Laparoscopic Partial Splenectomy Using Radiofrequency Ablation for Nonparasitic Splenic Cysts in Two Children

Laparoscopic Partial Splenectomy: A Critical Appraisal of an Emerging Technique. A Review of the First 457 Published Cases

Background: Laparoscopic partial splenectomy (LPS) may allow avoiding total splenectomy (TS) complications and maximizing the advantages of mini-invasive approach. The objective of this review is to assess feasibility and safety of LPS, to compare this approach with alternative options. Materials and Methods: A literature review of articles reporting LPS is performed. Several parameters, including age, indication, surgical technique, devices used for splenic section/hemostasis, adverse outcomes, including morbidity/mortality, conversions to open surgery, conversions to TS, operative time (OT), and hospital stay (HS), are analyzed. Articles comparing LPS' results with those of open partial splenectomy and laparoscopic TS are also analyzed. Results: Fifty-nine articles reporting 457 LPS were included. Patients' characteristics varied widely, concerning age and indications, including hematological disease (hereditary spherocytosis, drepanocytosis), splenic focal masses, and trauma. Several technical options are reported. Mean OT and HS are 128 ± 43.7 minutes and 4.9 ± 3.8 days, respectively. No mortality and 5.7% morbidity are reported. Conversion rates to open surgery and to TS are 3.9% and 3.7%, respectively. Conclusions: In conclusion LPS is feasible and safe, with no mortality, low morbidity, and low conversion rates to laparotomy and to TS. LPS may be accomplished by various techniques and tools. Major complications are sporadically reported, thus potential risks should not be underestimated.

Massive splenic cyst in pregnancy: case report

BACKGROUND

Primary splenic cysts are very rarely diagnosed in pregnancy, with only thirteen cases described in the literature. We examine the approach towards diagnosing and managing uniquely large abdominal masses that significantly complicate obstetric care.

CASE PRESENTATION

A 37-year-old primigravida woman presented with abdominal distension and discomfort, yet otherwise asymptomatic. On ultrasound, an incidental pregnancy at 25 weeks of gestation and a large pelvic lesion were discovered. MRI defined a 28 × 29 cm lobulated, complex cystic mass in the upper abdomen. The patient underwent two ascitic drainages throughout her pregnancy. At 34 weeks of gestation, she had a classical caesarean section. Then at five-weeks postpartum, she underwent a laparotomy and total splenectomy with 16 L of fluid drained. Histopathological analysis revealed an epithelial cyst of the spleen. Her recovery was complicated by complete portal vein thrombosis.

CONCLUSION

This case describes the largest splenic cyst ever reported in pregnancy and explores the diagnostic dilemmas and treatment challenges associated. We introduce the utility of serial ascitic drainages in prolonging the pregnancy and emphasise the reliance on imaging for surveillance of splenic size and fetal wellbeing.

Laparoscopic partial splenectomy with temporary occlusion of the trunk of the splenic artery in fifty-one cases: experience at a single center

BACKGROUND

Laparoscopic partial splenectomy (LPS) for splenic benign space-occupying lesions has been reported by many researchers; however, few studies have described methods to control intraoperative bleeding. Trustworthy experience in LPS with a satisfactory intraoperative hemorrhage control technique is therefore necessary. The current study aims to present our experience in LPS with temporary occlusion of the trunk of the splenic artery for controlling intraoperative bleeding with a large sample of 51 cases and to evaluate the safety, feasibility, and reproducibility of this technique.

METHODS

Fifty-one patients from August 2014 to April 2019 who underwent LPS in our institution were retrospectively analyzed. Surgical techniques were described in detail.

RESULTS

All patients had successfully undergone LPS with temporary occlusion of the trunk of the splenic artery. Conversions to open surgery, hand-assisted laparoscopic splenectomies, or blood transfusions were not needed. The operative time was 94.75 ± 18.91 min, the estimated blood loss was 71.13 ± 53.87 ml, and the volume of resected spleen was 34.75 ± 12.19%. The range of postoperative stays was 4-14 days. One female patient (2%, 1/51) suffered from postoperative complications. No perioperative mortality, incision infections, postoperative pancreatic fistulas (POPFs), splenic infarctions, or portal/splenic vein thromboembolic events occurred.

CONCLUSION

LPS is an effective spleen-preserving surgery. Although there are many other bleeding control methods, temporarily occluding the trunk of the splenic artery was found to be a safe, feasible, and reproducible technique in LPS. The outcomes of this technique and the efficacy of splenic parenchyma preservation are acceptable.

