Laparoscopic surgery of the spleen: state of the art

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.

Quest for the optimal technique of laparoscopic splenectomy - vessels first or hilar transection?

Introduction

Throughout our 20 years of experience, we have used several different techniques for laparoscopic splenectomy (LS). However, two methods have been used most frequently: "vessels first" and "hilar transection".

Aim

To evaluate the outcomes of LS performed with these two different approaches.

Material and methods

It was an observational study based on retrospective analysis of consecutive patients undergoing LS in a tertiary referral surgical center in the period 1998-2017. We excluded patients with splenic trauma, initially submitted to open surgery, stapled transection of splenic hilum, partial resections of the spleen and other spleen-preserving procedures. Patients were divided into two groups: group 1 ("vessels first") with 188 patients, and group 2 ("hilar transection") with 287 patients.

Results

Mean operative time was shorter (p < 0.001) and blood loss was lower (p < 0.001) in group 2. The need for blood transfusions and the conversion rate were higher in group 1 (p = 0.044 and p = 0.003 respectively). There was no difference in intraoperative adverse events (p = 0.179). Overall postoperative morbidity did not differ between groups (p = 0.081) and we noted mortality of 0.21% (1 patient of group 2). The morbidity rate associated with accidental injury of the pancreatic parenchyma was significantly higher in group 1 (p = 0.028). Median length of hospital stay was 4 days (range: 1-99) and did not differ between groups (p = 0.175).

Conclusions

The "vessels first" technique is associated with longer operative time, higher blood loss and increased risk of conversion. "Hilar transection" is associated with lower incidence of local complications related most likely to accidental injury of the pancreatic tail. In the case of a large caliber of splenic vessels the "vessels first" approach remains the technique of choice.

20 years' experience with laparoscopic splenectomy. Single center outcomes of a cohort study of 500 cases

BACKGROUND

Laparoscopic splenectomy (LS) has become the gold standard in elective spleen surgery. Although it is considered relatively safe, treatment results vary depending on a hospital's profile and the experience of the surgeon and center. We would like to present experience of a high-volume referral center with minimally invasive operations of the spleen.

MATERIAL AND METHODS

The retrospective cohort study included consecutive patients undergoing laparoscopic splenectomy in tertiary referral surgical center in 1998-2017. The entire study population (500 patients) was grouped into 5 cohorts of 100 consecutively operated patients. The primary endpoints were short-term outcomes of LS and secondary - analysis of indications and operative technique. The study group consisted of 316 women and 184 men, 46 (28-59) years old on average.

RESULTS

The most common indications for splenectomy were ITP (53%), lymphoma (21%) and spherocytosis (7%). Ratio of ITP versus other indications decreased significantly over time in favor of more difficult cases (<0.001). Average operative time of 100 (75-132.5) min and blood loss of 50 (20-150) ml were changing during study. Forty two patients required a blood transfusion with no difference among groups (p = 0.765). The use of postoperative drainage diminished from 100% to 7% (p < 0.001). The overall conversion rate (3%) and intraoperative complications (5%) did not differ among groups (p = 0.863 and 0.888). Perioperative morbidity was 8.6% and decreased significantly over time (OR: 0.78, 95%CI: 0.62-0.98). We noted mortality of 0.4% (1 patient in 1st and 1 in 5th group). Median LOS was 4 (1-16) days. A significant change in the operative technique from vessels first to hilar transection was noted.

CONCLUSION

Laparoscopic splenectomy seems to be a safe method associated with a low risk of perioperative complications and mortality. A careful reproducible operative technique, along with a well-trained team and standardized modern postoperative care is critical to improving outcomes.

Clinical, Anatomical, and Pathological Grading Score to Predict Technical Difficulty in Laparoscopic Splenectomy for Non-traumatic Diseases

BACKGROUND

We aimed to develop a grading system based on preoperative parameters that would predict surgical difficulty and morbidity in elective laparoscopic splenectomy.

