Putative predictive parameters for the outcome of laparoscopic splenectomy: a multicenter analysis performed on the Italian Registry of Laparoscopic Surgery of the Spleen. Ann Surg. 2010;251:287-291. [PMID: 20010087 DOI: 10.1097/sla.0b013e3181bfda59]

Effects of laparoscopic splenectomy on surgical site wound infection in patients with spleen rupture: A meta-analysis

A meta-analysis was performed to compare the effects of laparoscopic splenectomy (LS) and open splenectomy (OS) for splenic rupture on postoperative surgical site wound infections and postoperative complications. A comprehensive computerised search was conducted for studies comparing LS with OS for the treatment of splenic rupture in the PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang databases, with the search including studies published in any language between the creation of the databases and August 2023. Two researchers independently screened the literature and extracted the data. Literature quality was assessed using the Newcastle-Ottawa Scale, and the included data were collated and analysed using Stata 17.0 software for meta-analysis. Twenty-two studies involving 1545 patients were included. LS was superior to OS in the following aspects: reduced risk of postoperative surgical site wound infection (OR = 0.19, 95% CI: 0.11-0.34, p = 0.000), shortened hospital stay (standardised mean difference = -1.73, 95% CI: -2.05 to -1.40, p = 0.000), and reduced postoperative complication rate (OR = 0.22, 95% CI: 0.16-0.31, p = 0.000). Compared with OS, LS has a lower rate of postoperative wound infection, shorter hospital stay, and reduced rate of postoperative complications. LS is safe and effective for the treatment of splenic rupture and can be promoted clinically.

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.

Impact of Underlying Disease and Preoperative Factors on Postoperative Outcomes After Laparoscopic Splenectomy: A Bicentric Retrospective Analysis

BACKGROUND

Although the laparoscopic approach is considered the gold standard for elective splenectomy, it is still debated whether the underlying disease affects postoperative outcomes. Given the importance of good patient selection in the early stages of the learning curve for laparoscopic splenectomy (LS), this study aimed to compare the postoperative outcomes following LS for malignant diseases and benign diseases (MDs and BDs).

MATERIALS AND METHODS

A retrospective review of patients who underwent LS was performed at 2 different institutions between January 2013 and September 2020. Patients were classified into 2 groups based on the underlying BDs or MDs, and the 30 days postoperative outcomes were compared. Risk factors for overall complications were determined using logistic regression analysis.

RESULTS

LS was performed for BDs and MDs in 51 (67%) and 25 (33%) patients, respectively. The overall morbidity rate and the intraoperative and postoperative complication rates were significantly higher in the MD group ( P <0.05). In the univariate analysis, the underlying MD, age above 49.5 years, body mass index >24.9, the long axis of the spleen >16 cm, and spleen weight >600 g were significantly associated with increased postoperative morbidity.

CONCLUSION

In addition to the underlying disease, preoperative conditions may also affect the complication rates after LS. These findings may be helpful in patient selection, especially in the early stages of the learning curve for minimally invasive splenectomies.

Application of Real-Time Augmented Reality Laparoscopic Navigation in Splenectomy for Massive Splenomegaly

OBJECTIVES

To evaluate the clinical impact and technical feasibility of augmented reality laparoscopic navigation (ARLN) system in laparoscopic splenectomy for massive splenomegaly.

METHODS

The clinical data of 17 consecutive patients who underwent laparoscopic splenectomy using ARLN (ARLN group) and 26 patients without ARLN guidance (Non-ARLN group) between January 2018 and April 2020 were enrolled. Propensity score matching (PSM) analysis was performed between the patients with and without ARLN guidance at a ratio of 1:1.

RESULTS

Mean intraoperative blood loss was significantly lower in the ARLN-group than in the Non-ARLN group (306.6 ml vs. 462.6 ml, p = 0.047). All the patients in the ARLN-group achieved successful splenic artery dissection, while surgical success was achieved in 12 patients in the Non-ARLN group (p = 0.044). Postoperative hospital stay was significantly longer in the Non-ARLN group (3.8 days vs. 4.5 days, p = 0.040).

CONCLUSIONS

ARLN can provide feasible and accurate intraoperative image guidance, and it could be helpful in the performance of laparoscopic splenectomy for massive splenomegaly.

