Laparoscopic splenectomy: ligasure or clip ligation?

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

High-energy devices in different surgical settings: lessons learnt from a full health technology assessment report developed by SICE (Società Italiana di Chirurgia Endoscopica)

BACKGROUND

The present paper aims at evaluating the potential benefits of high-energy devices (HEDs) in the Italian surgical practice, defining the comparative efficacy and safety profiles, as well as the potential economic and organizational advantages for hospitals and patients, with respect to standard monopolar or bipolar devices.

METHODS

A Health Technology Assessment was conducted in 2021 assuming the hospital perspective, comparing HEDs and standard monopolar/bipolar devices, within eleven surgical settings: appendectomy, hepatic resections, colorectal resections, cholecystectomy, splenectomy, hemorrhoidectomy, thyroidectomy, esophago-gastrectomy, breast surgery, adrenalectomy, and pancreatectomy. The nine EUnetHTA Core Model dimensions were deployed considering a multi-methods approach. Both qualitative and quantitative methods were used: (1) a systematic literature review for the definition of the comparative efficacy and safety data; (2) administration of qualitative questionnaires, completed by 23 healthcare professionals (according to 7-item Likert scale, ranging from - 3 to + 3); and (3) health-economics tools, useful for the economic evaluation of the clinical pathway and budget impact analysis, and for the definition of the organizational and accessibility advantages, in terms of time or procedures' savings.

RESULTS

The literature declared a decrease in operating time and length of stay in using HEDs in most surgical settings. While HEDs would lead to a marginal investment for the conduction of 178,619 surgeries on annual basis, their routinely implementation would generate significant organizational savings. A decrease equal to - 5.25/-9.02% of operating room time and to - 5.03/-30.73% of length of stay emerged. An advantage in accessibility to surgery could be hypothesized in a 9% of increase, due to the gaining in operatory slots. Professionals' perceptions crystallized and confirmed literature evidence, declaring a better safety and effectiveness profile. An improvement in both patients and caregivers' quality-of-life emerged.

CONCLUSIONS

The results have demonstrated the strategic relevance related to HEDs introduction, their economic sustainability, and feasibility, as well as the potentialities in process improvement.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Guidelines for the performance of minimally invasive splenectomy

BACKGROUND

Minimally invasive splenectomy (MIS) is increasingly favored for the treatment of benign and malignant diseases of the spleen over open access approaches. While many studies cite the superiority of MIS in terms of decreased morbidity and length of stay over a traditional open approach, the comparative effectiveness of specific technical and peri-operative approaches to MIS is unclear.

OBJECTIVE

To develop evidence-based guidelines that support clinicians, patients, and others in decisions on the peri-operative performance of MIS.

METHODS

A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) including methodologists used the Grading of Recommendations Assessment, Development and Evaluation approach to grade the certainty of evidence and formulate recommendations.

RESULTS

Informed by a systematic review of the evidence, the panel agreed on eight recommendations for the peri-operative performance of MIS for adults and children in elective situations addressing six key questions.

CONCLUSIONS

Conditional recommendations were made in favor of lateral positioning for non-hematologic disease, intra-operative platelet administration for patients with idiopathic thrombocytopenic purpura instead of preoperative administration, and the use of mechanical devices to control the splenic hilum. Further, a conditional recommendation was made against routine intra-operative drain placement.

Laparoscopic splenectomy: clip ligation or en-bloc stapling?

Objectives

Various techniques are used in the management of splenic hilum during laparoscopic splenectomy. Among them, the most used ones are polymer clips, en-bloc stapling and ultrasonic devices. To the best of our knowledge, there is no study in the literature comparing the results of clip and stapler techniques. This study was aimed to compare our results of clip ligation and en-bloc stapling of the splenic hilum.

Material and Methods

The records of 67 patients undergoing laparoscopic splenectomy between December 2012 and October 2017 were reviewed. Patients were divided into two groups according to surgical method (stapler group: 26 patients and clip group: 41 patients). Patient age, sex, diagnosis, surgical technique, operation time, spleen dimensions, perioperative complications, postoperative hospital stay, blood transfusions, postoperative thrombocyte and hemoglobin levels were recorded.

Results

Operating time was median 115 min (75-230) in the stapler group and 120 min (60-210) in the clip group, and there was no significant difference between the groups (p= 0.2593). There were no significant difference between the groups in terms of the postoperative complications (p= 0.59). Postop- erative hospital stay was median 3.5 (2-8) days in the stapler group and 3 (2-6) days in the clip group with no significant difference (p= 0.0733).

Conclusion

Clip ligation and en-bloc stapling techniques have no superiority over each other. Our results also showed that both techniques are safe and feasible. We suggest opting for the method according to the surgeon's experience and hospital facilities.

Randomized clinical trial of ligasure™ versus conventional splenectomy for injured spleen in blunt abdominal trauma

BACKGROUND

Spleen is the most common organ damaged in cases of blunt abdominal trauma and splenectomy and splenorrhaphy are the main surgical procedures that are used in surgical treatment of such cases. In routine open splenectomy cases, after laparotomy, application of sutures in splenic vasculature is the most widely used procedure to cease the bleeding. This clinical trial evaluates the role and benefits of the Ligasure™ system in traumatic splenectomy without using any suture materials and compares the result with conventional method of splenectomy.