Feasibility and Safety of Laparoscopic Partial Splenectomy: A Systematic Review

BACKGROUND

Laparoscopic partial splenectomy (LPS) is a challenging procedure. The aim of this review was to evaluate its feasibility, safety, and potential benefits.

METHODS

We conducted a comprehensive review for the years 1995-2018 to retrieve all relevant articles.

RESULTS

A total of 44 studies with 252 patients undergoing LPS were reviewed. Six studies described combined operations. Ranges of operative time and estimated blood loss were 50-225 min and 0-1200 ml, respectively. There are eight patients need blood transfusion in 231 patients with available data. The conversion rate was 3.6% (9/252). Overall, 27 patients (10.7%;27/252) developed postoperative or intraoperative complications. Overall mortality was 0% (0/252). The length of postoperative stay (POS) varied (1-11 days). Among four comparative studies, one showed LPS could reduce POS than laparoscopic total splenectomy (LTS) (LTS 5.4 ± 1.8 days, LPS 4.2 ± 0.8 days, p = 0.027) and complications (pleural effusion (LTS 9/22, LPS 0/15, p = 0.005), splenic vein thrombosis (LTS 10/22, LPS 0/15, p = 0.002)). Another comparative study showed LPS may benefit emergency patients. However, one comparative study showed LPS was associated with more pain, longer time to oral intake, and longer POS in children with hereditary spherocytosis. The fourth comparative study showed robotic subtotal splenectomy was comparable to laparoscopy in terms of POS and complication. The main benefits were lower blood loss, vascular dissection time, and a better evaluation of splenic remnant volume.

CONCLUSIONS

In early series of highly selected patients, LPS appears to be feasible and safe when performed by experienced laparoscopic surgeons.

Partial splenectomy: Who, when and how. A systematic review of the 2130 published cases

BACKGROUND/PURPOSE

In order to avoid consequences of total splenectomy (including severe postsplenectomy sepsis), partial splenectomy (PS) is increasingly reported. Without guidelines and indications concerning a rarely-indicated procedure, a review of literature should be an asset.

METHODS

A systematic review of all PSs from 1960 to December 2017 was performed, with special focus on surgical indications, sites of resection, approaches and techniques of vascular dissection and parenchymal section/hemostasis of the spleen, perioperative morbidity/mortality, including complications compelling to perform total splenectomy.

RESULTS

Among 2130 PSs, indications for resection were hematological disease in 1013 cases and nonhematological conditions in 1078, including various tumors in 142 and trauma in 184. Parenchymal transection was performed using several techniques through the years, most frequently after having induced partial ischemia by splenic hilum vascular dissection/ligation. 371 laparoscopic/robotic PSs were reported. Rescue total splenectomy was required in 75 patients.

CONCLUSIONS

Although good results are probably overestimated by such a retrospective review, PS should be considered as a procedure associated with a low morbidity/mortality. Nevertheless, severe complications are also reported, and the need of total splenectomy should not to be minimized. Laparoscopic/robotic procedures are increasingly performed, with good results and rare conversions.

TYPE OF STUDY

Systematic review.

LEVEL OF EVIDENCE

IV.

Management of nonparasitic splenic cysts in children: A French multicenter review of 100 cases

BACKGROUND

The management of nonparasitic splenic cysts (NPSC) remains controversial. Surgical resection is indicated for symptomatic or complicated forms, but no guidelines are available for asymptomatic NPSC. The aims of this study were to evaluate the management of NPSC in French hospitals and to analyze the results of management.

METHODS

We conducted a retrospective multicenter study from January 2004 to December 2014 in 16 university hospitals in France. Patients with a follow-up less than 6months were excluded. Data were extracted from the medical reports.

RESULTS

One hundred patients were included. Median follow-up was 12.8months. No complications were observed for NPSC smaller than 5cm. The size of NPSC increased significantly between the ages of 10 and 12years. Fifteen patients were under observation; 58.3% of cysts decreased in size and 41.7% remained stable. Among the 85 operated patients, no recurrence occurred in the splenectomy group, while 11 recurrences were observed in the cystectomy group (57.9%), 3 of which required redo surgery.

CONCLUSIONS

Observation is a safe treatment option for asymptomatic NPSC smaller than 5cm. Surgery is indicated for symptomatic patients, and can be proposed for asymptomatic NPSC larger than 5cm. Laparoscopic partial splenectomy is the technique of choice. Follow-up must be continued until the end of puberty.

