Laparoscopic splenectomy is a safe and effective procedure for patients with splenomegaly due to portal hypertension

Concomitant Laparoscopic Splenectomy and Cholecystectomy: A Systematic Review of the Literature

Background: Concomitant laparoscopic splenectomy and cholecystectomy (CLSC) is performed for concurrent pathologies of the spleen and gallbladder. This systematic review aimed to evaluate the available evidence on its indications, operative technique, and outcomes. Materials and Methods: The PubMed and Cochrane bibliographical databases were searched from the beginning of time (last search: December 6, 2019) for studies reporting on CLSC. The National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool was utilized for the evaluation of eligible articles. Results: Eight studies met inclusion criteria and concerned collectively 108 patients (53 males and 55 females) with a mean age of 27.02 ± 20.48 years (mean, SD). The most common surgery indications were hereditary spherocytosis (38.9%) and sickle cell disease or β-thalassemia (32.4%). Laparoscopic cholecystectomy preceded splenectomy in the majority of cases (75%). A five-trocar approach was most frequently (89.8%) utilized. The mean operation duration was 170.18 ± 53.07 minutes (mean, SD). Resected spleen weight was 601.82 ± 386.02 g (mean, SD) and had a length of 18.74 ± 5.3 cm (mean, SD). The conversion rate was 2.7%, while 20.4% of included cases experienced postoperative complications. Most frequent ones included pulmonary infection (6.5%) and portal/splenic vein thrombosis (4.6%). No postoperative death was recorded. Mean hospitalization period was 5.43 ± 3.18 days (mean, SD). Conclusions: CLSC is a safe and feasible operation for simultaneous diseases of the spleen and gallbladder that require elective procedures. High-quality clinical trials are essential to further elucidate clinical evidence and standardize operative technique.

Efficacy and safety of laparoscopic splenectomy and esophagogastric devascularization for portal hypertension: A single-center experience

Many patients in China have portal hypertension secondary to liver cirrhosis. Splenectomy and devascularization have become an efficacious surgical procedure for portal hypertension, and has been recommended in China as the first choice for the treatment of portal hypertension for a long time. As a result of advances in laparoscopic equipment and techniques, splenectomy and esophagogastric devascularization have been carried out with laparoscope.From January 2012 to December 2017, 453 patients who were diagnosed with portal hypertension and serious gastroesophageal varices received surgical management in our institution. 250 patients chose laparoscopic splenectomy and esophagogastric devascularization and 203 underwent open splenectomy and esophagogastric devascularization.We retrospectively analyzed the perioperative data and follow-up data of these patients. The operation time of laparoscopic group was longer than open group (P ≤ .001). Intraoperative blood loss was less (P ≤ .001), the passing of flatus was earlier (P = .042), and postoperative hospital stay was shorter (P = .001) in the laparoscopic group. During postoperative follow-up of 4 to 75 months, the incidence of esophagogastric variceal rebleeding, encephalopathy, and secondary liver cancer showed no significant differences.Laparoscopic splenectomy and esophagogastric devascularization were safe and more effective than open surgery for portal hypertension and gastroesophageal varices.

Safe approach to the splenic hilum by first mobilizing the pancreatic tail in laparoscopic splenectomy

INTRODUCTION

We employed a safe approach during laparoscopic splenectomy by first mobilizing the pancreatic tail and then dissecting the splenic vessels at the splenic hilum before mobilizing the spleen.

MATERIALS AND SURGICAL TECHNIQUE

Patients were placed in the lithotomy position, and only the upper body was twisted to the right side. Five trocars were placed. After the bursa omentalis was opened, an avascular layer was identified behind the pancreas. This avascular layer was bluntly dissected, and the pancreatic tail was isolated from the retroperitoneum. The tissue surrounding the splenic hilum was dissected by a handling tape that was placed around the pancreatic tail. Because the spleen remained connected to the retroperitoneum with the splenorenal ligament, a good operative view of the splenic hilum was obtained with proper extension. After sufficient space was secured between the pancreatic tail and the spleen, the splenic vessels were divided with a linear stapler. The spleen was detached in the final stage.

DISCUSSION

The current standardized procedure is highly recommended for a safe laparoscopic splenectomy.