Robotic vs. Laparoscopic Splenectomy in Management of Non-traumatic Splenic Pathologies: A Systematic Review and Meta-Analysis

We aimed to evaluate comparative outcomes of robotic and laparoscopic splenectomy in patients with non-traumatic splenic pathologies. A systematic search of electronic databases and bibliographic reference lists were conducted, and a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in electronic databases were applied. Intraoperative and post-operative complications, wound infection, haematoma, conversion to open procedure, return to theatre, volume of blood loss, procedure time and length of hospital stay were the evaluated outcome parameters. We identified 8 comparative studies reporting a total of 560 patients comparing outcomes of robotic (n = 202) and laparoscopic (n = 258) splenectomies. The robotic approach was associated with significantly lower volume of blood loss (MD: -82.53 mls, 95% CI -161.91 to -3.16, P = .04) than the laparoscopic approach. There was no significant difference in intraoperative complications (OR: 0.68, 95% CI .21-2.01, P = .51), post-operative complications (OR: .91, 95% CI .40-2.06, P = .82), wound infection (RD: -.01, 95% CI -.04-.03, P = .78), haematoma (OR: 0.40, 95% CI .04-4.03, P = .44), conversion to open (OR: 0.63; 95% CI, .24-1.70, P = .36), return to theatre (RD: -.04, 95% CI -.09-.02, P = .16), procedure time (MD: 3.63; 95% CI -16.99-24.25, P = .73) and length of hospital stay (MD: -.21; 95% CI -1.17 - .75, P = .67) between 2 groups. In conclusion, robotic and laparoscopic splenectomies seem to have comparable perioperative outcomes with similar rate of conversion to an open procedure, procedure time and length of hospital stay. The former may potentially reduce the volume of intraoperative blood loss. Future higher level research is required to evaluate the cost-effectiveness and clinical outcomes.

A novel preoperative scoring system to predict technical difficulty in laparoscopic splenectomy for non-traumatic diseases

BACKGROUND

Laparoscopic splenectomy (LS) has been proven to be a safe and advantageous procedure. To ensure that resections of appropriate difficulty are selected, an objective preoperative grading of difficulty is required. We aimed to develop a predictive difficulty grading of LS based on intraoperative complications.

METHODS

A total of 272 non-traumatic patients who underwent LS were identified from a regional medical center. Patients were randomized into a training cohort (n = 222) and a validation cohort (n = 50). Data on demographics, medical and surgical history, operative and pathological characteristics, and postoperative outcome details were collected. Univariate and multivariate analyses of risk factors for intraoperative complications were performed to develop a difficulty scoring system. The Spearman correlation coefficient was used to evaluate the relationship between the difficulty grading score and intraoperative outcomes. Receiver operating characteristic (ROC) curve was used to evaluate the discriminatory power of this scoring system.

RESULTS

Three preoperative factors (spleen weight, esophagogastric varices, and INR) had a significant effect on operative time, bleeding, and conversion to open surgery. We created a difficulty grading score with three levels of difficulty: low (≤ 4 points), medium (5-6 points), and high (≥ 7 points), based on the three preoperative parameters. The correlation was highly significant (P < 0.01) according to Spearman's correlation. The area under the ROC curve was 0.695 (95% CI 0.630-0.755). The external validation showed significant correlations with the present model, with an AUC of 0.725 (95% CI 0.580-0.842). The comparison between our difficulty score and the previous grading system in the 272-patient cohort presented a significant difference in the AUC (0.701, 95% CI 0.643-0.755 vs. 0.644, 95% CI 0.584-0.701, P = 0.0452).

CONCLUSION

The present difficulty scoring system, based on preoperative factors, has good performance in predicting the risk of intraoperative complications of LS and could be helpful for enabling appropriate case selection with respect to the current experience of a surgeon.

Are there any limits for laparoscopy in splenomegaly? Our experience

Laparoscopic splenectomy in the case of massive or supermassive splenomegaly has been associated with higher conversion rates and morbidity. The purpose of our study is to evaluate the feasibility and safety of laparoscopic splenectomy for massive spleens and to identify if there are limits beyond which the laparoscopic approach is not recommended in massive and supermassive spleens. This is a retrospective study of 93 consecutive laparoscopic splenectomies in adult patients performed by a single surgeon, from January 2008 to December 2017. The data collected included the patient's age, sex, ASA, spleen weight, volume and dimension, type of disease, hospital stay, surgical technique, operative time. Median splenic weight was 400 g (range 65-3800 g) and median volume was 1365 cc (range 600-3800). Median operative time was 120 min and the overall conversion rate was 5.4%. Globally, 52 patients (55.9%) had a normal-weight spleen, 25 (26.9%) had massive and 16 (17.2%) had supermassive splenomegaly. In splenomegaly group (n = 41), patient's age, percentage of malignant diagnosis, spleen weight, anteroposterior (AP), medio-lateral (ML) and craniocaudal (CC) diameter, surgical time and conversion rate were significantly higher compared to normal-weight spleen patients. None of the normal-weight spleen patients underwent open conversion, while 5 patients among 41 splenomegalic cases underwent laparotomic conversion (12.2%). Comparing massive and super-massive patients, the latter showed longer operative time and hospital length of stay, and higher conversion rate. We identified as significant cut-off limits for higher conversion risk a spleen weight ≥ 1300 g and a spleen CC diameter ≥ 22 cm. In our experience laparoscopy was the gold standard in the case of spleen weight and diameter equal to or less than 1300 g and 22 cm, but it was safe and feasible also in the case of larger spleens, taking into account the greater risk of conversion.