LEVELS OF EVIDENCE RATING

Level III.

Ultrasound-guided percutaneous sclerosis of congenital splenic cysts using ethyl alcohol 96% and minocycline hydrochloride 10%: A pediatric series

INTRODUCTION

The management of congenital splenic cysts continues to evolve. In the past the standard treatment was splenectomy, but increased knowledge about the spleen's immunologic function has led most pediatric surgeons to preserve splenic tissue. A great number of studies using sclerosing substances have been published, but to date reports in children have been limited. Our study concerns a group of 15 children with congenital splenic cysts treated with percutaneous drainage and sclerosis with alcohol. We performed the procedure under general anesthesia and checked radiologically for possible leakage.

METHODS

In 2000 our group started managing pediatric patients with splenic cysts. During the first eight years surgery was the treatment of choice. From April 2008 to December 2014, a prospective study was conducted on 15 consecutive patients treated with percutaneous sclerotherapy. The outcomes regarding cystic dimensional variations before and after treatment were analyzed.

RESULTS

In 20% of patients complete disappearance of the cystic lesion was achieved. In 67% of the patients the maximum diameter of the cyst was reduced to below 50mm.

CONCLUSION

Our results should encourage the use of this treatment because it is a valid and safe option in childhood. The high success rate achieved with percutaneous drainage and sclerotherapy of cystic lesions supports our results.

Laparoscopic partial splenectomy for giant cyst using a radiofrequency-assisted device: a case report

Background

Although radiofrequency-assisted devices have sometimes been used in partial splenectomy, this is not a common technique. This report describes the first case of laparoscopic partial splenectomy using an RF-assisted device (Coolinside) which allows both coagulation and transection of the parenchyma and eventually the protective coagulation of the remnant side.

Case presentation

A 27-year-old woman was found to have a giant hydatic cyst measuring 12.0 × 14.0 × 16.6 cm that mainly occupied the lower pole of the spleen and retroperitoneal space. The patient underwent a laparoscopic partial splenectomy using an RF-based device designed to accomplish both the coagulation and dissection of the splenic tissue. The estimated blood loss was less than 200 mL.

Conclusions

Even though RF ablation has traditionally been used for hepatic parenchymal transection, it seems equally suited to partial splenectomy. This device seems to provide good results, minimizing blood loss during partial splenectomy; however, randomized trials will be necessary to see if the results are superior to those of other techniques.

Laparoscopic partial splenectomy performed by monopolar saline-cooled radiofrequency coagulation

BACKGROUND

Partial splenectomy is preferred to total splenectomy when possible to reduce the risk of life-threatening infection. Several techniques have been described, each with its merits. Laparoscopic transection with monopolar saline-cooled radiofrequency coagulation has not been previously described.

PATIENTS AND METHODS

Two patients with enlarging cystic splenic lesions consented to laparoscopic partial splenectomy. In 1 case, high-power saline-cooled monopolar radiofrequency transection was performed with a laparoscopic sealing hook; the procedure was performed with a rigid resectoscope and ball diathermy in the other.

RESULTS

Both cases were performed without complications. Transection with the resectoscope and ball diathermy was combined with selective clamping of the splenic hilar vessels and was performed in 100 minutes with estimated blood loss of 250 mL. Transection with the sealing hook was performed in 80 minutes without hilar vessel clamping, with an estimated blood loss of 100 mL. No additional hemostatic agents were required for either case.

CONCLUSIONS

Laparoscopic partial splenectomy can be performed with monopolar saline-cooled radiofrequency for parenchymal transection and hemostasis in a simple and effective manner.

Partial spleen resection with a radiofrequency needle device--a pilot study

INTRODUCTION

Total splenectomy leads to an immunocompromised state, with an increased lifetime risk of infection. The lifetime risk of developing overwhelming postsplenectomy infection is 5 %, with a mortality rate of approximately 50 %. In addition to vaccination and antibiotic prophylaxis, partial splenectomy is believed to improve patient safety.

METHODS

We performed partial splenectomy in seven patients using a radiofrequency (RF) technique with Habib® needles. In seven patients, an open access partial splenectomy was performed. In three patients, a partial splenectomy was performed simultaneously with intraabdominal tumour resection. In two patients, the upper pole of the spleen was removed due to tumours of the spleen. In one patient, a large symptomatic splenic cyst was resected and in another patient, a partial splenectomy was performed due to trauma. RF was applied using Habib® needles (AngioDynamics, Manchester, GA, 31816, USA).

