed that major complications may occur even in expert hands, mainly during hilar dissection or spleen extraction. Technically, sealing devices and ICG fluorescence were helpful to perform a safer and faster procedure. We believe that lateral decubitus and 30° optic should be considered technical key points to provide excellent organ exposure and easier dissection of hilar structures.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

INTRODUCTION

 Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery.

MATERIALS AND METHODS

 Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification.

RESULTS

 A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades.

CONCLUSION

 Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

The Alexis® system for laparoscopic splenectomy in pediatric patients

The laparoscopic splenectomy in pediatric patients is performed worldwide but often the disproportion between size of patients and size of organs requires an extra laparotomic access for spleen removal. The aim of the present study was to evaluate the safety and effectiveness of the Alexis^® system to retrieve the spleen without additional laparotomic access. The charts of all patients who underwent splenectomy at our center during the last 5 years were retrieved. In all the cases the Alexis^® system was placed in the umbilicus, thru which a 10 mm camera was inserted. Three additional 5 mm standard trocars were inserted. Seven patients, affected by spherocytosis (3), epidermoid cyst (2), idiopathic thrombocytopenic purpura (2) and thalassemia (1), underwent laparoscopic splenectomy at a median age of 10 years (range: 8–17). Median patients’ weight was 32.5 kg (range: 25–71) and spleen size 15 cm (11–18). In all the cases, upon removal of the camera, the retrieval bag was inserted thru the umbilicus under direct view, the spleen retrieved, morcellated, and removed. No conversion nor enlargement of one of the ports nor an extra laparotomic access were required. The patients were discharged on the fifth post-operative day and the cosmetic results were excellent. Removal of the spleen can be safely performed without any additional laparotomy thru the Alexis^® system placed in the umbilicus. This system is effective also in case of major patient/organ size disproportion and the final cosmetic aspect is excellent.

The Effect of Technical Problems on the Operation Process in Pediatric Laparoscopy

Objectives:

The aim of this study was to determine the technical problems in pediatric laparoscopic surgery and to evaluate its results.

Methods:

The technical problems encountered in 30 laparoscopic operations performed between 3 November 2012 and 31 December 2017 were retrospectively analyzed.

Results:

The technical problems experienced in 30 laparoscopic surgeries were analyzed. There were 6 splenectomies, 15 appendectomies, 1 hernioplasty, 2 ovarian cyst excisions, 4 cholecystectomies, 1 intra-abdominal exploration of the testes, and 1 varicocele surgery. The technical errors included instrument failure in 10, human errors in 8, device problems in 12, and multiple problems in 2 cases. In 5 patients, we switched to open surgery.

Conclusion:

Technical problems prolong the operation, and cause a conversion to open surgery. In order to solve these problems, it is necessary to register and report these problems and take the necessary preventive measures.

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.

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.

Intra-Abdominal Splenosis Following Laparoscopic Splenectomy Causing Recurrence in a Child with Chronic Immune Thrombocytopenic Purpura

In this paper, we present the case of a 12-year-old boy with refractory, symptomatic immune thrombocytopenic purpura (ITP) who underwent a laparoscopic splenectomy (LS). During morcellation of the spleen the retrieval bag ruptured. Thirteen (13) months postoperatively, the patient developed further symptoms and was found to be thrombocytopenic. Tc-99m heat-damaged red blood cell scintigraphy showed an accumulation of heat-damaged red cells in the upper left quadrant, raising the possibility of missed accessory spleen. Laparoscopic exploration revealed widespread intra-abdominal splenosis, and a therapeutic omentectomy was carried out. Fourteen (14) months post-surgery, platelet counts improved and the patient remains well. Following an elective splenectomy, a relapse in ITP may be the result of missed accessory spleen or splenosis; in others, it may the result of ongoing platelet consumption in non-splenic, reticulo-endothelial tissue. During LS, consideration must therefore be given to the risk of not only leaving additional splenic tissue behind, but also to the possibility of accidental autotransplantation, such as that from laparoscopic bag rupture. The risk of rupture can be minimized by using blunt instruments and stronger bag materials. If a rupture does occur, immediate suction and a thorough search for splenic fragments must be undertaken. Further development is needed into new techniques for organ retrieval and stronger bag materials.

