Laparoscopic versus open splenectomy in the management of splenomegaly: our preliminary experience. Surgery. 1998;124:839-843. [PMID: 9823396 DOI: 10.1016/s0039-6060(98)70006-6]

The Diagnostic Utility of Splenectomy in Idiopathic Splenomegaly

INTRODUCTION

With increasing frequency, patients with idiopathic splenomegaly are referred to surgeons for splenectomy. We evaluated the diagnostic utility of splenectomy and feasibility of a minimally invasive approach in the face of idiopathic splenomegaly.

METHODS

We retrospectively reviewed 68 patients who underwent splenectomy for idiopathic splenomegaly. The primary endpoint was the rate of definitive diagnosis based on final surgical pathology of the removed spleen.

RESULTS

Preoperative workup included a bone marrow biopsy and peripheral blood smear in 93% and 100% of patients, respectively, with none having lymphadenopathy warranting biopsy. Splenectomy provided a definitive diagnosis for 44 (64.7%) patients. Of these, 34 (50%) patients had an underlying malignancy, of which more than half were splenic marginal zone lymphoma. There were 33 (48.5%) laparoscopic, 23 (33.8%) open, 10 (14.7%) laparoscopic converted to open, and two (2.9%) laparoscopic hand-assist cases. Conversion to open was due to splenic size [median craniocaudal length 21.8 cm (cm)] in eight and staple line bleeding at the splenic hilum in two patients. Overall, the laparoscopic approach was completed in patients with a smaller splenic size compared to open (median craniocaudal length 15.2 vs. 26.0 cm, p < 0.0001). The open group had one (1.5%) intra-operative mortality due to uncontrollable hemorrhage. Thirty-day complication rates were similar for laparoscopic and open approaches (p = 0.10).

CONCLUSION

Splenectomy is an effective diagnostic modality in determining a pathologic cause for splenomegaly in this patient population. Laparoscopic splenectomy can be performed safely in appropriate cases with craniocaudal splenic size having the largest influence on surgical approach.

Outcomes of Laparoscopic Splenectomy for Treatment of Splenomegaly: A Systematic Review and Meta-analysis

OBJECTIVES

To review the evidence regarding the outcomes of laparoscopic techniques in cases of splenomegaly.

BACKGROUND

Endoscopic approaches such as laparoscopic, hand-assisted laparoscopic, and robotic surgery are commonly used for splenectomy, but the advantages in cases of splenomegaly are controversial.

REVIEW METHODS

We conducted a systematic review using PRISMA guidelines. PubMed/MEDLINE, ScienceDirect, Scopus, Cochrane Library, and Web of Science were searched up to February 2020.

RESULTS

Nineteen studies were included for meta-analysis. In relation to laparoscopic splenectomy (LS) versus open splenectomy (OS), 12 studies revealed a significant reduction in length of hospital stay (LOS) of 3.3 days (p = <0.01) in the LS subgroup. Operative time was higher by 44.4 min (p < 0.01) in the LS group. Blood loss was higher in OS 146.2 cc (p = <0.01). No differences were found regarding morbimortality. The global conversion rate was 19.56%. Five studies compared LS and hand-assisted laparosocpic splenectomy (HALS), but no differences were observed in LOS, blood loss, or complications. HALS had a significantly reduced conversion rate (p < 0.01). In two studies that compared HALS and OS (n = 66), HALS showed a decrease in LOS of 4.5 days (p < 0.01) and increase of 44 min in operative time (p < 0.01), while OS had a significantly higher blood loss of 448 cc (p = 0.01). No differences were found in the complication rate.

CONCLUSION

LS is a safe approach for splenomegaly, with clear clinical benefits. HALS has a lower conversion rate. Higher-quality confirmatory trials with standardized splenomegaly grading are needed before definitive recommendations can be provided. Prospero registration number: CRD42019125251.