STUDY DESIGN

We retrospectively assessed morbidity in 439 patients who underwent laparoscopic splenectomy for benign and malignant disorders between 1993 and 2013. Medical and surgical records were reviewed and analyzed. We compared preoperative data concerning demographic, clinical, pathological, anatomical, laboratory, and radiological factors with three surgical outcomes: operative time, intraoperative bleeding, and surgical conversion. Univariate and multivariate analyses were performed to identify statistically significant variables. A logistic regression model was used to identify determinant variables and to compose a predictive score. External validation of the score was performed using an independent cohort of 353 patients.

RESULTS

Four preoperative parameters (age, male sex, type of pathology, and spleen size based on final spleen weight) were significantly related with operative time, operative bleeding, and conversion to open surgery. Using these results, we developed a classification system with three levels of difficulty: low (≤4 points), medium (4.5-5.5 points), and high (≥6 points), based on the four preoperative parameters. The correlation was highly significant (p = <0.001) according to Spearman's correlation. The area under the ROC curve was 0.671 (95 % CI 0.596-0.745). The external validation showed significant correlations with the present model.

CONCLUSIONS

The grading score described here is simple to calculate from the physical examination, laboratory tests, and US or CT images, and we believe it could be useful to preoperatively assess the technical complexity of laparoscopic splenectomy.

Laparoscopic Splenectomy for Massive Splenomegaly: Does Size Matter?

BACKGROUND

Laparoscopic splenectomy (LS) has become the most common approach for elective splenectomy, but use of LS for patients with massive splenomegaly (MS) remains controversial. By the 2008 European guidelines, LS for MS (spleen size >20 cm) is generally not recommended.

METHODS

We performed a retrospective analysis of 229 consecutive patients undergoing LS, hand-assist (HALS), and open splenectomy (OS) at our institution from January 1, 1995 to December 2016. Eighty-six (38%) had MS. Patient demographics, comorbidities, operative details, and outcomes were analyzed.

RESULTS

Of 86 patients with MS, 27 (31%) underwent LS, 12 (14%) HALS, and 47 (55%) OS. No significant difference was revealed in patient demographics, comorbidities, American Society of Anesthesiologists class, and spleen size (24.2 cm vs. 23.7 cm vs. 26.6 cm, P = .06). Benign spleen diseases (23), malignancy (57%), and miscellaneous (20%) were indications for surgery. The mean operative time and estimated blood loss in LS, HALS, and OS were 153, 168, and 131 minutes (P = .17) and 100, 162, and 278 mL (P = .24), respectively. Three patients (11.1%) with LS and 1 (8.3%) with HALS required conversion to OS for different reasons (spleen size, technical difficulties, bleeding). Morbidity was similar in all three groups (P = .99). One mortality (1.1%) was noted after OS. Six (7%) patients in the LS group and three (3.5%) in the OS group developed postsplenectomy thrombosis of splenic, mesenteric, and portal veins. Length of stay was shorter in patients with LS and almost reached clinical significance (3.2 vs. 4.9 vs. 5.2 days; P = .06).

CONCLUSION

LS is safe, feasible, and associated with shorter hospital stay than HALS and OS for MS.

A via videolaparoscópica pode ser utilizada como rotina nas esplenectomias?