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.

Esplenectomia laparoscópica nas doenças hematológicas

OBJETIVO: Relatar a experiência inicial do Centro Infantil Boldrini com a esplenectomia laparoscópica (EL) em crianças e adultos jovens. MÉTODO: Foram revisados os prontuários de 40 pacientes (mediana da idade de 6,6 anos; 1 a 22,8) submetidos à EL entre Julho de 2000 e Maio de 2002. As principais indicações de acordo com a doença de base foram: doença falciforme (DF) em 20 pacientes (50%), esferocitose hereditária em 10 (25 %), púrpura trombocitopência idiopática em oito (20 %), doença de Hodgkin em um e anemia hemolítica a esclarecer em um. RESULTADOS: Trinta e oito esplenectomias foram completadas por via laparoscópica (duas conversões) e em doze foi realizada adicionalmente a colecistectomia. A mediana do tempo operatório foi de 127,5 minutos (90-240 min) e sete (17,5 %) baços acessórios foram encontrados. Sangramento intra-operatório foi significativo apenas nas duas conversões, mas não houve necessidade de transfusões. A mediana do peso dos baços foi de 250 g (106-1000; n=36). Complicações pós-operatórias ocorreram em sete (17,5 %) pacientes e, nos portadores de DF, 35% desenvolveram síndrome torácica aguda. A mediana da permanência hospitalar pós-operatória foi de dois dias (2 - 14). O seguimento variou de 23 dias a dois anos (mediana de 11 meses). CONCLUSÕES: A EL pode ser realizada de modo seguro mesmo em baços de grande tamanho e é opção atrativa que pode substituir o procedimento aberto. Em pacientes com DF, a taxa de complicações permanece alta, sugerindo mecanismos outros que vão além da escolha da via de acesso cirúrgica.

Laparoscopic resection of type I choledochal cyst

Type I choledochal cyst is a rare saccular or fusiform congenital dilatation of the extrahepatic biliary tract. It is usually treated by laparotomy at which the cyst is completely excised and a Roux-en-Y hepaticojejunostomy is performed to establish biliary enteric drainage. We report the laparoscopic excision and hepaticoduodenostomy of type I choledochal cyst in two girls aged 1 and 3 years. The entire procedure was performed laparoscopically using needlescopic instruments. A 7-mm telescope port was inserted at the umbilicus, a 3-mm port in the right upper quadrant, and a 6-mm port in left upper quadrant. An additional 3-mm fan-shaped liver retractor was passed through the abdominal wall without a trocar. The gallbladder and choledochal cyst was dissected and removed en bloc. The lower end of the common bile duct was closed with 5-0 polydioxanone. The duodenum was anastomosed to the common hepatic duct below the confluence of the right and left hepatic ducts. There were no intraoperative complications, and the children were asymptomatic with no episodes of cholangitis at 6 months follow-up. Pediatric surgeons trained in advanced laparoscopic techniques including intracorporeal suturing can perform laparoscopic repair of choledochal cyst safely.

Current concepts in minimal access surgery for children

Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.

Laparoscopic splenectomy

The laparoscopic technique for splenectomy has become the preferred method for splenectomy at many institutions over the last 10 years. The advantages of laparoscopic splenectomy include a shortened postoperative hospitalization, improved cosmesis, and less analgesic requirements. It is associated with longer operating times, a steep learning curve, and may be difficult in cases of splenomegaly. A careful search should be made for accessory spleens, and capsular disruption must be avoided. New techniques and smaller instruments have facilitated recent advances in the technical aspects of laparoscopic splenectomy.