Gastroesophageal Variceal Bleeding Successfully Controlled by Partial Splenic Embolization

A 53-year-old male patient with a history of hepatocellular carcinoma developed gastroesophageal varices refractory to endoscopic injection sclerotherapy (EIS). He required EIS six times in 2 years for recurring variceal bleeding. After hepatic resection, he developed massive splenomegaly. Partial splenic embolization (PSE) was performed to reduce the portal pressure. Varices and variceal bleeding were not detected during 13-year follow up, until the patient died of hepatocellular carcinoma. This is a unique case of gastroesophageal varices controlled by PSE and improved portal hypertension.

Postoperative outcomes after open splenectomy versus laparoscopic splenectomy in cirrhotic patients: a meta-analysis

BACKGROUND

Laparoscopic splenectomy is considered the gold standard for resecting normal-to-moderately bigger spleens in benign conditions, and in addition could be tried for patients with malignant splenic disorders. However, the safety of laparoscopic splenectomy in patients with hypersplenism is not well-known. This study aimed to investigate the efficacy and safety of laparoscopic splenectomy for patients with hypersplenism secondary to liver cirrhosis by comparing with the open splenectomy.

DATA SOURCES

Several databases were searched to identify comparative studies fulfilling the predefined selection criteria from January 2000 to June 2015. The subsequent key words were utilized for browsing "laparoscopy" or "laparoscopic", "open", "splenectomy", and "liver cirrhosis". Studies evaluating laparoscopic and open splenectomy for patients with liver cirrhosis were incorporated. Two evaluators personally strained the title and abstract of each publication. Citations with contemplated compliance within our eligibility criteria underwent compressed review. Meta-analysis was carried out according to the recommendations of the Cochrane Collaboration software (review manager 5.1).

RESULTS

Seven studies containing 509 patients were included. Compared with the open splenectomy group, patients in the laparoscopic splenectomy group had significantly less intraoperative blood loss (MD=210.30; 95% CI: 11.28-409.32; P=0.04), longer operative time (MD=-31.58; 95% CI: -53.34--9.82; P=0.004), shorter duration of postoperative hospital stay (MD=3.41; 95% CI: 2.39-4.43; P<0.01), lower incidence of postoperative complications (RR=1.34; 95% CI: 0.88-2.01; P=0.17), and decreased liver damage [ALT (MD=8.52; 95% CI: 0.19-16.85; P=0.05) and total bilirubin (MD=5.12; 95% CI: 0.37-9.87; P=0.03)].

CONCLUSION

Hypersplenism secondary to cirrhosis and portal hypertension should not be a contraindication for laparoscopic splenectomy.

A meta-analysis study of laparoscopic versus open splenectomy with or without esophagogastric devascularization in the management of liver cirrhosis and portal hypertension

INTRODUCTION

The aim of this meta-analysis was to determine whether laparoscopic splenectomy (LS) and LS with esophagogastric devascularization (LSED) were the minimally invasive alternative for portal hypertension.

MATERIALS AND METHODS

A meta-analysis of comparative clinical trials was performed to assess our questions noted above. The databases PubMed, ScienceDirect, and Springerlink were searched.

RESULTS

In total, 725 patients with liver cirrhosis and/or portal hypertension from eight published comparative trials were included. The operation time in the laparoscopic group was more than that in the open group [weighted mean difference (WMD) 35.24 (16.74, 53.74); P<.001]. However, there were less intraoperative blood loss [WMD -194.84 (-321.34, -68.34); P=.003] and a shorter postoperative hospital stay [WMD -4.33 (-5.30, -3.36); P<.001] in the laparoscopic group. The incidence of complications was similar in the two groups. In the subgroup studies about LS versus open splenectomy, no significant differences were found in operation time, intraoperative blood loss, and complication rates. The postoperative hospital stay in the LS group was apparently decreased [WMD -4.07 (-4.93, -3.21); P<.001]. Although the operation time of LSED was longer [WMD 43.23 (17.13, 69.32); P=.001], LSED was associated with less intraoperative blood loss [WMD -189.26 (-295.71, -82.81); P<.001] and a shorter postoperative hospital stay [WMD -5.41 (-7.84, -2.98); P<.001]. Meta-analysis did not favor either LSED or open splenectomy with esophagogastric devascularization in term of complication rates.