Hand-assisted Laparoscopic Splenectomy Advantages Over Complete Laparoscopic Splenectomy For Splenomegaly

BACKGROUND

Laparoscopic splenectomy (LS) is generally applied for splenectomy, However, it also brings some technical challenges, especially for splenomegaly. Hand-assisted laparoscopic splenectomy (HALS) can help to overcome these drawbacks while maintaining the superiority of LS. This study was aimed to evaluate the efficacy and advantage of HALS for splenomegaly.

MATERIALS AND METHODS

Between January 2014 and November 2017, 91 patients with splenomegaly in 2 surgical centers were randomly assigned to either HALS (n=45) or LS (n=46). The patients' characteristics, intraoperative details, and the postoperative outcomes in both groups were compared.

RESULTS

Baseline features (sex, age, main diameter, Child-Pugh grade) of both groups had no significant difference (P<0.05). Compared with LS group, the HALS group operation time (141±46 vs. 172±43 min; P=0.001) was shorter, intraoperative blood loss [215 (122.332) vs. 230 (130.740) mL; P=0.026], hospital expenses (5.5±1.5 vs. 6.4±2.4 WanRMB; P=0.022), and conversion rate (1/45 vs. 9/46; P=0.015) were lower. However, there was no significant difference for hospital stay (6.4±2.8 vs. 6.7±3.0 d; P=0.662) and complications (15/45 vs. 12/46; P=0.893) between the 2 groups. In addition, there were no significant differences in postoperative white blood cell (10.6±2.9 vs. 10.9±3.5; P=0.747), AST [61 (47.94) vs. 57 (37.86) U/L; P=0.513], and ALT [68 (54.120) vs. 55 (36.99) U/L; P=0.302] levels.

CONCLUSIONS

HALS can maximize the benefits for patients, while maintaining the advantages of LS and open splenectomy. It is the ideal surgical treatment for splenomegaly.

Laparoscopic splenectomy in malignancies: is safe and feasible?

BACKGROUND

Laparoscopic splenectomy (LS) is considered the treatment of choice for benign hematologic diseases of the spleen. However, the role of LS in malignancies is still controversial. Technical difficulties, hemorrhagic risk, the need of pathological characterization of malignant disease, may be considered contraindications to LS in malignancies. This study aims to verify the efficacy and feasibility of LS for hematologic malignancies.

METHODS

One hundred and forty-five patients underwent LS for hematologic disease and were retrospectively shared in two groups: Group A (N.=83) patients with preoperative diagnosis of benign hematologic disease and Group B (N.=62) with malignancies. Bipolar spleen diameter, mean operative time, conversion rate and causes, complications and need of transfusion were evaluated.

RESULTS

Median splenic diameter was greater in Group B than in Group A with a statistically significant difference (P<0.005), and the number of accessory mini-laparotomies (P<0.005) and the conversion rate (P=0.024) in the group of patients with a diagnosis of malignancy were also higher. The mean operative time was 117.6 minutes in group A and 148.1 minutes in Group B (P<0.005). Besides, there were no significant differences relative to intraoperative and postoperative transfusions and the incidence of postoperative complications. No perioperative mortality occurred.

CONCLUSIONS

The analysis of our data highlights that LS for hematologic malignancies is effective and feasible even if it associated with higher conversion rate due to splenomegaly and difficult hilum dissection. Besides, no differences in the patient outcome were highlighted. LS may be considered a safe procedure in the treatment of haematological malignancies of the spleen.

Hand-assisted laparoscopic splenectomy is a useful surgical treatment method for patients with excessive splenomegaly: A meta-analysis

BACKGROUND

Hand-assisted laparoscopic splenectomy (HALS) can help overcome the drawbacks of laparoscopic splenectomy (LS) while maintaining its advantages.

AIM

To evaluate the efficacy and advantages of HALS for splenomegaly.