Laparoscopic versus Open Splenectomy in the Pediatric Population: A Contemporary Single-Center Experience

The purpose of this study was to compare a recent contemporaneous experience between laparoscopic (LS) and open (OS) splenectomy in children. All splenectomy cases between 1994 and 1999 at our institution were reviewed. The study included open and laparoscopic cases performed according to surgeon preference. Emergency splenectomies for trauma were excluded. The patient record was reviewed for the diagnosis, indications, postoperative length of stay, operative technique, postoperative complications, blood loss/blood transfusion, total amount of parenteral narcotics, and time to resumption of oral intake. Chi-square and t tests were used to compare measured differences for statistical significance. Between May 1994 and December 1999, 52 splenectomies were performed at Vanderbilt Children's Hospital. Of these, 45 were elective operations with 29 open and 16 laparoscopic procedures. During four OS and five LS operations a concomitant cholecystectomy was performed. The median patient age was 9.2 years (range 0.5 to 17.3). There was no statistical difference between the two groups in terms of age, weight, American Society of Anesthesiologists class, or estimated blood loss. There were no immediate postoperative complications in either group. There were no conversions from LS to OS. The mean duration of surgery was 264 minutes (LS) versus 169 minutes (OS) ( P < 0.05). The average time to first oral intake was shorter in patients undergoing LS (1.1 vs 1.6 days, P < 0.05) and the mean postoperative length of stay was also shorter in the LS group (1.3 vs 3.1 days, P < 0.05). The use of postoperative intravenous narcotics (in morphine-equivalent doses) was significantly less in LS patients than in OS patients (7.5 mg or 0.15 mg/kg vs 46.9 mg or 1.5 mg/kg, P < 0.001), as was the need for PCA pump analgesia (90% in the OS group vs 25% in LS group, P < 0.01). Overall the average hospital charge (anesthesia fee, narcotics charge, and hospital room charge) was $5400 (range $4240–6250) in the OS group and $4950 (range $4450–6240) in the LS group ( P < 0.05). Among the nine patients undergoing splenectomy with cholecystectomy, findings between the OS and LS groups were similar except for one late complication consisting of a diaphragmatic hernia in an LS patient. Both LS and OS with or without a concomitant procedure can be accomplished safely in children. LS appears to result in longer operative times but shorter lengths of stay, earlier first oral intake, and significantly fewer requirements for intravenous narcotics; all of these contribute to a reduction in hospital charges compared with the open operation.

Optimal teaching environment for laparoscopic splenectomy

BACKGROUND

Traditional surgical teaching depends on graduated acquisition of skill learned in residency. The introduction of minimal access techniques after residency training has created a new paradigm dependent on animate course experiences and limited preceptor training. The outcome of performance of a new skill "learned" in these settings has not been assessed. The purpose of this study was to test the benefit of an animate course compared with a precepted operating room experience in learning to perform a laparoscopic splenectomy.

METHODS

All attending surgeons who had taken a 1-day course to learn laparoscopic splenectomy (n = 37) and those who had undergone an intraoperative preceptorship (in their hospital) by the lead author (n = 15) were polled to ascertain their previous experience with laparoscopy and with laparoscopic splenectomy since the intervention. The course included lectures, operative videos, and an animal lab. Statistical differences were measured using a t test.

RESULTS

Thirty-two of the 37 (86.5%) taking the course and all 15 of the precepted surgeons responded. There was no difference between the groups regarding prior laparoscopic experience (P = 0.73), laparoscopic training during residency (P = 0.74), academic or private practice (P = 0.48), or follow-up since the intervention (P = 0.36). The participants graded the courses (1 to 5, 5 = excellent) at an average of 4.72. Fourteen of 15 precepted surgeons have performed laparoscopic splenectomy as compared with 2 of 32 taking courses (nonprecepted surgeons; P <0.0001). The number of laparoscopic splenectomies performed totaled 112 for precepted surgeons and 4 for nonprecepted surgeons (P = 0.0003). The nonprecepted surgeons performed significantly more open splenectomies than laparoscopic (95 versus 13 respectively, P = 0.02). Reasons quoted not to proceed with laparoscopic splenectomy included waiting for the perfect patient, concern of hilar management, and splenic size.