CONCLUSIONS

The results of this meta-analysis were in favor of LS and LSED for being a safe, minimally invasion alternative for patients with liver cirrhosis and portal hypertension.

Left-sided portal hypertension: Successful management by laparoscopic splenectomy following splenic artery embolization

INTRODUCTION

Left-sided portal hypertension is a rare clinical condition most often associated with a pancreatic disease. In case of hemorrhage from gastric fundus varices, splenectomy is indicated. Commonly, the operation is carried out by laparotomy, as portal hypertension is considered a relative contraindication to laparoscopic splenectomy (LS). Although some studies have reported the feasibility of the laparoscopic approach in the setting of cirrhosis-related portal hypertension, experience concerning LS in left-sided portal hypertension is lacking.

PRESENTATION OF CASE

A 39-year-old man was admitted to the Emergency Department for haemorrhagic shock due to acute hemorrhage from gastric fundus varices. Diagnostic work up revealed a chronic pancreatitis-related splenic vein thrombosis causing left-sided portal hypertension with gastric fundus varices and splenic cavernoma. Following splenic artery embolization (SAE), the case was successfully managed by LS.

DISCUSSION

The advantages of laparoscopic over open splenectomy include lower complication rate, quicker recovery and shorter hospital stay. Splenic artery embolization prior to LS has been used to reduce intraoperative blood losses and conversion rate, especially in complex cases of splenomegaly or cirrhosis-related portal hypertension. We report a case of complicated left-sided portal hypertension managed by LS following SAE. In spite of the presence of large varices at the splenic hilum, the operation was performed by laparoscopy without any major intraoperative complication, thanks to the reduced venous pressure achieved by SAE.

CONCLUSION

Splenic artery embolization may be a valuable adjunct in case of left-sided portal hypertension requiring splenectomy, allowing a safe dissection of the splenic vessels even by laparoscopy.

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.

Role of splenectomy in patients with hepatocellular carcinoma and hypersplenism

INTRODUCTION

Hypersplenism with thrombocytopenia is a common complication of cirrhosis with portal hypertension. We evaluated the role of splenectomy in patients with hepatocellular carcinoma (HCC) in terms of the improvement of biochemical indices and liver volume.

METHODS

Nineteen patients with HCC underwent liver resection and splenectomy from January 2000 to December 2009. Thirty-nine patients who underwent liver resection during the same period were enrolled as case-matched controls. We performed a retrospective review of prospectively collected data. We analysed the results of biochemical tests, disease-free survival and overall survival and measured the liver volume before and at 90 days after operation.

RESULTS

Preoperative white blood cell counts (P = 0.001), platelet counts (P = 0.021), total bilirubin (P ≤ 0.001) and prothrombin time by international normalized ratio (P = 0.043) were significantly different. However, these results had converged to similar levels 90 days after the operation. The degree of increment in liver volume were similar (P = 0.763). In splenectomy group, portal vein thrombosis developed in eight patients and all patients except one recovered using only conservative treatments. There was an operative mortality because of liver failure by thrombosis.

CONCLUSIONS

Although splenectomy may induce thrombosis, liver failure and subsequent mortality, splenectomy may improve liver function and expand the indication of liver resection if postoperative management is conducted conservatively.

Laparoscopic splenectomy with or without devascularization of the stomach for liver cirrhosis and portal hypertension: a systematic review

BACKGROUND

Open splenectomy and devascularization are effective treatments for cirrhotic patients with severe thrombocytopenia and variceal bleeding. However, it remains controversial whether laparoscopic splenectomy (LS) and devascularization (LSD) can be indicated and beneficial in these patients.

OBJECTIVES

A systematic review of the efficacy and safety of LS and LSD for patients with liver cirrhosis and portal hypertension was undertaken to clarify controversy about their utilization in such patients.

METHODS

A systematic search strategy was performed to retrieve relevant studies from PubMed and Embase.com. The literature search and data extraction were independently performed by two reviewers.