Clinical Significance of Splenic Vessels and Anatomical Features in Laparoscopic Splenectomy

Introduction: Laparoscopic splenectomy (LS) has become the standard treatment for benign hematological disorders and hypersplenism. However, serious complications such as pancreatic fistula and portal venous thrombosis (PVT) sometimes occur. We investigated the clinical significance of splenic vessels and anatomical features in LS. Methods: Patient data were collected from 32 patients who underwent LS. The indications for LS were hypersplenism due to liver cirrhosis, idiopathic thrombocytopenic purpura, hereditary spherocytosis, and others. Close contact of pancreatic tail with splenic hilum, spleen volume, and diameters of splenic vessels were evaluated on computed tomography images. Results: Close contact of pancreatic tail with splenic hilum was recognized in 15 of the patients. The close contact was significantly associated with operation time (P = .038), spleen volume (P = .021), and spleen volume/body surface area (BSA) ratio (P = .001). In multivariate analysis, spleen volume/BSA ratio was an independent factor for close contact (P = .022). PVT occurred in 3 cirrhosis patients, and the diameter of the splenic vein (SV) was significantly associated with PVT as a result of multivariate analysis (P = .027). Conclusion: Close contact of the pancreatic tail with the splenic hilum may cause a longer operation time at LS and be associated with spleen volume/BSA ratio. A larger SV diameter in cirrhosis patients may be related to PVT after LS.

A Study on the Efficacy of Empirical Antibiotic Therapy for Splenectomized Children with Fever

Thalassemia represents a heterogeneous group of inherited diseases characterized by the lack or reduced production of hemoglobin β-chains. Many patients with thalassemia require splenectomy. What should be considered in the evaluation and management of candidates for splenectomy is to cover vaccination against infections such as pneumococci and the implementation of antibiotic prophylaxis. This study aimed to investigate the effect of the antibiotic type on the outcome of acute post-splenectomy infection in patients with thalassemia. This investigation is a retrospective cohort study. One hundred fifty medical records of hemoglobinopathy patients who underwent splenectomy were collected from the Ali-Asghar Hospital, Tehran, Iran. SPSS v. 20 and SAS v. 1.9 were used to analyze the data. A total of 150 patients that were vaccinated against post-splenectomy infections and were under antibiotic prophylaxis underwent splenectomy. The most commonly prescribed drugs were ceftriaxone or cefotaxime (132 cases, 88%), followed by ceftriaxone plus clindamycin (5.3%), ceftriaxone plus amikacin (3.3%), clindamycin (1.3%), vancomycin plus amikacin (0.7%), and others (1.3%). In terms of treatment outcomes, 143 cases (95.3%) were treated with the same antibiotics, and 4 (2.7%) experienced a changed antibiotic regimen with vancomycin. The results show that perceptions of treatment for fever in splenectomized children need to be changed, and most of them do not require hospitalization and initiation of broad-spectrum antibiotics such as vancomycin for initially refractory cases, and can only be treated with daily intravenous ceftriaxone.

Laparoscopic Splenectomy Versus Open Splenectomy In Massive and Giant Spleens: Should we Update the 2008 EAES Guidelines?

The objective of this study was to derive some useful parameters to define the feasibility of laparoscopic splenectomy (LS) in massive [spleen longitudinal diameter (SLD)>20 cm] and giant spleens (SLD>25 cm). Between December 1996 and May 2017, 175 patients underwent an elective splenectomy. A laparoscopic approach was used in 133 (76%) patients. Massive spleens were treated in 65 (37.1%) patients, of which 24 were treated laparoscopically. In this subset of massive spleens, the results of laparoscopic splenectomy in massive spleens (LSM) and open splenectomy in massive spleens (OSM) were compared. The clinical outcome of a subgroup of patients with giant spleens was also analyzed. The LSM group resulted in significant longer operative times (143±31 vs. 112±40 min; P=0.001), less blood loss (278±302 vs. 575±583 mL; P=0.007), and shorter hospital stay (6±3 vs. 9±4 d; P=0.004). No conversions were experienced in the LSM group, and the morbidity rate was similar in both the LSM and OSM groups (16.6% vs. 20%; P=0.75). When considering the subset of 9 LSM patients and 26 OSM patients with giant spleens, the same favorable tendency of the laparoscopic group as regards surgical conversion, blood loss, and hospital stay was maintained. The laparoscopic approach can be successfully proposed in the presence of massive splenomegaly also after a careful preoperative evaluation of the expected abdominal "working space." In experienced hands, LS is safe, feasible, and associated with better outcomes than open splenectomy for the treatment of massive and giant spleen, with a maximum SLD limit of 31 cm.