METHODS

The relevant literature was reviewed using the PubMed, EMBASE, Cochrane, Ovid Medline, and Wanfang databases to compare the clinical outcomes of HALS and LS. Odds ratios or mean differences were calculated with 95% confidence intervals for fixed-effects and random-effects models. Overall, 754 patients from 16 trials who met the inclusion criteria were selected.

RESULTS

In pure splenectomy, blood loss volume (P < 0.001) and conversion rate (P = 0.008) were significantly lower in the HALS group than in the LS group. Conversely, for splenomegaly, the operative time (P = 0.04) was shorter and blood loss volume (P < 0.001) and conversion rate (P = 0.001) were significantly lower in the HALS group than in the LS group. However, no significant difference was observed in hospital stay length, blood transfusion, time to food intake, complications, or mortality rate between the two groups. Moreover, in splenectomy and devascularization of the upper stomach (DUS), the operative time (P = 0.04) was significantly shorter and blood loss volume (P < 0.001) and conversion rate (P = 0.05) were significantly lower in the HALS + DUS group than in the LS + DUS group. However, no significant difference was observed in hospital stay length, timing of diet, and complications between the two groups.

CONCLUSION

HALS is an ideal surgical treatment method for splenomegaly because it can maximize the benefits for patients while maintaining the advantages of LS.

Outcome of Laparoscopic Splenectomy for Malignant Hematologic Diseases

Aim

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

Patients and methods

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

Results

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

Conclusions

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

Outcomes of Open Splenectomy for Hematologic Malignancy with Splenomegaly: A Contemporary Perspective

Splenectomy for hematologic malignancy (HM) is considered a high-risk procedure, especially in cases of splenomegaly. We analyzed the postoperative course of 82 patients undergoing open splenectomy for HM-related splenomegaly (splenic craniocaudal length 15 cm or greater) in a high-volume center. Primary outcome measures were: perioperative clinical course, rate and severity of postoperative complications (Clavien-Dindo classification), and length of hospital stay. Risk factors analyzed for morbidity and mortality by logistic regression analysis were: gender, age, American Society of Anesthesiologists (ASA)grade, body mass index (BMI), steroidal treatment, preoperative white blood cell count, spleen size, spleen weight, and operative time. The postoperative mortality rate was 1.2 per cent. Only 15.9 per cent of patients required surgical, endoscopic, or radiological intervention after splenectomy (Grade 3 or greater complication). Overall postoperative morbidity rate (as Grade 2 or greater complication) was 52.4 per cent. Surgical complications, mainly bleeding, occurred in 40.2 per cent of patients and 32.9 per cent of patients required blood transfusion. Medical complication rate was 24.4 per cent. Pulmonary disorders were prevalent among medical complications. At multivariate analysis, only ASA score was an independent risk factor for postoperative complications. Open splenectomy can be performed in high-volume centers with low mortality and acceptable morbidity in patients with HM-related splenomegaly, provided that patients at highest risk of postoperative complication (ASA greater than 3) are carefully evaluated.

Laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension

Since the first laparoscopic splenectomy (LS) was reported in 1991, LS has become the gold standard for the removal of normal to moderately enlarged spleens in benign conditions. Compared with open splenectomy, fewer postsurgical complications and better postoperative recovery have been observed, but LS is contraindicated for hypersplenism secondary to liver cirrhosis in many institutions owing to technical difficulties associated with splenomegaly, well-developed collateral circulation, and increased risk of bleeding. With the improvements of laparoscopic technique, the concept is changing. This article aims to give an overview of the latest development in laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension. Despite a lack of randomized controlled trial, the publications obtained have shown that with meticulous surgical techniques and advanced instruments, LS is a technically feasible, safe, and effective procedure for hypersplenism secondary to cirrhosis and portal hypertension and contributes to decreased blood loss, shorter hospital stay, and less impairment of liver function. It is recommended that the dilated short gastric vessels and other enlarged collateral circulation surrounding the spleen be divided with the LigaSure vessel sealing equipment, and the splenic artery and vein be transected en bloc with the application of the endovascular stapler. To support the clinical evidence, further randomized controlled trials about this topic are necessary.