CONCLUSION

Surgeons precepted in their own operating room performed a laparoscopic splenectomy more readily than those gaining experience from a course only (93% versus 6%, respectively) despite no difference in their preintervention experience and having the opportunity to do so. The expectation of the eventual performance of advanced laparoscopic techniques depends on a precepted experience.

Experience with laparoscopic splenectomy

BACKGROUND/PURPOSE

The laparoscopic splenectomy (LS) often is adopted to treat children affected by hematologic diseases. Many of the pitfalls of LS are related to the 2 steps-dissection and extraction. Although various methods have been adopted, the conversion rate still is too high during the learning curve period. The authors analyse their experience in 54 laparoscopic splenectomies performed by their teams in 3 European countries.

METHODS

From 1995 to 1999, 54 children underwent laparoscopic splenectomy, 4 of whom also underwent a concomitant cholecystectomy. There were 29 girls and 25 boys with ages ranging between 4 and 19 years (median, 8.1 years). All patients underwent an elective laparoscopic splenectomy: Thirty children had hereditary spherocytosis, 13 had an idiopathic thrombocytopenic purpura, 10 were affected by a beta thalassemia, and 1 child had sickle cell disease.

RESULTS

Mean operating time was 140 minutes (range, 100 to 250 minutes). Hospital stay ranged from 2 to 6 days (median, 3 days). In 7 patients the spleen was removed through a 7-cm minilaparotomy; in another 46 cases the spleen was captured into an extraction bag, fragmented, and then removed through the umbilical or left orifice. There was one conversion to open surgery because of a camera failure during the operation.

CONCLUSIONS

On the basis of our experience we believe that the operating time of LS is still too long compared with open surgery, and the extraction phase still not simple enough. A perfect control of hemostasis is fundamental because severe complications can arise from even a slight bleeding episode. It also is very important to search for and remove any accessory spleens. In our series this occurred in 7 patients, one of whom had 3 accessory spleens. The laparoscopic approach is today a good alternative to open splenectomy.

Laparoscopic Splenectomy in Children with Hematological Disorders: Preliminary Experience at the Children's Hospital of New Orleans

Minimally invasive surgery has recently gained acceptance as the surgical approach of choice for a variety of surgical disorders in children. Although traditional open surgery is still regarded as the standard approach for a splenectomy in children when necessary for hematologic disorders a few cases of successful laparoscopic splenectomy (LS) have been reported. We present our initial 11 cases of LS in children assessing surgical outcome. Eleven patients ages 2 through 15 years underwent LS between June of 1996 and July of 1999 at the Children's Hospital of New Orleans. Indications for surgery included idiopathic thrombocytopenic purpura, congenital spherocytosis, and hemolytic anemia. In all patients the diameter of the spleen was less than 15 cm. Surgical outcome was assessed according to the following parameters: operative time, postoperative length of stay, postoperative morbidity, and cosmetic results. Data were accumulated on the basis of retrospective chart review. LS was completed in all 11 patients. Postoperative morbidity was minimal and the median postoperative stay was 2.4 days (range 1–5). Mean operative time was 3 hours and 10 minutes (range 1.5–7 hours) with the last six procedures completed in an average of just over 2 hours. Intravenous analgesia was discontinued in <48 hours in all patients. Cosmetic results were judged excellent in all cases. We conclude that LS was safe in children with certain hematologic disorders. Adequate selection of patients, appropriate preoperative preparation of patients, meticulous surgical technique, and careful postoperative care were key factors in obtaining the same long-term results as with open surgery.

Technical advances in pediatric laparoscopy have had a beneficial impact on splenectomy

PURPOSE

The aim of this study was to demonstrate the effects of recent technical advances on the safety and benefits of pediatric laparoscopic splenectomy.