Operative outcomes after laparoscopic splenectomy with special reference to prophylactic antibiotics

INTRODUCTION

We conducted a retrospective study to investigate the progress of the operative outcome after laparoscopic splenectomy (LS), with a special reference to the administration of prophylactic antibiotics (PA).

METHODS

The study included 123 patients who underwent elective LS. Operative outcomes before and after the operative procedure was standardized and the impact of treatment with PA on surgical-site infection were investigated.

RESULTS

With regard to complications, wound infection developed in one (0.8%), portal trunk thrombosis in one (0.8%), pancreatic fistula in one (0.8%), postoperative bleeding in two (1.6%), pleural effusion in one (0.8%), and reoperation because of bowel injury in one (0.8%). Although morbidity did not differ between patients in the early (until the end of 2010) and late (after the beginning of 2011) periods, intraoperative blood loss was lower in patients in the late period. During the late period, no patients required conversion to open surgery. The proportion of patients with surgical-site infection did not differ between those who received PA 1 h before the start of surgery and every 3 h during surgery and those who received PA 1 h before the start of surgery, every 3 h during surgery, and twice a day for 24-72 h after surgery.

CONCLUSION

Operative outcomes after LS improved after the standardization of the operative procedure. The administration of PA 1 h before surgery and every 3 h during surgery seems to be sufficient to prevent surgical-site infection during LS.

Laparoscopic splenectomy in malignancies: is safe and feasible?

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Analysis of Risk Factors of Pancreatic Injury during Elective Laparoscopic Splenectomy in Children

Introduction:

Laparoscopic splenectomy (LS) became the standard choice for splenectomy in children with benign hematological disease. There are few reports about pancreatic injury during LS. The purpose of this study is to spot on factors increasing the risk of pancreatic injury during LS in children.

Patients and Methods:

A total of 140 children had LS for benign causes. Children were categorized into A and B groups. LigaSure™ was used to control pedicle in Group A, while endoscopic staplers were used in Group B. Preoperative levels of amylase, lipase, and lactate dehydrogenase (LDH) were obtained. The mean of pancreatic enzymes and LDH values was calculated on the 3 postoperative successive days.

Results:

A total of 71 boys and 69 girls had LS. The mean splenic size was 13.50 cm in Group A and 12.51 cm in Group B. The mean operative time in Group A was 41.91 min and in Group B was 56.36 min. The mean level of amylase was 42.99 IU/ml in Group A and 75.70 IU/ml in Group B (P = 0.001). The mean level of lipase was 37 IU/ml in Group A and 76.66 IU/ml in Group B (P = 0.001).

Conclusion:

Pancreatic injury during LS is a rare complication usually presented on biochemical level. We believe that it is a hemostatic-dependent complication rather than splenic size or nature of disease.

Laparoscopic "double-port" splenectomy. A new minimally-invasive option in a giant spleen

INTRODUCTION

In case of massive splenomegaly, laparoscopic splenectomy (LS) becomes challenging, uncomfortable and risky both for the surgeon and for the patient. As a consequence of ongoing research to obtain efficient and cheaper "scarless surgery", single-port technique and hand-assisted devices were developed and improved in this field.

PRESENTATION OF CASE

We present the clinical case of a patient affected by idiopathic myelofibrosis (MF) and splenomegaly who was admitted to our Department to perform a splenectomy for a suspected 5-cm splenic lesion.

DISCUSSION

The splenic longitudinal diameter measured 26 cm. The patient underwent splenectomy by laparoscopy, combining a single-port access and a gel-port device. The operation was completed laparoscopically. The operating time was 220 min and the estimate blood loss was 100 ml. The patient was discharged at 11 post-operative day in overall good conditions. Upon pathological analysis the splenic lesion was a localization of diffuse large B-cell Lymphoma in the context of MF.