RACIONAL: A esplenectomia laparoscópica é alternativa para o tratamento de pacientes submetidos à esplenectomia eletiva. Uma de suas principais indicações está nas doenças hematológicas que não respondem ao tratamento clínico. A videolaparoscopia apresenta vantagens para os pacientes, quando comparados à laparotomia: menos dor no pós-operatório, recuperação mais célere das funções do trato gastrointestinal, melhores resultados estéticos e menor tempo de hospitalização. OBJETIVO: Apresentar série de casos de esplenectomia videolaparoscópica de um hospital universitário. MÉTODOS: Forram avaliadas as esplenectomias realizadas entre junho de 2005 e outubro de 2012. A análise foi prospectiva dividida em pré, trans e pós-operatórios dos seguintes dados: gênero, idade, indicação da operação, taxa de conversão para laparotomia, duração do procedimento, tamanho do baço, presença de baço acessório, tempo de internação e resposta em oito semanas do pós-operatório. RESULTADOS: Foram analisadas 44 esplenectomias laparoscópicas realizadas no período. Os pacientes foram com púrpura trombocitopênica idiopática sem resposta ao tratamento farmacológico representaram 56,8%; anemia hemolítica auto-imune foi de 13,6%; esferocitose de 11,3% e 18,3% por outras causas não-hemolíticas. O tempo cirúrgico médio foi de 166,7 (60-319) minutos. Apenas quatro pacientes (9,1%) tiveram complicações pós-operatórias, e nenhum deles teve sangramento pós-operatório. A resposta positiva, em curto prazo, após oito semanas do tratamento foi conseguida por 88% dos pacientes. CONCLUSÕES: A esplenectomia laparoscópica é alternativa segura para todas as principais indicações de esplenectomia e pode ser utilizada de forma rotineira.

Single incision versus reduced port splenectomy--searching for the best alternative to conventional laparoscopic splenectomy

BACKGROUND

Laparoscopic splenectomy (LS) is a well accepted approach for the treatment of multiple hematologic diseases. Single port access splenectomy (SPAS) emphasizes the concept of surgery through one small incision. The reduced port access splenectomy (RPAS) entails the use of fewer trocars of smaller sizes. The aim of this study was to compare the clinical outcomes after LS, SPAS, and RPAS, and to analyze the aesthetic result and patient satisfaction.

METHODS

We included patients who underwent LS (group 1, n = 15), SPAS (group 2, n = 8), and RPAS (group 3, n = 10) between June 2008 and February 2012, whose final spleen weight was less of 500 g. The outcome parameters analyzed were operative time, need of additional trocars, blood loss, blood transfusion, weight of the spleen, postoperative complications, and duration of hospital stay. To evaluate the cosmetic result, patients were asked to take the Body Image Questionnaire.

RESULTS

Patients in group 3 were younger than group 1. Operative time was significantly longer in group 2 compared to groups 1 and 3 (83 ± 19 vs. 131 ± 43 vs. 81 ± 22 min, p = 0.01). There was no need to convert to open surgery in any group, nor were there differences in intra- or postoperative outcome. There were no differences between the groups in relation to the analgesic requirements. Twenty-two out of the 33 patients answered the questionnaire. There was a significant advantage in group 2 and 3 in the body image index with respect to group 1. There were no differences between groups 2 and 3 (7.3 ± 2.8 vs. 5.8 ± 1.3 vs. 5.1 ± 0.4, p < 0.02).

CONCLUSIONS

RPAS is a good alternative to LS and SPAS. It improves the aesthetic results as compared to LS, whereas minimizes the technical challenges faced with SPAS.

Single-port laparoscopic splenectomy for idiopathic thrombocytopenic purpura

Laparoscopic splenectomy has been performed with an average of 4 trocars since the early 1990s, and it has become the gold standard for elective splenectomy. Recently, single-port laparoscopic (SPL) surgery has emerged as an alternative to multiport laparoscopy, but SPL splenectomy in a patient with idiopathic thrombocytopenic purpura (ITP) has not been reported to date in Saudi Arabia or the region. A case report of SPL splenectomy in a patient with ITP is briefly described along with the surgical technique needed for such a procedure. The patient was an otherwise healthy 24-year-old female woman with medically refractory ITP and a platelet count of 2200. A standard splenectomy was performed using a SPL technique. The patient did well intraoperatively and postoperatively, was happy with her incision, and was discharged home with no complications 3 days after the procedure. In conclusion, SPL splenectomy is feasible in select patients and may provide a less painful, cosmetically better alternative.