RESULTS

The partial splenectomy procedures were easy and safe in all seven patients. The RF application with the Habib® needles led to primary haemostasis. The blood loss was less than 50 ml in all cases. After a minimum follow-up of 1 year, there were no cases of infections or other adverse events related to the previous partial splenectomy.

CONCLUSION

In our experience, partial splenectomy with Habib® needles is easy to perform and safe for the patient. Thus, radiofrequency resection is a good alternative to total splenectomy in many patients and reduces the risk of postsplenectomy infections.

Laparoscopic partial splenectomy for littoral cell angioma

Littoral cell angioma (LCA) is a rare benign splenic vascular neoplasm. We report a case of a 58-year-old man with a 5.5-cm lesion in the upper pole of the spleen. A laparoscopic partial splenectomy was performed. He was discharged on the second postoperative day. Pathology revealed LCA.

Laparoscopic partial splenectomy can be performed safely in selected cases and is an appropriate option in patients with benign conditions as it enables preservation of the immunologic function of the spleen. Long-term follow up in patients with LCA is important given its high association with other malignancies.

Splenic cysts, many questions are yet to be answered: a case report

We present two patients with splenic cysts. The first is a female 29-years-old who presented with upper abdominal discomfort of one-year duration. Imaging revealed a huge splenic cyst. Splenectomy was undertaken. Pathological examination revealed a lymphatic cyst. The second was an 18-years-old female who presented to the emergency department with a ruptured splenic cyst. Splenectomy was undertaken, it proved to be a simple cyst.

Partial laparoscopic splenectomy for splenic abscess because of Salmonella infection: a case report

Splenic abscess as a presentation of a Salmonella infection is described in children and adults. A combination of antibiotics and splenectomy is the standard treatment. We report a 12-year-old girl admitted to the hospital with fever, abdominal pain, and anorexia. White blood cell count was 17,900/microL and C-reactive protein level was 230 mg/L; abdominal ultrasound and abdominal computed tomographic (CT) scan showed a splenic abscess of 11.3 x 12.9 x 13.8 cm in the upper part of the spleen. She was treated with percutaneous drainage and antibiotics for 8 days. A week later, she represented with a recurrent abscess and identical symptoms. She was treated with percutaneous drainage and intravenous (i.v.) antibiotics for 21 days followed by oral therapy for another 2 weeks. Abscess culture grew Salmonella type B. Because of a persistent abscess on CT scan, she underwent a partial laparoscopic splenectomy with radiofrequency ablation to preserve functional splenic tissue. The operative and postoperative course was uneventful. Pathologic finding showed an inflammatory cystic reaction without epithelial cell lining. Splenic abscess in children is a rare condition. Long-term antibiotic therapy is needed. Percutaneous drainage can be a temporary solution, but (partial) splenectomy is the final treatment in most cases.

Laparoscopic internal marsupializaton for large nonparasitic splenic cysts: effective organ-preserving technique

BACKGROUND

Primary splenic cyst is a rare disease, and therefore there is no information regarding its optimal management. Most such cysts are classified as epithelial cysts. During the last few years, the laparoscopic approach has gained increasing acceptance in splenic surgery. We present our experience with the laparoscopic (organ-preserving) management of splenic cysts.

METHODS

We managed 11 patients with large symptomatic nonparasitic splenic cysts from 1996 to 2006. All the patients had fullness in the left upper abdomen and a palpable mass. Preoperative diagnosis was established with ultrasonography and computed tomography. All patients were treated with either laparoscopic partial cystectomy or marsupialization.

RESULTS

Seven patients had mesothelial cysts, two had epidermoid cysts, and two had pseudocysts. Nine patients did not have any problems or recurrence during an average follow-up of 29.5 months. Two patients had cyst recurrence after 14 months.

CONCLUSION

Laparoscopic organ-preserving surgery should be the goal of therapy in most cases. Total splenectomy is reserved for cases in which cyst excision cannot be done or most of the splenic tissue is replaced by the cyst. Plication of the cyst wall edges prevents the cyst walls from adhering and causing recurrence, as well as helping to control hemorrhage. Laparoscopic partial cystectomy/marsupialization is an acceptable procedure for the treatment of splenic cysts; and after short to mid-term follow-up, it seems that a reasonable rate of success is possible.