CONCLUSION

this novel "hybrid technique" of splenectomy, combining the advantages of reduced number of abdominal incisions of the single-port technique to those of the hand assistance, is feasible in massive splenomegaly with good results. Furthermore, the use of the sovrapubic retrieval incision as the introduction site for the hand assisted device is convincing, since it's useful for both tasks. Further studies with large casuistries are necessary to confirm the effectiveness of the technique.

Robotic vs laparoscopic splenectomy for splenomegaly: A retrospective comparative cohort study

BACKGROUND

The aim of this study was to evaluate the role of robotic total splenectomy for splenomegaly, comparing this approach with the laparoscopic technique.

METHODS

We conducted a retrospective review of all patients who underwent minimally invasive splenectomy for splenomegaly (maximum splenic diameter>15 cm) at our institution between 2000 and 2017.

RESULTS

A total of 39 patients (27 laparoscopic vs 12 robotic splenectomies) were included in the study. Operative time was significantly longer in the robotic group (270 min vs 180 min, p = 0.007). Median intraoperative blood loss was 350 ml for laparoscopic procedures while it was 100 ml for the robotic ones (p = 0.032). Conversion to open surgery was required in 4 cases of laparoscopic splenectomy while no conversion were registered in the robotic group. No significant differences were seen in postoperative morbidity and mortality between the two groups.

CONCLUSIONS

Robotic splenectomy for splenomegaly is associated with less blood loss and longer operative times than the laparoscopic procedure.

Preoperative Predictive Factors of Conversions in Laparoscopic Splenectomies

PURPOSE

Presently, laparoscopic splenectomy (LS) is being performed for several indications in clinical practice. However, conversion to open surgery is occasionally required in some patients. We analyzed the intraoperative indications and potential preoperative predictors associated with conversion to open surgery in those presenting for LS.

METHODS

We reviewed 107 patients who underwent LS. We analyzed the surgical indications, spleen size, surgical procedure performed, operative time, rate of and indications for conversions, as well as postoperative complications.

RESULTS

Among the 15 patients (14.0%) who underwent conversion, the conversion was related to the occurrence of a splenic lymphoma in 10, severe bleeding in 3, a lack of anatomic definition in 1, and splenic candidiasis in 1 patient. A comparison between the results obtained in the initial 30 patients (LS performed during the learning curve) and those obtained in the remaining 77 patients, showed that conversions appeared to be related to the experience/expertise of the surgical team excluding patients with splenic malignancies. Conversion was not associated with a higher morbidity-mortality rate, but only a longer length of hospitalization.

CONCLUSIONS

LS is a gold standard procedure when performed by experienced and competent surgeons. However, careful patient selection is recommended before using the laparoscopic approach in those presenting with splenic malignancies.

Use of Iodized Oil and Gelatin Sponge Embolization in Splenic Artery Coiling Reduces Bleeding from Laparoscopic Splenectomy for Cirrhotic Portal Hypertension Patients with Complicating Hypersplenic Splenomegaly: A Comparative Study

OBJECTIVE

Laparoscopic splenectomy (LS) is relatively contraindicated in cirrhotic portal hypertension (CPH) patients with complicating hypersplenic splenomegaly (HS). This study aimed to evaluate the effectiveness and safety of incorporation of iodized oil and gelatin sponge embolization to conventional splenic artery embolization (cSAE) with coiling in CPH/HS patients undergoing LS.

PATIENTS AND METHODS

Between April 2012 and March 2014, eligible CPH/HS patients (n = 56) were assigned to preoperative modified SAE (mSAE) with LS (mSAE+LS group, n = 16), cSAE with LS (cSAE+LS group, n = 20) or LS alone (LS group, n = 20). Main outcome measures included frequency of conversion to laparotomy, operative time, intraoperative bleeding, and transfusion.

RESULTS

The three groups had similar baseline characteristics (all P > .05). mSAE and cSAE similarly decreased LS conversion frequency (mSAE+LS versus cSAE+LS versus LS, 0.0% versus 10.0% versus 30.0%, P = .030) and operative time (155 ± 23 minutes versus 170 ± 26 minutes versus 221 ± 42 minutes, P < .001) compared with LS alone. mSAE significantly reduced bleeding (178 ± 22 mL versus 250 ± 27 mL versus 328 ± 67 mL, P < .001) compared with cSAE and LS alone. The three groups had similar postoperative recovery times and surgical morbidities (all P > .05).

CONCLUSIONS

In CPH/HS patients, preoperative SAE reduced LS conversion frequency and reduced operative time compared with LS alone, while mSAE further decreased volume of blood loss.

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.