The feasibility and safety of laparoscopic splenectomy for massive splenomegaly: a comparative study

BACKGROUND

Laparoscopic splenectomy used for massive splenomegaly is still controversial. The purpose of our current study was to identify the feasibility and safety of laparoscopic splenectomy for massive splenomegaly.

METHODS

From January 2006 to January 2010, laparoscopic splenectomy was performed on 33 patients with massive splenomegaly in our hospital, compared with 29 patients who received open splenectomy (group 2) and 48 patients with normal-size spleens who underwent laparoscopic splenectomy (group 3). Perioperative outcomes of these patients were compared.

RESULTS

Compared with patients in group 2, the patients in group 1 required more operative time, less blood transfusion, and a shorter postoperative hospital stay; furthermore, patients in group 1 had less estimated blood loss and fewer complications. No statistically significant difference was found in the patients' spleen volume and spleen weight. Group 1 had statistically significant differences in operative time, estimated blood loss, postoperative hospital stay, spleen volume, and spleen weight compared with patients in group 3. No significant differences were found in the conversion, blood transfusion, or complication rate.

CONCLUSIONS

Laparoscopic splenectomy is a technically feasible and safe procedure for splenomegaly.

Laparoscopic partial splenectomy using a detachable clamp with and without partial splenic embolisation

BACKGROUND

In many centres, the laparoscopic total splenectomy is a well-established routine procedure. However, the crucial immunological role of the spleen in combating bacterial infections, in particular pneumonias, has led to a search for splenic-preserving techniques whenever possible. Yet, laparoscopic partial splenectomies are still rarely described possibly due to difficulties in controlling intra-operative parenchymal bleeding during splenic transection.

METHODS

Here, we present a case series of laparoscopic partial splenectomies using a new technique. The main splenic artery and vein were temporarily clamped using a detachable clip. Transection of the spleen was possible working with the LigaSure™ instrument. After transection, the margin was sealed with a collagen fleece. In one case of a haemangioma, the patient underwent a radiological coil embolisation of the feeding arteries of the splenic pole in question. This was done 4 weeks prior to surgery and included embolisation of the tumour.

RESULTS

Three patients (2 males, 1 female, mean age 58.3 years) have been successfully treated using a detachable clamp. The pre-surgical mean size of the spleen was 8.0 × 16.7 cm (range 6 × 14-11 × 22 cm). The removed specimens had a mean size of 4.2 × 5.5 cm (range 2.5 × 4.0-5.0 × 6.5 cm). The time of surgery averaged 144 min (range 110-187 min). Blood loss was minimal thereby avoiding the need for blood transfusions. The post-surgical course was uneventful; patients were discharged 5 days following surgery. Histopathology showed a benign splenic haemangioma, a benign splenic hamartoma and the presence of Hodgkin's disease stage III.

CONCLUSIONS

The technique of laparoscopic partial splenectomy and, in certain patients, pre-surgical partial splenic embolisation is safe and effective for patients with localised diseases of the spleen. This approach combines the benefits of the minimal surgical access with saving a significant amount of splenic tissue, thereby preserving the immune function of the spleen.

Single incision approach for splenic diseases: a preliminary report on a series of 8 cases

BACKGROUND

There is a current trend to reduce the invasiveness of minimally invasive procedures, and the single-incision laparoscopic approach (SILS) has been proposed for several intra-abdominal surgical interventions. The spleen poses specific problems for techniques, such as SILS, due to its volume and texture, and little clinical information is available on the topic. We describe our initial experience using SILS for the management of splenic diseases.