RESULTS

Sixteen articles met the inclusion criteria. The methodology of the identified articles was poor. Six hundred and fifty-one patients, including 478 LS patients and 173 LSD patients, were involved in efficacy and safety evaluations. There was wide variability in the outcome measures between studies. There was only one death in the patients underwent LSD. Reported major complications included post-operative bleeding requiring re-surgery, pancreatic leakage and gastric perforation. Seven studies were identified with comparisons between laparoscopic and open procedures. No meta-analysis was possible because of heterogeneity between studies and lack of randomization.

CONCLUSIONS

The publications reviewed revealed LS and LSD to be safe and effective in the setting of liver cirrhosis and portal hypertension. From the comparison articles, laparoscopic procedures appear to be superior to open procedures regarding blood loss, hospital stay, complication rate and liver function impairment. However, it is difficult to draw firm statistical conclusions due to lack of high-quality evidence.

Hand-assisted laparoscopic splenectomy is a better choice for patients with supramassive splenomegaly due to liver cirrhosis

BACKGROUND

The current laparoscopic splenectomy (LS) procedure used for cirrhotic patients still has limitations. The aim of our study was to determine a standard according to the splenic size for hand-assisted LS (HALS) in patients with splenomegaly and hypersplenism due to cirrhosis.

PATIENTS AND METHODS

We conducted a retrospectively review of cirrhotic patients who underwent splenectomy between 2008 and 2011. All patients were divided into two groups: Group A (19 patients), in which patients' operations were conducted by HALS, and Group B (20 patients), in which patients were treated with LS. Then the patients in Group A were classified on the basis of the spleen size: massive splenomegaly (Group A1) and supramassive splenomegaly (Group A2). Likewise, so were patients in Group B: massive splenomegaly (Group B1) and supramassive splenomegaly (Group B2). Perioperative outcomes of these patients were compared.

RESULTS

The comparison of HALS and LS based on spleen size demonstrated that in the massive splenomegaly groups, Group A1 and Group B1 had similar estimated blood loss and morbidity, and no transfusion was required in these patients. In the supramassive splenomegaly groups, compared with Group A2, Group B2 had longer operative time, more estimated blood loss, more patients requiring transfusion, and more complications that needed surgical intervention. However, no significant differences were observed in the requirement of analgesia, time of returning to oral intake, and length of hospitalization in these paired groups.

CONCLUSIONS

In cirrhotic patients with supramassive splenomegaly, HALS should be considered because of its safety, feasibility, and effectiveness.

Comparative treatment and literature review for laparoscopic splenectomy alone versus preoperative splenic artery embolization splenectomy

BACKGROUND

Although laparoscopic splenectomy has been gradually regarded as an acceptable therapeutic approach for patients with massive splenomegaly, intraoperative blood loss remains an important complication. In an effort to evaluate the most effective and safe treatment of splenomegaly, we compared three methods of surgery for treating splenomegaly, including open splenectomy, laparoscopic splenectomy, and a combination of preoperative splenic artery embolization plus laparoscopic splenectomy.

METHODS

From January 2006 to August 2011, 79 patients underwent splenectomy in our hospital. Of them, 20 patients underwent a combined treatment of preoperative splenic artery embolization and laparoscopic splenectomy (group 1), 30 patients had laparoscopic splenectomy alone (group 2), and 29 patients underwent open splenectomy (group 3). Patients' demographics, perioperative data, clinical outcome, and hematological changes were analyzed.

RESULTS

Preoperative splenic artery embolization plus laparoscopic splenectomy was successfully performed in all patients in group 1. One patient in group 2 required an intraoperative conversion to traditional open splenectomy because of severe blood loss. Compared with group 2, significantly shorter operating time, less intraoperative blood loss, and shorter postoperative hospital stay were noted in group 1. No marked significant differences in postoperative complications of either group were observed. Compared with group 3, group 1 had less intraoperative blood loss, shorter postoperative stay, and fewer complications. No significant differences were found in operating time. There was a marked increase in platelet count and white blood count in both groups during the follow-up period.