Validation of a Difficulty Grading Score in Laparoscopic Splenectomy

INTRODUCTION

Laparoscopic splenectomy (LS) is the gold standard for the treatment of many spleen-related disorders. However, in the presence of splenomegaly, the rate of conversion to open surgery can be as high as 33.9% and is associated with longer operative times and higher costs. In an attempt to improve risk stratification and patient selection for LS, a score that includes four preoperative parameters (age, gender, diagnosis, and spleen size) has been developed. The aim was the validation of a difficulty grading score, in predicting conversion and poorer outcomes.

METHODS

Retrospective analysis of 153 consecutive patients subjected to LS from January 2006 through December 2016 was performed. Several parameters were reviewed and correlation with evaluated outcomes was analyzed.

RESULTS

Conversion to open surgery occurred in 13 (8.50%) patients and was highly associated with serious intraoperative complications. Spearman correlation showed a significant association between the score and risk of conversion, operative time, and postoperative complications, but not with intraoperative bleeding.

DISCUSSION

Patient and disease features, incorporated in a difficulty grading score, can reliably determine the difficulty of LS and predict risk of conversion, intraoperative, and postoperative complications. This simple and reproducible score improves risk stratification for LS and could be practical in daily clinical activities.

Laparoscopic Splenectomy for Benign Hematological Disorders in Adults: A Systematic Review

BACKGROUND

Since its introduction in the early 1990s, laparoscopic splenectomy (LS) has gained worldwide acceptance for spleen removal, especially in hematological patients.

AIM

The present review summarizes the current knowledge and results of LS for the treatment of benign hematological diseases in adults.

MATERIALS AND METHODS

A MEDLINE/PubMed database research was performed using the terms: "laparoscopic splenectomy" OR "laparoscopy" OR "splenectomy" AND "hematological disorders" OR "hematological disease" OR "hematology" AND "adults" as key words. We set our analysis starting date as January 1st 2010 and the end date as December 31st 2016. We identified 247 relative articles. All the references from the identified articles were searched for relevant information.

RESULTS

Twenty-seven articles were deemed appropriate for our analysis. LS was found to be feasible and safe in the majority of patients with benign hematological disorders, with a mortality rate ranging from 0% to less than 4% and the postoperative complications rate from 0% to 35.7%. The conversion rate was also very low (4%) and response (complete or partial) was achieved in more than 80% of patients. Lateral approach with four trocars was the most commonly used approach with concommitant cholecystectomy being correlated with increased operative time and morbidity.

CONCLUSION

Current literature holds that whenever splenectomy is required for the treatment of hematological disorders in adults, a laparoscopic approach should be offered as the gold standard. However, to strengthen the clinical evidence in favor of LS, more high-quality clinical trials on several issues of the procedure are necessary.

Impact of preoperative platelet count on perioperative outcome after laparoscopic splenectomy for idiopathic thrombocytopenic purpura

INTRODUCTION

Laparoscopic splenectomy (LS) is the preferred treatment of idiopathic thrombocytopenic purpura (ITP) when medical treatment fails. The objective was to evaluate the feasibility and safety of LS according to the preoperative platelet count.

METHODS

This study is a retrospective analysis of a series of 199 patients who underwent LS for ITP from 1993 to 2015. The patients were divided into 3 groups according to platelet count: group i (<10×10(9)/L), group ii (10-50×10(9)/L) and group iii (> 50×10(9)/L).

RESULTS

Operative time was significantly lower in Group III compared to Group I and II (100±53 and 105±61min, P<.025)). Intraoperative blood loss was statistically higher in group i (263±551ml) with respect to the other 2: group ii (128±352ml) and group iii (24±62ml) (P<.003). Hospital stay was 6.4±5.8 days in group i, significantly higher compared to groups ii and iii (3.8±2.3 and 3.2±1.8 days, respectively (P<.003)).

CONCLUSION

Conducting a LS in ITP patients with low platelet counts is effective and safe.

Pancreatic fistula after laparoscopic splenectomy in patients with hypersplenism due to liver cirrhosis: effect of fibrin glue and polyglycolic acid felt on prophylaxis of postoperative complications

BACKGROUND

This study aimed to determine the effect of fibrin glue and polyglycolic acid (PGA) felt on prevention of pancreatic fistula (PF) after laparoscopic splenectomy in patients with hypersplenism due to liver cirrhosis.

METHODS

Fifty consecutive patients were enrolled in this prospective study. Twenty-three patients underwent laparoscopic splenectomy with a fibrin sheet (fibrin sheet group). The sealing ability of each treatment was evaluated by an ex vivo pressure test model. Based on the results from ex vivo experiments, 27 patients received prophylaxis using fibrin glue and PGA felt (PGA with fibrin group). The primary endpoint was the incidence of PF.