METHODS

After making decision for splenectomy secondary to a blunt abdominal trauma, patients in control group (39) underwent splenectomy using conventional method with silk suture ligation of splenic vasculature. In the interventional group (41) a Ligasure™ vascular sealing system was used for ligating of the splenic vein and artery. The results of operation time, volume of intra-operation bleeding and post-operative complications were compared in both groups.

RESULTS

The mean operation times in control and interventional group were 21 and 12 min respectively (p < 0.05). The average volume of bleeding in control group during open splenectomy was 280 cc, but in the interventional group decreased significantly to 80 ml (p < 0.05) using the Ligasure system. Post-operative complications such as bleeding were non-existent in both groups.

CONCLUSION

The application of Ligasure™ in blunt abdominal trauma for splenectomy not only can decrease the operation time but also can decrease the volume of bleeding during operation without any additional increase in post-operative complications. This method is recommendable in traumatic splenic injuries that require splenectomy in order to control the bleeding as opposed to use of traditional silk sutures.

Laparoscopic Splenectomy and Esophagogastric Devascularization for Liver Cirrhosis and Portal Hypertension Is a Safe, Effective, and Minimally Invasive Operation

BACKGROUND

In the recent years, laparoscopic splenectomy and esophagogastric devascularization (LSD) for liver cirrhosis and portal hypertension rapidly gained the interest of hepatobiliary surgeons due to its minimal invasion. This study aimed to gather and analyze available data from the observational studies that have compared LSD and open splenectomy and esophagogastric devascularization (OSD) for liver cirrhosis and portal hypertension.

MATERIALS AND METHODS

All the studies comparing LSD and OSD for liver cirrhosis and portal hypertension were searched on the available databases, including the Cochrane Central Register of Controlled Trials, Medline, Science Citation Index, EMBASE, China National Knowledge Infrastructure, Wanfang Database, and China Biomedical Database. Data were analyzed using Review Manager software version 5.0.

RESULTS

After the literature search, a total of 17 studies were included in the meta-analysis, which involved 1093 patients: 552 in the laparoscopic group and 541 in the open group. The laparoscopic group was shown to have a lower overall postoperative complication rate (0.43; 95% confidence interval [CI; 0.29-0.64]) than the open group (P < .0001), which was not associated with heterogeneity between the studies. The laparoscopic group was shown to have a lower intraoperative blood loss (-320.62; 95% CI [-552.35 to -88.9]), shorter time of oral intake (-29.08 hours; 95% CI [-35.28 to -22.88]), and shorter hospital stay (95% CI [-6.19 to -2.19]) than those of the open group (P < .00001). The operative time of the laparoscopic group was 42.16 minutes longer (95% CI [32.20-52.11]) compared with the open group (P < .00001). There was no significant difference of hospitalization costs between the studies.

CONCLUSION

This meta-analysis demonstrated that laparoscopic left lateral resection is a safe and feasible option associated with a reduced overall complication rate. The current evidence suggested that it could be performed routinely in liver centers.

The Covidien LigaSure Maryland Jaw Device

Since its invention nearly 20 years ago, the Covidien LigaSure device along with its ForceTriad generator has dominated the Electrothermal Bipolar Vessel Sealing market. The LigaSure was used for surgical procedures, both open and laparoscopic. The purpose of this review is to provide evidence of the safety and utility of the LigaSure device compared to more traditional means of hemostasis and its ultrasonic competitor, particularly in laparoscopic applications. We will provide evidence related to electrothermal bipolar vessel sealing in general and look specifically at Covidien's newest product, the LigaSure Maryland Jaw Device.

Hand-assisted laparoscopic technique in the setting of complicated splenectomy: a 9-year experience

BACKGROUND

Laparoscopic splenectomy (LS) is significantly more challenging in patients with supramassive splenomegaly and those with portal hypertension. We hypothesized that hand-assisted laparoscopic splenectomy (HALS) could facilitate the procedure in these patients.

METHODS

Before October 2009, patients with supramassive splenomegaly and those with portal hypertension underwent LS. After October 2009, we routinely applied HALS in patients with these disorders.

RESULTS

We compared the HALS group (n = 41) with the LS group (n = 45). There were no conversions to open surgery in the HALS group, whereas there was an 4.5 % conversion rate in the LS group. The operating times were shorter, and there was less estimated blood loss, and fewer major complications in the HALS group. Analgesia requirement, time to full diet, and postoperative stay were comparable in the two groups.

CONCLUSIONS

We concluded that HALS was superior to LS in patients with supramassive splenomegaly and in those with portal hypertension.

[Comparison of laparoscopic and open splenectomy]

INTRODUCTION

Conventional operative techniques are gradually being replaced by minimally invasive surgical methods in the surgery of the spleen. We summarized our 10-year-experience after the introduction of laparoscopic splenectomy at the University of Szeged, Department of Surgery, comparing open and minimally invasive techniques.