CONCLUSIONS

Preoperative splenic artery embolization with laparoscopic splenectomy reduced the operating time and decreased intraoperative blood loss when compared with laparoscopic splenectomy alone or open splenectomy. Splenic artery embolization is a useful intraoperative adjunctive procedure for patients with splenomegaly because of the benefit of perioperative outcomes.

Laparoscopic surgery in the management of hypersplenism and esophagogastric varices: our initial experiences

BACKGROUND

Owing to recent advances in laparoscopic surgery, devascularization of the upper stomach with splenectomy (Spx) or Hassab's procedure (Has) as well as Spx for patients with portal hypertension have been attempted laparoscopically in some facilities, the results of which have been reported. This article describes the authors' surgical techniques and their results.

METHODS

Between August 1999 and August 2010, the authors treated 110 cases of portal hypertension with Spx or Has. Among these patients, 56 who simultaneously underwent additional major operations were eliminated from the study, leaving 54 patients eligible. They included 38 with open surgeries and 16 with laparoscopic surgeries, which consisted of 10 splenectomies and 6 Has operations. The perioperative data for the 2 groups were compared.

RESULTS

Purely laparoscopic Spx (L-Spx) was completed for 9 patients. Conversion from laparoscopic to hand-assisted laparoscopic surgery (HALS) was necessary for 1 patient because of poor visualization. Operative time was significantly longer in L-Spx than in the open method. Postoperative hospital stays were shorter for L-Spx. HALS was used for all 6 laparoscopic Has patients. There was no conversion from the laparoscopic to the open method. Operative time was significantly longer for laparoscopic Has than for open Has. Postoperative complication rates were significantly reduced, and postoperative hospital stays were significantly shorter for laparoscopic Has.

CONCLUSIONS

Although the data are still preliminary, laparoscopic surgery for patients with portal hypertension may prove to be a successful strategy.

Laparoscopic splenectomy is an effective and safe intervention for hypersplenism secondary to liver cirrhosis

BACKGROUND

Laparoscopic splenectomy has become the standard procedure for the normal to moderately enlarged spleens. We performed this study to investigate the safety, feasibility, and effectiveness of laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis.

METHODS

We performed a retrospective chart review of 24 cases of laparoscopic splenectomy (group 1), 24 cases of open splenectomy (group 2) for hypersplenism secondary to liver cirrhosis, and 68 cases of laparoscopic splenectomy for immune thrombocytopenic purpura (group 3). We performed comparisons between groups 1 and 2 and groups 1 and 3 in terms of demographic, intraoperative, postoperative variables, and changes in blood counts and liver function.

RESULTS

Patients in groups 1 and 2 had comparable demographic characteristics, but those in group 1 had less estimated blood loss, fewer complications, and shorter duration of oral intake, and they required less analgesia and shorter post-hospital stays. In both groups, leukocyte and platelet counts increased significantly and transaminase and total bilirubin decreased postoperatively, but not significantly, and there was no significant difference between the two groups. Compared with group 3, patients in group 1 were older, had lower preoperative hemoglobin levels and leukocyte counts, poorer Child-Pugh class, required more operation time, and suffered more estimated blood loss; however, there were no statistically significant differences in terms of conversion rates, transfusion rates, complication rates, and postoperative course.

CONCLUSIONS

Laparoscopic splenectomy is a safe, feasible, and effective procedure for hypersplenism secondary to liver cirrhosis.

Single-incision laparoscopic splenectomy using the "tug-exposure technique" in adults: results of ten initial cases

BACKGROUND

The application of single-incision laparoscopic surgery (SILS) to splenectomy is still challenging with much room for technical improvement. The purpose of this study was to describe the tug-exposure technique, an innovative technique for performing safe single-incision laparoscopic splenectomy (SILS-Sp).

METHODS

We performed SILS-Sp in ten consecutive adult patients with a variety of pathology requiring total splenectomy. A SILS™ Port with three 5-mm trocars was placed in the umbilicus as a single-access site. A flexible 5-mm laparoscope and an articulating grasper were used in addition to standard laparoscopic equipment. A cloth tape was introduced intraperitoneally to encircle and tug the splenic hilum. Both ends of the tape were extracted through an extra needle hole in the skin. Pulling the tape in appropriate directions provided excellent exposure of the splenic hilum (the tug-exposure technique). Under sufficient tension and exposure by tugging the spleen, a linear stapler was introduced for stapling and dividing the splenic hilum and the splenic artery and vein. The spleen was extracted through the umbilical wound within a retrieval bag. The umbilical wound was closed with subcutaneous sutures.