METHODS

A retrospective review was conducted of patients undergoing laparoscopic splenectomy from January 1998 to January 2000. Technical advances utilized during this period included the harmonic scalpel, a specialized flexible hilar retractor, a larger, wire-rimmed specimen bag, and lateral patient positioning.

RESULTS

Laparoscopic splenectomy was performed successfully on 18 patients aged 3 to 17 years (median, 9). The indications were hereditary spherocytosis (n = 10), idiopathic thrombocytopenic purpura (n = 5), and other (n = 3). Eight patients had concomitant procedures including cholecystectomy (n = 3), resection of an accessory spleen (n = 3), and other (n = 2). The median operating time, including the concomitant procedures, was 125 minutes (range, 70 to 235). Patients tolerated a regular diet on median postoperative day 1 (range, 1 to 3), and 16 were discharged home on or before postoperative day 2. None of the patients required blood product transfusion or conversion to an open technique. There were no complications, and all patients had returned to usual activity by 2 weeks.

CONCLUSION

With recent technological advances, the laparoscopic approach has become easy to perform, safe, and should be considered the procedure of choice for pediatric splenectomy.

The response to splenectomy in pediatric patients with idiopathic thrombocytopenic purpura who fail high-dose intravenous immune globulin

BACKGROUND

A recent article by Law et al concluded that patients with idiopathic thrombocytopenic purpura (ITP) who have a poor response to intravenous immune globulin (IgG) are unlikely to have a good or excellent response to surgical splenectomy.

METHODS

The authors studied retrospectively 23 pediatric patients age 11.7 +/- 1.0 years with ITP who had been treated with IgG before undergoing splenectomy. As in the aforementioned article, the responses to the 2 treatments were classified on the basis of the platelet count as poor (<50,000/mm3), good (50,000 to 150,000/mm3), or excellent (>150,000/mm3). For patients who received multiple IgG treatments, both initial and final treatment responses were analyzed.

RESULTS

Sixteen patients had an excellent or good initial response to IgG. Of these 16 patients, 14 had an excellent or good response to splenectomy. Among the 7 patients who had a poor response to IgG there were 3 who had an excellent or good response to splenectomy (43%), and 4 patients who had a poor response to splenectomy. A good or excellent response to initial treatment with IgG was associated with a significant probability of a good or excellent response to splenectomy (P = .045).

CONCLUSIONS

A good or excellent response to IgG may be predictive of a favorable response to splenectomy. However, a poor response to IgG does not preclude a satisfactory response to splenectomy in pediatric patients with ITP.

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.

Splenectomy revised: manually assisted splenectomy with the dexterity device--a feasibility study in 22 patients

Laparoscopic splenectomy claims a number of advantages over open surgery: less trauma, quicker recovery, and faster return to normal activity. On the other hand, laparoscopic splenectomy is complex and time consuming, and so far, many surgeons are reluctant to perform such an operation. A new device was designed to give manual access to the abdomen through a utility laparotomy. By using one hand in the abdomen during laparoscopy, the surgeon regains direct tactile sense and hand-eye coordination. A pilot study to assess the feasibility of this method has been performed in 22 patients. The operation could be completed easily in 21 patients (95%). The average blood loss was 230 mL, and the average postoperative stay was 3.9 days. With this simple, inexpensive method, it is possible to combine the established convenience, safety, efficacy of open surgery with the advantages of minimally invasive surgery.

Laparoscopic splenopexy for pediatric wandering spleen

Wandering spleen is an uncommon condition, showing a splenic hypermobility that results from laxity or maldevelopment of its suspensory ligament. This condition results in constant danger of splenic torsion and infarction. Wandering spleen was diagnosed in a 2-year-old girl who complained of intermittent abdominal pain, and viability of the spleen was confirmed by doppler ultrasound scan. Elective laparoscopic splenopexy was performed by anchoring the spleen wrapped in absorbable mesh. To our knowledge, this is the first reported case of laparoscopic splenopexy for wandering spleen. The authors believe that this approach is a safe and effective procedure for wandering spleen with the advantage of minimally invasive surgery.