Splenectomy in older adults: indications and clinical outcomes

The aim of this study was to improve the understanding of the indications and associated outcomes among older adults undergoing splenectomy. Data regarding patients of age ≥60 years treated between 1998 and 2008 were reviewed. Fifty patients (age 71.6 ± 8) were identified. Common indications for splenectomy included idiopathic thrombotic purpura (26.0 %) and lymphoma (28.0 %). Patient co-morbidities included hypertension (54 %), coronary artery disease (24 %) and diabetes mellitus (20 %). Twenty-seven patients (54 %) underwent laparoscopic surgery; 23 (46 %) had open procedures; more than half of open splenectomies were conversions from attempted laparoscopy. Mean post-operative length of stay (LOS) was 5.9 ± 5 days (range 1-21). Two patients died in hospital; an additional three died within 6 months. Five patients were discharged to an extended care facility (ECF). Three patients required readmission within 30 days. Increased age was associated with need for ECF (p = 0.01). Increasing LOS, but not age, was associated with 6-month mortality (p = 0.04). Although we noted a 10 % in hospital mortality rate, splenectomy appears to be safe for carefully selected older adults.

Laparoscopic and open splenectomy for splenomegaly secondary to liver cirrhosis: an evaluation of immunity

OBJECTIVE

We sought to investigate the perioperative inflammatory response and immunological function of patients with portal hypertension-induced splenomegaly who underwent laparoscopic (LS) or open splenectomy (OS).

METHODS

This prospective study investigated a total of 34 patients with splenomegaly due to portal hypertension who underwent either LS (n = 18) or OS (n = 16) between May 2009 and September 2010. Peripheral venous blood samples were taken from these patients prior to surgery and on postoperative days (POD) 1, 3, and 7. The perioperative clinical outcomes and immunological function results were analyzed and compared within each surgical group.

RESULTS

The demographics of the two groups did not differ. The patients in the LS group experienced longer operating time, less intraoperative blood loss, earlier resumption of diet, and shorter postoperative hospital stay. Both the open and laparoscopic groups exhibited statistically significant differences in interleukin -6 and C-reactive protein levels, and total lymphocyte, CD4 T, and natural killer cell numbers on POD 1 and 3 compared with pre splenectomy. The immune responses in the LS group were significantly lower than those in the OS group. The LS group exhibited better preserved cellular immune response and faster recovery than the OS group on POD 7.

CONCLUSIONS

An examination of the inflammatory reaction and cellular immune response after LS and OS demonstrated that there are significant differences in the immune responses observed in the two groups. Further human studies are required to determine the permanent effects of LS on immune function.

Laparoscopic splenectomy: conventional versus robotic approach--a comparative study

BACKGROUND

Laparoscopic splenectomy is accepted as a safe approach in the surgical treatment of blood disorders worldwide. Compared with the laparotomic technique, it is associated with a lower risk of intraoperative bleeding, less postoperative pain, and faster discharge times. The advent of robotic surgery (RS) has changed the concept of minimally invasive surgery because, in addition to allowing a three-dimensional view, it permits greater freedom of movement and higher levels of accuracy than laparoscopic surgery (LS). The aim of this study was to comparatively evaluate whether RS presents advantages over LS in spleen surgery.

METHODS

In two Surgical Units with experience in laparoscopic splenectomy, over a 7-year period, two groups of 45 patients underwent LS and RS. The two groups were well matched for demographic characteristics, indications, and spleen size.

RESULTS

No statistically significant differences were found regarding intraoperative blood loss, conversion rate to laparotomy, food intake, drain removal, postoperative complications, and median time to discharge. On the contrary, statistically increased differences were observed in median operative time and costs. In both groups, the transfusion and mortality rate was 0%. At the 6-month follow-up no surgical complications were observed.