RESULTS

The tug-exposure technique was successfully used in all patients and markedly improved the exposure of the splenic hilum during SILS-Sp. The median intraoperative blood loss was 15 (range 0-1,000) ml. Only one patient (10%) required conversion to open surgery. Median operative time was 230 (range, 150-378) min, the median extracted spleen weight was 260 (range, 100-580) g, and the median postoperative hospital stay was 7 (range, 4-9) days. All patients were discharged uneventfully. The umbilical incision was nearly invisible at the 1-month follow-up.

CONCLUSIONS

The tug-exposure technique is an innovative technique that enables easy and safe SILS splenectomy by experienced surgeons.

A Laparoscopic Splenectomy Allows the Induction of Antiviral Therapy for Patients with Cirrhosis Associated with Hepatitis C Virus

It is difficult to treat patients with cirrhosis-associated hepatitis C with pegylated interferon (PEG-IFN) and ribavirin because of thrombocytopenia-related hypersplenism. Both safety and clinical efficacy were retrospectively analyzed for patients who underwent a laparoscopic splenectomy (LS) from January 2003 to December 2007. A total of 35 patients with cirrhosis associated with hepatitis C virus had LS for thrombocytopenia before PEG-IFN and ribavirin therapy, and all patients had thrombocytopenia, which was a contraindication for antiviral therapy. The hepatopathy was Child A in 24 patients, Child B in 10 patients, and Child C in one patient. All 35 patients increased platelet count from 48,000 ± 15,000 to 155,000 ± 55,000/μl ( P < 0.0001) after LS. The median hospital stay and blood loss were 13.0 days (range, 8 to 57 days) and 342.0 mL (range, 5 to 2350 mL). There was no postoperative death. Twenty-nine (83%) patients had PEG-IFN and ribavirin therapy after LS; 18 had complete therapy and 11 had partial therapy. Of these, nine had a sustained virologic response. A laparoscopic splenectomy for patients with cirrhosis associated with hepatitis C virus can be performed safely and allows induction of antiviral treatment.

Minimizing intraoperative bleeding using a vessel-sealing system and splenic hilum hanging maneuver in laparoscopic splenectomy

BACKGROUND/PURPOSE

The most common cause of conversion to laparotomy (open splenectomy) during laparoscopic splenectomy (LS) is bleeding from the splenic hilar vessels. Recently, the efficacy of Ligasure (a vessel-sealing system) as a safety device for sealing vessels and reducing intraoperative blood loss has been reported with various laparoscopic procedures. The objective of this report was to describe our techniques for minimizing bleeding during LS, characterized by the application of Ligasure (which reduces the number of clips and staples, and reduces unnecessary bleeding) and a splenic hilum hanging maneuver with a Diamond-Flex flexible retractor to obtain optimal exposure of the splenic hilum.

METHODS

We have performed 87 LSs since February 1993, and have employed the Ligasure instead of metal clips and staplers since September 2003. We have also introduced the splenic hilum hanging maneuver paired with Ligasure use. We have performed this new LS in 30 consecutive adult patients presenting with idiopathic thrombocytopenic purpura (n = 14), benign splenic tumor (n = 5), lymphoma (n = 4), hereditary spherocytosis (n = 2), liver cirrhosis (n = 2), and other pathologies (n = 3). The splenic ligaments and vessels, including the splenic artery and vein, were divided using a 5-mm Ligasure instead of a clip or stapler. The splenic hilum was encircled and elevated, using a Diamond-Flex, to ensure better exposure in all patients.

RESULTS

LS was successfully completed in 29 patients (97%), with only one conversion to open splenectomy. Mean blood loss for all patients with completed LS was only 21.6 ml (range 0-250 ml). Moreover, blood loss was not determinable (considered as 0 ml in this study) in 15 patients (52%). Mean spleen weight and operating time were 319.4 g (range 80-1605 g) and 143.4 min (range 90-180 min), respectively. No postoperative mortalities were encountered. Two patients experienced complications, including grade B pancreatic fistula and atelectasis, for an overall morbidity rate of 6.7%. Mean postoperative stay was 6.5 days (range 3-14 days).