RESULTS

Significantly more (5, 22%) patients developed PF in the fibrin sheet group than in the PGA with fibrin group (0%, P = .037).

CONCLUSIONS

Our new application of fibrin glue and PGA felt is an effective prophylactic procedure for preventing development of PF after laparoscopic splenectomy.

Bacterial Infections Following Splenectomy for Malignant and Nonmalignant Hematologic Diseases

Splenectomy, while often necessary in otherwise healthy patients after major trauma, finds its primary indication for patients with underlying malignant or nonmalignant hematologic diseases. Indications of splenectomy for hematologic diseases have been reducing in the last few years, due to improved diagnostic and therapeutic tools. In high-income countries, there is a clear decrease over calendar time in the incidence of all indication splenectomy except nonmalignant hematologic diseases. However, splenectomy, even if with different modalities including laparoscopic splenectomy and partial splenectomy, continue to be a current surgical practice both in nonmalignant hematologic diseases, such as Immune Thrombocytopenic Purpura (ITP), Autoimmune Hemolytic Anemia (AIHA), Congenital Hemolytic Anemia such as Spherocytosis, Sickle Cell Anemia and Thalassemia and Malignant Hematological Disease, such as lymphoma. Today millions of people in the world are splenectomized. Splenectomy, independently of its cause, induces an early and late increase in the incidence of venous thromboembolism and infections. Infections remain the most dangerous complication of splenectomy. After splenectomy, the levels of antibody are preserved but there is a loss of memory B cells against pneumococcus and tetanus, and the loss of marginal zone monocytes deputed to immunological defense from capsulated bacteria. Commonly, the infections strictly correlated to the absence of the spleen or a decreased or absent splenic function are due to encapsulated bacteria that are the most virulent pathogens in this set of patients. Vaccination with polysaccharide and conjugate vaccines again Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis should be performed before the splenectomy. This practice reduces but does not eliminate the occurrence of overwhelming infections due to capsulated bacteria. At present, most of infections found in splenectomized patients are due to Gram-negative (G-) bacteria. The underlying disease is the most important factor in determining the frequency and severity of infections. So, splenectomy for malignant diseases has the major risk of infections.

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

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

Outcomes following splenectomy in patients with myeloid neoplasms

BACKGROUND AND OBJECTIVES

Myeloid neoplasms are classified into five major categories. These patients may develop splenomegaly and require splenectomy to alleviate mechanical symptoms, to ameliorate transfusion-dependent cytopenias, or to enhance stem cell transplantation. The objective of this study was to determine which clinical variables significantly impacted morbidity, mortality, and survival in patients with myeloid neoplasms undergoing splenectomy, and to determine if operative outcomes have improved over time.

METHODS

The records of all patients with myeloid neoplasms undergoing splenectomy from 1993 to 2010 were retrospectively reviewed.

RESULTS

Eighty-nine patients (n = 89) underwent splenectomy for myeloid neoplasms. Over half of patients who had symptoms preoperatively had resolution of their symptoms post-splenectomy. The morbidity rate was 38%, with the most common complications being bleeding (14%) or infection (20%). Thirty-day mortality rate was 18% and median survival after splenectomy was 278 days. Decreased survival was associated with a diagnosis of myelodysplastic syndrome/myeloproliferative neoplasm, anemia, abnormal white blood cell count, and hypoalbuminemia. Patients who underwent stem cell transplantation did not show an increased risk for morbidity or mortality.

CONCLUSIONS

Patients with myeloid neoplasms have a poor prognosis after splenectomy and the decision to operate is a difficult one, associated with high morbidity and mortality.

Current concepts of laparoscopic splenectomy in elective patients

Formerly, open splenectomy represented the conventional surgical treatment for many hematologic diseases. Currently, thanks to permanent technical development and improved skills, also laparoscopic splenectomy (LS) has become a recognized procedure in the treatment of spleen diseases, even in case of splenomegaly. A systematic review was performed with the aim of recalling the proved concepts of this surgical treatment and to browse new devices and techniques and their impact on the surgical outcome. The literature search was initially conducted in PubMed by entering general queries related to LS. The record identified through PubMed searching (n = 1599) was then screened by applying several criteria (study published in English from 1991 to 2013 with abstract available, by excluding systematic/non-systematic reviews, meta-analysis, practice guidelines, case reports, and study involving animals). The articles assessed for eligibility (n = 160) were primarily evaluated by excluding studies that did not report operative time and conversion to open surgery. For articles that treated multiport LS we included only clinical trials with patients > 20. The studies included in qualitative synthesis were 23. The search strategy carried out in PubMed does not allow to obtain an overview of the items returned by the main queries. With this aim we replicated the search in the Web of Science^TM database, only including the studies published in English in the period 1991-2013 with no other filter/selection criteria. The full records (n = 1141) and cited references returned by Web of Science^TM were analyzed with the visualization of similarities (VOS) mapping technique. Maps of title/abstract text corpus and bibliographic coupling of authors obtained by applying the VOS approach were presented. If in normal-size or moderately enlarged spleens the laparoscopic approach is unquestionable, in massive splenomegaly the optimal technique remain to be determined. In this setting, prospective randomized trials to compare open vs LS are needed. Between the new techniques of LS the robotic single port splenectomy has the ability to join all the positive aspects of both techniques. Data about this topic are too initial and need to be confirmed with further studies.