CONCLUSIONS

Although RS offers a three-dimensional view, greater freedom of movement, and higher levels of accuracy, it is associated with longer operative times and higher costs. It can consequently be concluded that with the intrinsic limits of the study design used, at the current time, RS does not have any significant advantage over LS in splenectomy.

Laparoscopic versus open pediatric splenectomy for massive splenomegaly

Laparoscopic splenectomy (LS) has rapidly evolved into the technique of choice compared with open splenectomy (OS) because of the advantages of the minimally invasive approach. Splenomegaly increases the technical difficulties of LS. LS for massive splenomegaly has generally been found to fail in adults and children. With improvements in laparoscopic technique and accumulation of laparoscopic experience, however, concerns about completing the procedure in pediatric cases with even massive splenomegaly have been lowered. A retrospective review (April 1997-October 2009) of databases at 2 institutions identified 145 children undergoing splenectomy, 79 laparoscopic and 66 open. We defined splenic margin below the umbilicus or anteriorly extending over the midline as massive splenomegaly. By this definition, 22 cases of pediatric laparoscopic and 17 cases of open splenectomies for massive splenomegaly were performed. Perioperative and follow-up data of laparoscopic pediatric splenectomies were compared with those of open splenectomies, including operative time, bleeding, spleen size, complications, and hospital stay. There were no deaths, wound infections, or instances of pancreatitis. No accessory spleen was missed by laparoscopic; accessory spleens were missed in 2 patients in open splenectomies. The complication rate of laparoscopic versus open was 13.6% versus 41.2%. No subsequent surgery was necessary for dealing with complications both in laparoscopic and open series. Laparoscopic pediatric splenectomy for massive splenomegaly is a feasible, effective, and safe procedure and is associated with low morbidity and a short hospital stay.

Splenic volume model constructed from standardized one-dimensional MDCT measurements

OBJECTIVE

The purposes of this study were to construct a model for estimation of splenic volume from standardized one-dimensional diameters of the spleen and to compare that model with the ellipsoid model for estimation of splenic volume.

MATERIALS AND METHODS

In this retrospective study, segmentation software was used for semiautomated quantification of splenic volume by counting CT voxels in 193 consecutively registered patients. For standardization of one-dimensional measurements, the software was used to measure transaxial diameter in the slice with the largest splenic cross-sectional area. By incorporation of splenic volume and the product of width, thickness, and length into the linear regression equation, a model for estimation of splenic volume was constructed, and its performance was externally assessed. Splenic volume also was calculated with the formula for a prolate ellipsoid. The ellipsoid volume and best-fit volumes were compared with segmented splenic volume by use of Bland-Altman plot and Lin concordance correlation. A value of p < 0.05 denoted statistical significance.

RESULTS

Splenic width was the best one-dimensional predictor of splenic volume (r = 0.84, p < 0.05). The linear regression fitted model for estimation of splenic volume (V(R)) in the initial 100 patients was V(R) = (0.36 × W × T × L) + 28, where W is width, T is thickness, and L is length (R(2) = 0.91, p < 0.05) and was externally validated by estimation of splenic volume in the other 93 patients. Compared with that observed with use of the ellipsoid formula, mean bias decreased from 22.57% to 0.93%, and the Lin coefficient increased from 0.81 to 0.96 with application of the best-fit model for calculation of splenic volume.

CONCLUSION

The best-fit model V(R) = (0.36 × W × T × L) + 28 is more optimized than the ellipsoid formula and is associated with less bias for estimation of splenic volume.

Outcome of laparoscopic splenectomy with preoperative splenic artery embolization for massive splenomegaly

BACKGROUND

Laparoscopic splenectomy (LS) has become a safe and feasible procedure for cases involving spleens of normal size. Only a few publications report on the outcome of LS with preoperative splenic artery embolization (SAE) for massive splenomegaly. The authors present their experience in patients with massive splenomegaly who underwent laparoscopic-assisted splenectomy (LAS) or hand-assisted laparoscopic splenectomy (HALS) following SAE.