METHODS

Between December 2008 and September 2009, we attempted SILS in eight patients: four men and four women with a median age of 44 (range, 26-73) years, and body mass index of 24.5 (range, 18-31). Preoperative diagnosis was malignancy (n = 3), ITP (n = 1), HIV-related hypersplenism (n = 1), spherocytosis (n = 1), and splenic cyst (n = 2). SILS was attempted transumbilically in four cases and through a 15-mm subcostal single incision in the other four. As entry port we used either three trocars (one of 12 mm and two of 5 mm) inserted through the single-site incision or the umbilicus, or a multiport (Triport, Olympus) device. Instrumentation used consisted of curved instruments, a flexible-tip 10-mm scope, and the harmonic scalpel. Visualization of the spleen and standard dissection of attachments was accomplished, and splenectomy was completed by stapling of the splenic hilum. The spleen was extracted through the single-site incision. In two cases, unroofing of a splenic cyst was performed transumbilically.

RESULTS

The SILS procedure was successful in six of the eight patients (75%). Conversion to conventional laparoscopic splenectomy (LS) was required in two patients due to adhesions and spleen size. Median operative time was 97 (range, 60-150) min. There were no postoperative complications, and median stay was 4 (range, 2-5) days. Median spleen weight was 485 (range, 340-590) g.

CONCLUSIONS

SILS access can be safely used for operative visualization, hilum transection, and spleen removal, further reducing parietal wall trauma. The definitive clinical, esthetic, and functional advantages require further analysis.

Single-port access: a feasible alternative to conventional laparoscopic splenectomy

HYPOTHESIS

The laparoscopic approach has become the gold standard for splenectomy despite the fact that the spleen is a solid organ located deep in the splenic fossa. There is currently a trend to reduce the invasiveness of minimally invasive procedures. Transabdominal or transumbilical single-incision laparoscopic (SILS) approaches are an alternative to natural orifice transluminal endoscopic surgery techniques, but no reports of their use have yet been published in relation to the spleen.

AIM

To describe the SILS technique for splenectomy in 2 patients.

MATERIAL AND METHODS

Two patients were approached by SILS, a 26-year-old male diagnosed of autoimmune thrombocytopenia and a 45-year-old male with recurrent Hodgkin disease. In both cases 3 trocars (1 of 12 mm and 2 of 5 mm) were inserted through the umbilicus in one and in a left subcostal in the other, and a curved transanal endoscopic microsurgery instrument, a flexible-tip 10-mm scope, and the UltraCision were introduced. Visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transumbilicus stapling of the splenic hilum. The spleen was extracted through the umbilical incision, intact in one case and after morcellation in the other.

RESULTS

The postoperative course was uneventful. Both patients had minimal postoperative pain and scarring and were discharged on the second postoperative day.

CONCLUSIONS

SILS access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.

[Laparoscopic splenectomy: indications, techniques, outcomes]

Laparoscopic splenectomy (LS) has become the standard approach to splenectomy for benign and malignant hematologic diseases despite a paucity of high-level evidence. The procedure requires expertise in laparoscopic surgical techniques and meticulous dissection of the spleen. Management should include a preoperative radiologic assessment to measure splenic volume and to detect the presence of accessory splenic tissue; the patient should undergo preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections. Prophylactic antibiotics are used in the perioperative period as well as prophylactic anticoagulation therapy which may be continued long-term in high-risk patients. LS is associated with a low morbidity and mortality; when compared to laparotomy, it reduces the length of hospital stay and improves the quality of life by decreasing postoperative ileus and pain. There are a variety of laparoscopic approaches; the hand-assisted technique and newer coagulating devices have facilitated the operative technique leading to increasing acceptance of laparoscopy as the preferred approach - even in patients with malignant hematologic disease and/or massive splenomegaly.

NOTES-assisted transvaginal splenectomy: the next step in the minimally invasive approach to the spleen

HYPOTHESIS

Natural orifice transluminal endoscopic surgery (NOTES) has marked yet another step forward in less-invasive surgical procedures. Access to solid organs located deep in the left hypochondrium can be difficult using this technique but the transvaginal approach with the patient positioned in full lateral decubitus may be an option.

MATERIAL AND METHODS

We present the case of a 60-year-old woman with a symptomatic splenic polycystic tumor. The procedure was carried out by a multidisciplinary team using a standard flexible videogastroscope and endoscopic instruments. Transvaginal visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transvaginal stapling of the splenic hilum. The organ was extracted transvaginally.