MATERIAL AND METHOD

Between 1st January 2002 and 1st December 2011 we performed 141 splenectomies of which 17 were acute operations. Of the 124 elective procedures 54 were laparoscopic and 70 open operations. In 40 cases (open procedures) splenectomy was part of multivisceral surgery which were excluded from the analysis. In this retrospective analysis a comparison of laparoscopic and open elective technique was carried out.

RESULTS

Average operating time of laparoscopic procedures was slightly longer than that of open technique (133 vs. 122 minutes, p = 0.074). After the learning period, duration of laparoscopic procedures became shorter (first five years: 147 min., second five years: 118 min, p = 0.003), larger spleens were removed (220 vs. 450 grams, p = 0.063) and conversion rate became lower. In cases of laparoscopic procedures fewer reoperations needed to be performed (1.5% vs. 6%, p = 0.718), bowel motility recovered earlier (2 vs. 3 days, p = 0.002) and hospital stay was shorter (5 vs. 8 days, p ≤ 0.001).

CONCLUSION

Our study proves that laparoscopic splenectomy is a safe method with many advantages. Our results correlate with data of international publications.

Laparoscopic splenectomy: a single center experience. Unusual cases and expanded inclusion criteria for laparoscopic approach

Laparoscopic splenectomy (LS) is nowadays considered as the gold standard for most hematological diseases where splenectomy is necessary, but many questions still remain. The aim of this study was to analyze our 5-years experiences consisting of 48 consecutive LS cases in order to assess the optimal approach and the feasibility of the procedure also in malignant diseases and unusual cases such as a primary spleen lymphoma, a big splenic artery aneurism, or a spleen infarct due to a huge pancreatic pseudo-cyst. Forty-eight consecutive patients underwent LS from January 2006 to January 2011 with at least 1-year follow-up. Clinical data and immediate outcome were retrospectively recorded; age, diagnosis, operation time, perioperative transfusion requirement, conversion rate, accessory incision, hospital stay, and complications were analyzed. We had 14 cases of malignant splenic disease, the most frequent malignant diagnosis was non-Hodgkin's lymphoma (12/14, 85.7 %). Splenomegaly (interpole diameter (ID) >20 cm) was observed in 12 cases (25 %) and massive splenomegaly (ID >25 cm) in 3 cases (6.25 %). Conversion to laparotomy occurred in two patients (4.16 %), both associated to uncontrollable bleeding in patients with splenomegaly. Mean operative time was 138 ± 22 min. Mean hospital stay was 4.5 days. Postoperative morbidity rate was 8.8 % for the benign group and 35.7 % in the malignant group. Mortality occurred in 1/48 patients (2.08 %), as a result of overwhelming post-splenectomy infection (OPSI). LS can be performed safely for malignant splenic disease and splenomegaly without any statistically significant increase of morbidity and mortality rate. Conversion rate is increased for massive splenomegaly. LS should be considered as the preferential approach even in patients with malignant disease, splenomegaly, or unusual cases. Massive splenomegaly should be considered as relative contraindication to LS even at experienced centers.

Primary versus secondary splenic pedicle dissection in laparoscopic splenectomy for splenic diseases

BACKGROUND

Some areas of laparoscopic splenectomy (LS), such as the approach to splenic pedicle dissection, remain controversial. Here we recommend a technique for dissecting the secondary splenic pedicle vessels on the basis of analysis of retrospective data.

STUDY DESIGN

A retrospective review (April 2006 to October 2011) of databases at 2 institutions identified 136 patients who had undergone LS. In 34 patients with massive splenomegaly, primary splenic pedicle dissection technique (PSPD) had been used in 19 patients and secondary splenic pedicle dissection technique (SSPD) had been used in 15 patients. In 102 patients with normal-sized spleen or moderate splenomegaly, PSPD had been used in 56 patients and SSPD in 46 patients. We compared perioperative and follow-up data.

RESULTS

Laparoscopic splenectomy was completed in 128 patients. In the massive splenomegaly group, the conversion rate was 5.3% for PSPD and 33.3% for SSPD, the complication rate was 42.1% vs 20%, hospital stay was 3.2 ± 2.0 days vs 7.5 ± 3.5 days, and transfusion requirement was 1.1 ± 1.2 U vs 3.2 ± 0.9 U, respectively. However, in the normal or moderate splenomegaly group, except for complications, there were no significant differences between PSPD and SSPD techniques in perioperative findings. In the 2 groups, there were significant differences between the PSPD and SSPD techniques in pancreatic leakage (15.8% vs 0 and 8.9% vs 0, respectively) and postoperative fever (15.8% vs 6.7% and 10.7% vs 2.2%, respectively).

CONCLUSIONS

Secondary splenic pedicle dissection can decrease the incidence of splenic fever and pancreatic leakage and is a valuable technique for LS for normal-sized spleen or moderate splenomegaly. It is not a safe procedure for massive splenomegaly because of the high conversion rate.