METHODS

A retrospective review of patients with massive splenomegaly undergoing LAS or HALS after preoperative SAE during the years 2004 to 2006 at the authors' institution was performed. Patients with a craniocaudal spleen length of 20 cm or greater were included in the study irrespective of their primary diagnosis. The data collected included information on patient demographics, operative details, rates of conversion to open procedures, perioperative blood transfusions, and postoperative complications. Routine Doppler ultrasound of the abdomen was performed on postoperative days 7 and 30 to screen for portal vein thrombosis (PVT).

RESULTS

A total of 19 patients were identified. The median spleen length was 23 cm, and the median spleen weight was 1,740 g. Nine patients underwent LAS, and 10 underwent HALS. The median operative time was 130 min, and the median hospital stay was 6 days. There were no conversions to open laparotomy. The median estimated blood loss was 200 ml. One patient required reoperation 24 h after LAS due to bleeding, and PVT developed in three patients postoperatively.

CONCLUSIONS

In the setting of massive splenomegaly, LAS or HALS with preoperative SAE is safe and has a low conversion rate. Postoperative imaging surveillance for PVT should be performed routinely in this patient population.

Laparoscopic splenectomy in portal hypertension: a single-surgeon 13-year experience

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 LS are not clearly defined. Portal hypertension from liver cirrhosis still is a contraindication to LS in the clinical practice guidelines of the European Association for Endoscopic Surgery published in 2008. This study aimed to evaluate the feasibility of LS for hypersplenism secondary to liver cirrhosis and portal hypertension.

METHODS

The study retrospectively analyzed 206 laparoscopic splenectomies performed for a variety of indications over 13 years. According to diagnosis, the patients were divided into group A (hypersplenism secondary to liver cirrhosis and portal hypertension, n = 96) and group B (hematologic and other disorders, n = 110). A detailed review of medical records was conducted. The perioperative data for the two groups were compared including patient characteristics, diagnosis, operative details, complication rates, and postoperative hospital stay.

RESULTS

Laparoscopic splenectomy was completed for 201 patients. Conversion from laparoscopic to open surgery was necessary for 5 patients (2.4%) because of hemorrhage, and 26 patients (12.6%) had complications. There were significant differences between groups A and B in terms of mean operation time (2.8 vs. 2.1 h), complication rates (17.7% vs. 8.2%), and postoperative stay (7.1 vs. 4.7 days). However, the two groups showed no significant differences with respect to intraoperative blood loss, blood transfusion, and conversion rate.

CONCLUSION

Laparoscopic splenectomy is a feasible, effective, and safe surgical procedure for patients who require splenectomy. Hypersplenism secondary to cirrhosis and portal hypertension should not be considered contraindications for LS.

Modified laparoscopic splenectomy: a beneficial technique for ABO-incompatible living donor renal transplantation candidates on hemodialysis

Advances in laparoscopy have enabled minimally invasive surgical treatment of splenic diseases. Even with these advances, laparoscopic splenectomy in patients on dialysis can be difficult because of tissue fragility due to the underlying renal disease. We report a safe surgical technique for laparoscopic splenectomy in patients on maintenance dialysis that is suitable for use before ABO-incompatible living donor renal transplantation (LDRTx). Between June 1972 and December 2006, a total of 800 patients underwent LDRTx in our department, including 82 patients who underwent ABO-incompatible LDRTx. Between April 2001 and December 2006 we performed laparoscopic splenectomy in 48 hemodialysis patients as a pretreatment before ABO-incompatible LDRTx. Under general anesthesia the operation was performed using a new technique, referred to as the "splenic hilum lump method." We evaluated the surgical outcomes, such as the operative time, amount of blood loss, efficacy, and complications. The mean operative time was 131.6 +/- 38.4 min and mean blood loss was 126 +/- 395 mL. Blood transfusion was required in three patients. All cases had satisfactory kidney function after LDRTx and none developed kidney graft failure due to acute rejection. Almost all patients could walk the day after laparoscopic splenectomy and were satisfied with the cosmetic appearance of the scar after wound healing. The surgical technique we report here can be safely performed on patients with renal failure who require caution because of tissue fragility. Laparoscopic splenectomy is a safe, effective and less invasive operative procedure as a pretreatment for ABO-incompatible LDRTx.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