CONCLUSIONS

LS using a Ligasure in combination with the splenic hilum hanging maneuver may reduce intraoperative blood loss.

Laparoscopic splenectomy may be a superior supportive intervention for cirrhotic patients with hypersplenism

BACKGROUND AND AIMS

To evaluate and compare laparoscopic splenectomy and partial splenic embolization as supportive intervention for cirrhotic patients with hypersplenism to overcome peripheral cytopenia before the initiation of and during interferon therapy or anticancer therapy for hepatocellular carcinoma.

METHODS

Between December 2000 and April 2008, 43 Japanese cirrhotic patients with hypersplenism underwent either laparoscopic splenectomy or partial splenic embolization as a supportive intervention to facilitate the initiation and completion of either interferon therapy or anticancer therapy for hepatocellular carcinoma. We reviewed the peri- and post-intervention outcomes and details of the subsequent planned main therapies. For interferon therapy, the rate of completion, the rate of treatment cessation and virological responses were evaluated. Anti-cancer therapies for hepatocellular carcinoma included liver resection, ablation therapy, intra-arterial chemotherapy, and transarterial chemoembolization.

RESULTS

All patients tolerated the operations well with no significant complications. The platelet count was significantly higher in the laparoscopic splenectomy group than in the partial splenic embolization group at 1 and 2 weeks after the intervention. Interferon therapy was stopped in two patients in the partial splenic embolization group due to recurrent thrombocytopenia whereas all patients in the laparoscopic splenectomy group completed interferon therapy. The planned anticancer therapies were performed in all patients, and were completed in all patients without any problems or major complications.

CONCLUSION

Laparoscopic splenectomy may be superior to partial splenic embolization as a supportive intervention for cirrhotic patients with hypersplenism. Future prospective, randomized controlled patient studies are required to confirm these findings.

Laparoscopic versus open splenectomy for hypersplenism secondary to liver cirrhosis

BACKGROUND

Since the first laparoscopic splenectomy (LS) in 1991, LS has become the gold standard for the removal of normal-to-moderately enlarged spleens in benign conditions. Compared with open splenectomy (OS), fewer postsurgical complications and better postoperative recovery were observed, but it is contraindicated for hypersplenism secondary to liver cirrhosis 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.

METHODS

OS and LS performed for hypersplenism secondary to liver cirrhosis at our institution were analyzed. Relationships between postoperative increases in platelet counts, white blood cell counts, hemoglobin, and liver function were examined. Perioperative data of LSs were compared with those of OSs, including operative time, blood loss, excised spleen weight, complications, and hospital stays.

RESULTS

A total of 216 splenectomies (135 OS and 81 LS) were performed from April 1999 to March 2007. Five laparoscopic cases were converted to open surgery owing to operative bleeding or bleeding of splenic fossa. The other 76 patients were performed LSs successfully. No major operative complications occurred. There was no operative death. Excised spleen weight >400 g was present in 56% of cases in this series. At 7 days postoperatively, the platelet counts, white blood cell counts, and hemoglobin significantly increased after open and laparoscopic surgeries, and increase of alanine aminotransferase, aspartate aminotransferase, total bilirubin, and directed bilirubin of LS were significantly different with open cases. Operation times of LS and OS were 2.9+/-0.7 hours and 2.6+/-0.6 hours, respectively. Blood losses were 150.6+/-135.4 mL and 633.8+/-340.3 mL (P<0.01), excised spleen weights were 585.7+/-184.6 g and 591.1+/-153.4 g (P>0.05), and hospital stay were 8.2+/-2.0 days and 11.9+/-3.8 days (P<0.01). Operative associated complications were noted in both LS and OS. Less blood loss, shorter hospital stay, and less impairment of liver function were observed in LS than OS.

CONCLUSIONS

LS is feasible, effective, and safe procedures for hypersplenism secondary to liver cirrhosis and contributes to less impairment of liver function, less blood loss, and shorter hospital stay.