RESULTS

The postoperative course was uneventful. The patient had minimal postoperative pain and minimal scars, and was discharged on the second postoperative day.

CONCLUSIONS

Transvaginal access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.

Laparoscopic versus open splenectomy in patients with beta thalassemia major

BACKGROUND

Laparoscopic splenectomy is considered the standard of care for the removal of the spleen in benign diseases. There are not sufficient data for the routine application of this technique in patients with beta thalassemia major.

MATERIALS AND METHODS

Twenty-eight consecutive beta thalassemia major patients who underwent elective splenectomy were randomized for open and laparoscopic splenectomy. Patient demographics, operative time, intraoperative and postoperative complications, conversion rate, transfusions, and length of stay were recorded.

RESULTS

There was no mortality in this series. There was no difference in complication rates between the two groups. Operative time was markedly increased in the group treated laparoscopically, as was the need for blood transfusions. Median hospital stay was decreased in the laparoscopic group (5 days) compared to the open group (6.5 days).

CONCLUSIONS

Laparoscopic splenectomy in patients with beta thalassemia major is feasible; however, it is more time consuming and bleeding occurs more often.

Handheld gamma probe used to detect accessory spleens during initial laparoscopic splenectomies

BACKGROUND

Preoperative determination of the accessory spleen still is a major factor in the failure of both laparoscopic and conventional techniques. This study aimed to evaluate the practicability and efficacy of a handheld gamma probe in identifying accessory spleens at the initial intervention.

METHODS

This study evaluated 17 patients undergoing laparoscopic splenectomy attributable to benign hematologic disorders. All the patients had preoperative ultrasonography, computed tomography (CT) scan, and nuclear scintigraphic examination of the abdominal cavity to assess the size of the spleen, and to determine the existence of the accessory spleen or spleens. For all the patients, a handheld gamma probe count was used intraoperatively as an adjuvant method to define the presence and location of the accessory splenic tissue. Control nuclear scintigraphic examinations of all the patients were performed 1 month after the surgical procedure.

RESULTS

In two cases, intraoperatively accessory splenic tissue was detected by gamma probe, confirming the preoperative CT findings for the patients. One of these patients had three accessory spleens, although preoperative CT scan showed only two of them. However, by the help of the gamma probe, a third spleen located retroperitoneally was defined. For two patients, laparoscopic exploration and handheld gamma probe count did not identify any accessory splenic tissue, although preoperative CT scan indicated accessory spleens. For detecting accessory splenic tissue, the sensitivities of the studied techniques were 0% for ultrasonography, 75% for CT scan, 0% for preoperative nuclear scintigraphy, 75% for laparoscopic exploration, and 100% for perioperative gamma probe examination.

CONCLUSION

Preoperative imaging methods for accessory spleen determination still have limited benefits because of their limited sensitivity. Thus, the handheld gamma probe technique may be an adjuvant method for laparoscopic exploration ensuring that no accessory splenic tissue is missed during the initial surgical treatment of benign hematologic disorders.

Laparoscopic Splenectomy in an Adipose Elderly Patient With Symptomatic Non-Hodgkin Lymphoma-related Splenomegaly and Traumatic Central Splenic Hematoma

During recent years, laparoscopic splenectomy has shown to be a safe and effective surgical approach in patients with hematologic disorders requiring spleen removal. Especially in cases with splenomegaly, the laparoscopic approach results in a shorter hospital stay and faster recovery of the patients. Due to the increasing experience in laparoscopy, this approach also is emerging to be a therapeutic option in patients with blunt abdominal trauma with splenic rupture or hematoma. We report the case of an 80-year-old female patient who underwent laparoscopic splenectomy for symptomatic splenomegaly due to non-hodgkin Lymphoma in combination with stable traumatic splenic hematoma after blunt abdominal trauma.