101 laparoscopic splenectomies for the treatment of benign and malignant hematologic disorders

BACKGROUND

Laparoscopic splenectomy (LS) is the surgical approach of choice for patients with hematologic disorders requiring splenectomy. Patients with idiopathic thrombocytopenic purpura (ITP) have normal to slightly enlarged spleens and benefit the most from LS.

METHODS

We reviewed the perioperative outcomes in 101 patients who underwent LS between May 1996 and December 2002. Patients were divided into three groups--ITP, other benign, and malignant hematologic disorders--and compared.

RESULTS

The ITP patients (n = 48) had significantly smaller spleens and operative times compared with the other groups. Splenomegaly in the other benign (n = 23) and malignant hematologic disorders (n = 30) groups was responsible for higher open conversion rates and greater need for hand-assisted laparoscopic splenectomy (HALS).

CONCLUSIONS

Laparoscopic splenectomy and HALS can be performed with good results for benign and malignant hematologic disorders. The benefits of HALS are similar to LS, so there should be a low threshold for HALS in patients with large spleens.

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.

Laparoscopic Adrenalectomy and Splenectomy are Safe and Reduce Hospital Stay and Charges

The proposed benefits of laparoscopy for certain surgical procedures have been decreased postoperative pain and hospital stay balanced against the proposed deficits of increased costs. We have reviewed our data to evaluate factors associated with patient, procedure, and hospital charges for patients undergoing open versus laparoscopic adrenalectomy and splenectomy during the same time period. Eighty-seven patients underwent adrenalectomy (n = 47) or splenectomy (n = 40) from October 30, 1995 to June 6, 2001 and were retrospectively reviewed. Patient and operative factors were analyzed by intent to treat; the major endpoints were operating room (OR) time in minutes, blood loss in cm3, length of hospital stay in days, and charges broken down by anesthesia/operation [OR/recovery room (RR)] and total charges in dollars x 1000. Comparisons of means were analyzed by unpaired t test; data are presented as mean ± SEM, and significance is defined as P < 0.05. Median age of the group was 47 years (range 20–77). Forty-five patients underwent a laparoscopic approach of which two were converted to open (4%) as compared with 42 undergoing an open operation; one patient from each group was excluded from outcome analyses because of prolonged hospitalization (>3 weeks). Operative mortality of the whole group was one per cent. There were no differences between the groups with respect to age, gender, or comorbidity. The laparoscopic group had significantly longer operative times and OR/RR charges. However, the length of hospital stay and the total charges for the patient undergoing a laparoscopic approach were significantly less ( P < 0.05). We conclude that a laparoscopic approach for adrenalectomy or splenectomy can be accomplished in approximately 95 per cent of patients selected for this procedure. Despite prolonged OR time and increased OR/RR charges the laparoscopic procedures resulted in significantly decreased length of hospital stay and overall patient charges. Laparoscopy is a safe and cost-effective approach and should be strongly considered in patients requiring adrenalectomy or splenectomy.

Hand-assisted laparoscopic splenectomy in patients with splenomegaly or prior upper abdominal operation

BACKGROUND

Laparoscopic splenectomy (LS) in patients with significant splenomegaly or prior upper abdominal operation is technically challenging with a high conversion rate to open operation. We hypothesized that hand-assisted laparoscopic splenectomy (HLS) in this setting would improve operative (OR) outcomes without impacting post-OR ileus, length of stay, morbidity, or mortality, compared with LS.