Laparoscopic surgery in children

The surgeon should be aware of the extensive applications of endoscopic surgery in the pediatric patient. The ability to provide surgical care in association with either outpatient or short-stay hospitalizations appear to be cost-effective and appropriate state-of-the-art medical care. Because the array of surgical instruments continues to evolve, new and innovative endoscopic procedures will continue to become increasingly available.

Laparoscopy improves outcomes for pediatric splenectomy

BACKGROUND

Pediatric laparoscopic splenectomy is a relatively new surgical procedure with a limited number of reports comparing its outcomes to that of the open procedure. The authors have minimized the invasiveness of our procedure by using only three ports and have described the technique as well as compared it with the open method.

METHODS

A retrospective review of seven laparoscopic splenectomies (LS) using a three port technique were compared with seven open splenectomies (OS) performed for similar indications at a single children's hospital.

RESULTS

The average age in the LS group was 8.7 years compared with 8.9 years for OS, (P value not significant), and the average weights were also similar. The indications for splenectomy were hereditary spherocytosis, idiopathic thrombocytopenic purpura, sickle cell anemia, and splenic cyst. All splenectomies were performed safely with an average estimated blood loss of 41 mL for LS and 34 mL for OS (P value not significant). Operative time averaged 147 minutes for LS and 86 minutes for OS (P < .05). LS patients recovered more rapidly and were discharged home on a median of postoperative day (POD) 2 versus POD 4 for OS (P < .05). LS patients received significantly less total amount of intravenous pain medication with an average of 0.18 mg/kg of morphine sulfate versus 0.8 mg/kg for OS (P< .05). Total hospital charges were higher for LS with an average of $10,899 versus $8,275 for OS (P < .05).

CONCLUSIONS

Laparoscopic splenectomy currently is a safe procedure, offering better cosmesis, much less pain, and a shorter hospital stay compared with the traditional open procedure. The more sophisticated equipment and time needed to carry out the procedure led to a modestly increased hospital cost.

Endoscopic surgery in infants and children: new approaches for surgical problems

Endoscopic surgery is rapidly becoming the most popular means of resolving surgical problems and is now performed with increased frequency in children. New technology has allowed for direct visualization of the surgical field using innovative surgical approaches and techniques. Decreased postoperative morbidity, shorter hospitalizations, and rapid recoveries are among the major advantages of this form of surgery. This article provides information concerning the benefits and potential risks of endoscopic surgery and reviews the major procedures that are currently available for infants and children.

The lateral approach for open splenectomy

BACKGROUND

Laparoscopic splenectomy (LS) has been used increasingly to treat children with hematologic disorders and has been reported to have advantages over open splenectomy performed through a standard vertical or subcostal incision. The authors perform open splenectomy (OS) through a lateral, muscle-splitting approach, and believe their approach is more reasonable in comparison with LS.

METHODS

Thirty-nine consecutive open splenectomies performed between 1991 and 1995 were reviewed retrospectively and compared with recent reports of LS. The series included 24 boys and 15 girls with an average age of 9 years and average weight of 37.5 kg. Indications included immune thrombocytopenic purpura (n = 20), hereditary spherocytosis (n = 18), and sickle cell anemia (n = 1). The operation was performed with the child in the lateral decubitus position through a left upper abdominal muscle-splitting incision (off the 11th rib), sparing the rectus muscle.

RESULTS

All 39 cases were completed without intraoperative complications with an average surgical time of 98.0 minutes (range, 30 to 302). The average surgical blood loss was 89 mL (range, 10 to 300). The children started feeding an average of 1.2 days (range, 0 to 4) postoperatively, were on a regular diet at an average of 2.0 days (range, 1 to 6) postoperatively, and had an average length of stay of 2.7 days (range, 1 to 6). There was no mortality or morbidity.

CONCLUSIONS

Open lateral splenectomy is performed with shorter surgical times, less blood loss, an excellent cosmetic result, no complications, and a length of stay comparable to any of the published series on laparoscopic splenectomy in children. This approach provides a reasonable basis for comparison with laparoscopic splenectomy.