Sutureless and stapleless laparoscopic splenectomy using radiofrequency: LigaSure device

BACKGROUND

Bleeding is the main complication and cause of conversion during laparoscopic splenectomy (LS). We present the advantages of the LigaSure vessel sealing system added to the lateral approach for achieving safe vascular control.

METHODS

We performed 63 consecutive LS in a 3-year period using LigaSure in two affiliated university hospitals. We employed a right semilateral position technique with dissection of the spleen and vessel sealing using LigaSure. Forty-two patients had benign hematological disease, 19 had malignant disease, and two had splenic cysts.

RESULTS

A total of 58 LS were completed with five conversions due to hilar bleeding (three cases), difficult dissection (one), and massive splenomegaly (one). In all but five patients, blood loss was less than 100 ml. No transfusions were needed. There were five postoperative complications: portal thrombosis (one case), hemoperitoneum (two), surgical wound infection (one), and pleural effusion (one).

CONCLUSIONS

The use of LigaSure, and the semilateral position, results in a gain of time and safety. Furthermore, average intraoperative bleeding is very low.

The Impact of Minimally Invasive Surgical Techniques

The use of minimally invasive techniques (MIT) in patient care is well documented in ancient history; however, it was not until the 1990s that advancements in technology enabled surgeons to realize the true potential of this approach. The minimally invasive approach has revolutionized surgical care, significantly reducing postoperative pain, recovery time, and hospital stays with marked improvements in cosmetic outcome and overall cost-effectiveness. It is now used around the world and in all major fields of surgery, compelling changes in training programs in order to assure quality control and patient safety. The bond between surgeons practicing minimally invasive surgery (MIS) and the high-tech industry is of utmost importance to future developments. Surgical robotic systems represent the most technologically advanced product of this collaboration, and their potential application in MIS shows much promise. As technology advances, additional developments in MIT are likely.

Laparoscopic splenectomy for lymphoproliferative disease

BACKGROUND

Elective laparoscopic splenectomy (LS) achieves excellent results for benign hematologic diseases. The role of LS for hematologic malignancies is harder to define owing to associated splenomegaly and patient disease that may alter outcome.

METHODS

Retrospective review of single institution experience 1996 through 2002. To limit variability of disease processes, only patients with immune thrombocytopenic purpura (ITP) and lymphoproliferative disease (LPD) were studied.

RESULTS

A total of 211 LS have been performed, including 73 for LPD and 86 for ITP. Patients with LPD were significantly older, 61 vs 46 years p<0.001; male, 45 (62%) vs 33 (38%), p<0.001; and larger splenic weight, 680 vs 162 g, p<0.001. Fifty-nine patients (81%) with LPD were operated with standard LS with a conversion rate of 15%. Hand-assisted LS was performed in 14 patients (19%), and three were converted to open. Compared to ITP, patients with LPD had longer operative time, 148 vs 126 min, p<0001, and higher blood loss, 200 vs 100 cc, p = 0.004. There was one mortality (0.6%), and morbidity occurred in six patients (8%) with LPD and seven (8%) with ITP. The median length of stay was 3 days for LPD and 2 days for ITP, p = 0.03. Forty-six patients were principally operated for a diagnosis, and 27 (60%) were found to have lymphoma.

CONCLUSIONS

LS can be performed safely in patients with LPD, and when used judiciously with hand-assisted techniques can be performed with low conversion and morbidity rates. Splenectomy plays an important role in establishing the diagnosis of lymphoma in LPD.

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.

Staged laparoscopic splenectomy and valve replacement in splenic abscess and infective endocarditis

Splenic abscess is a rare clinical entity that is most commonly associated with infective endocarditis. Valve replacement in the setting of an unaddressed splenic abscess is associated with a high incidence of prosthetic valve infection and death. We describe 2 patients with infective endocarditis and splenic abscess treated by laparoscopic splenectomy followed by valve replacement.