METHODS

All patients with splenomegaly (spleen weight > or = 500 g) or prior upper abdominal operation undergoing LS or HLS between March 1996 and June 2001 were reviewed. Nonparametric continuous variables were expressed as median and intraquartile range with statistical significance determined by Wilcoxon rank sum test.

RESULTS

Of 41 patients reviewed, 22 underwent HLS, whereas 19 underwent LS. Median OR time for HLS was significantly less than for LS (161 minutes vs 212 minutes, P =.004). HLS was associated with a lower conversion rate (13.6% vs 36.8%, P =.08) and blood loss (325 mL vs 550 mL, P =.18) than LS, which approached statistical significance. HLS did not increase post-OR ileus, length of stay, morbidity, or mortality.

CONCLUSIONS

HLS in patients with significant splenomegaly or prior upper abdominal operation significantly shortens OR time compared with LS without adversely impacting post-OR ileus, length of stay, morbidity, or mortality. In addition, HLS may be associated with a lower conversion rate and decreased blood loss.

Laparoscopic splenectomy for hematological diseases

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic splenectomy 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.

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 in high-risk patients with splenomegaly

BACKGROUND

Splenectomy in patients with massive splenomegaly and hematologic malignancy results in higher morbidity and mortality with primarily palliative benefit.

METHODS

From a 14-year experience with 172 splenectomies, the perioperative course of 39 high-risk patients with splenomegaly was reviewed for comorbidities, indications, complications, and mortality.

RESULTS

Twenty-three males and 16 females with a mean age of 54.2 years and a mean 12.8-day postoperative length of stay were reviewed. Sixteen patients (41%) had 23 major complications related to age (P = 0.047) and operative time (P = 0.01). Intraoperative transfusion was related to splenic size (P = 0.04), and estimated blood loss (P = 0.02) was inversely related to use of splenic artery preligation. Three perioperative deaths were secondary to sepsis and multi-organ system failure.

CONCLUSION

Splenomegaly and comorbidities of the primary disease result in higher morbidity and mortality. Splenic artery preligation is valuable to limit intraoperative blood loss and facilitate splenectomy.

Laparoscopic splenectomy in patients with hematologic malignancies

BACKGROUND

Although laparoscopic splenectomy (LS) for benign hematologic disease is well accepted, its role in hematologic malignancies is not clearly defined. This study examined the efficacy and feasibility of LS for hematologic malignancies.

METHODS

Records were reviewed from patients who underwent LS at two university hospitals. Charts from 77 open splenectomies for malignancy (OM) during the same period were also reviewed.

RESULTS

Fifty-three patients underwent LS, 22 for hematologic malignancies (LM) and 31 for benign hematologic disorders (LB). Median splenic weight was greater in the LM group (930 g) than in the LB group (164 g, P = 0.001). LM was associated with longer operations and greater blood loss than was LB. LM had a 41% conversion rate. Morbidity, mortality, and transfusion rates were similar. Median hospital stay was shorter for LM (4 days) than for OM (6 days, P = 0.001).

CONCLUSIONS

LS is feasible in hematologic malignancies but is associated with increased operative time and blood loss and a high conversion rate. Morbidity and mortality, however, was similar. Shorter hospital stays for LM compared with OM may translate into earlier recovery and initiation of antineoplastic therapy.

Laparoscopic splenectomy: single-centre experience of a district general hospital

We report the results of 20 consecutive laparoscopic splenectomies performed on haematology patients for a number of indications. Our series includes patients up to 77 years of age at the time of surgery and removal of spleens weighing up to 3530 g. The most significant benefit is the early rate of discharge post-operatively (median 2 d); however, there is a risk of conversion to open laparotomy (in this series 3/20, 15%). We show that laparoscopic splenectomy can be offered as a therapeutic option to patients unfit for conventional laparotomy and that even large and bulky spleens can be removed safely using this approach.