Pediatric laparoscopic splenectomy: are there real advantages in comparison with the traditional open approach?

The hospital records of patients who underwent splenectomy during the last 2 years were reviewed to compare the advantages of the laparoscopic approach with traditional open splenectomy (OS). Between March 1994 and March 1996, 16 children underwent splenectomy, in 8 using an open approach and 8 by a laparoscopic procedure. Of the patients who underwent laparoscopic splenectomy (LS), 2 had a concomitant cholecystectomy. Ages ranged between 4 and 11 years (mean 6.4 years); there were 9 girls and 7 boys. The indications for splenectomy were: hereditary spherocytosis (7 cases); idiopathic thrombocytopenic purpura (4); sickle-cell disease (3); and beta-thalassemia (2). The average operating time for OS was 100 min (range, 50-155), for LS 170 min (range 125-240). The hospital stay for patients who had OS ranged from 3 to 9 days (mean 4.7), for those who had LS from 2 to 5 days (mean 3). One OS patient developed a wound infection. In 3 of the LS patients, the spleen was removed via a 7-cm Pfannenstiel minilaparotomy in the suprapubic region; in 5 cases the spleen was captured into an extraction bag, crushed, and removed through the umbilical orifice. The authors believe that LS must be performed only when it is possible to use the extraction bag to remove the spleen from the umbilical orifice (spleens weighing less than 700 g) and when a concomitant procedure such as cholecystectomy is indicated; in other cases OS is preferable.

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.

Technical aspects of laparoscopic splenectomy in children

Different authors reported about their experiences in laparoscopic splenectomy. The preparation of vessels and ligaments are feasable without major problems. Nevertheless the handling of the organ during the operation and during splenic extraction can be very difficult, especially in larger organs. The authors report experience with the technique of laparoscopic splenectomy and describe a new technical aspect in handling the spleen during this procedure. A loop of an umbilical band is used for retracting the organ during the preparation and placing the spleen into a sterile bag for the removal of the organ. This device helps prevent damages to the capsule caused by forceps. Large organs can be placed into the pelvis, and the bag is placed and opened in the upper abdomen. The authors used this technique successfully in seven patients. The results are compared with previous experiences.

Comparative analysis of laparoscopic versus open splenectomy

BACKGROUND

Laparoscopic splenectomy (LS) has been used to treat a variety of splenic disorders. However, there have been few direct comparisons of this approach with open splenectomy (OS).

METHODS

Results and outcomes were compared retrospectively in 46 consecutive patients treated by laparoscopic (n = 26) or open splenectomy (n = 20) from January 1990 through March 1996. The two groups were similar in age, sex, and American Society of Anesthesiology classification. Splenectomy was performed for a variety of indications, and the majority of patients in both groups had normal or near-normal size spleens. All data are expressed as mean +/- standard deviation.

RESULTS

Laparoscopic splenectomy was successfully completed in all 26 attempted cases. Operative times were significantly longer for LS (202 +/- 55 minutes) than for OS (134 +/- 43 minutes) (P < 0.001); however, operative times in the last 13 LS cases (176 +/- 48 minutes) averaged 51 minutes less than in the first 13 cases (227 +/- 51 minutes). Estimated operative blood loss was less for LS (222 +/- 280 mL) than for OS (376 +/- 500 mL) (P = not significant). A mean of 2.0 units of red blood cells was transfused in 4 (15%) of 26 patients during LS vs 1.0 unit transfused in 2 (10%) of 20 patients who had OS (P = NS). Patients who underwent LS required significantly less parenteral pain medications, had a more rapid return to regular diet, and were discharged sooner than patients who had OS. Complication rates were similar in the two groups.

CONCLUSIONS

These results suggest that LS is technically safe and has several advantages over OS. Laparoscopic splenectomy should become the procedure of choice for the removal of normal and near-normal size spleens.