Laparoscopic splenectomy for primary immune thrombocytopenia: clinical outcome and prognostic factors

BACKGROUND

Laparoscopic splenectomy (LS) is considered the standard treatment for patients with refractory primary immune thrombocytopenia (ITP).

PATIENTS AND METHODS

All patients with ITP who underwent LS during the last 17 years and who had a minimum follow-up of 1 year were included. Several perioperative variables such as age, platelet count, and duration of preoperative therapy were recorded and analyzed, looking for potential predictive variables of clinical response.

RESULTS

In total, 150 patients were included: 108 (72%) women and 42 (28%) men, with a mean age of 37.3±15.8 years. In the evaluation 1 year after surgery, 133 (88.7%) patients had achieved complete response, 4 (2.7%) had a response, and in 13 (8.6%) there was no response. None of the analyzed preoperative variables was identified as a predictive factor of response at 1 year. Immediate responders after surgery (≥150,000 platelets/mL during the first week) had a higher platelet count and rate of complete response at 1 year (94.2%).

CONCLUSIONS

LS has a high success rate in patients with refractory ITP. Potential predictive indicators of success remain to be determined.

Chronic immune thrombocytopenia in children: who needs splenectomy?

In the field of emerging innovative therapies, such as thrombopoietin mimetics, the question of who needs splenectomy remains highly relevant. Removal of the spleen is an accepted and potentially curative treatment of immune thrombocytopenia (ITP) after decades with a favorable economical-effect ratio but with relevant morbidity particularly in the young patients. ITP is rare and splenectomy is performed in a minority of children, which makes its research almost impossible, resulting in a poor standardization of the procedure. Hence, in children, recommendation and decision for splenectomy is individually based and rests on expert opinions. Furthermore, local practice and availability of health products affect the frequency of splenectomy. Current guidelines agree on one point: splenectomy should be postponed for at least 12 months after the initial diagnosis of ITP, due to the high probability of improvement or even spontaneous remission. However, evidence-based data are lacking and splenectomy remains controversial. This article reviews the current literature and delineates controversies and complexities of splenectomy in children with ITP. There is an urgent need for consensus of this procedure in pediatric patients.

Laparoscopic splenectomy coupled with laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate the results of laparoscopic surgery performed for coexisting spleen and gallbladder surgical diseases.

METHODS

Between May 2004 and October 2012, 12 patients underwent concomitant laparoscopic splenectomy and cholecystectomy. Indications for surgery included idiopathic thrombocytopenic purpura in 5 patients, hereditary spherocytosis in 4 patients, and thalassemia intermedia in 3 patients.

RESULTS

The mean operative time was 100 minutes (range, 80 -160 minutes), and the blood loss ranged from 0 to 150 mL (mean, 50 mL). The mean longitudinal diameter of the spleen was 14 cm. One patient required conversion to open procedure. An accessory spleen was detected and removed in one case. The mean length of hospital stay was 5 days. No deaths or other major intraoperative and/or postoperative complications occurred.

CONCLUSION

Provided that the technique is performed by an experienced surgical team, concomitant laparoscopic splenectomy and cholecystectomy is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder diseases.

Consecutive laparoscopic gallbladder and spleen resections in cirrhotic patients

AIM: To evaluate the feasibility, safety, and effectiveness of consecutive laparoscopic cholecystectomy (LC) plus splenectomy (LS) in liver cirrhosis patients.

METHODS: From 2003 to 2013, 17 (group 1) patients with liver cirrhosis complicated by hypersplenism and symptomatic gallstones were treated with combined LC and LS, while 58 (group 2) patients with liver cirrhosis and hypersplenism received LS alone. An additional 14 (group 3) patients who received traditional open procedures during the same period were included as controls. Data were retrospectively collected and reviewed in regard to demographic characteristics and preoperative, intraoperative and postoperative features. Differences between the three groups were assessed by statistical analysis.

RESULTS: The three groups showed no significant differences in the demographic characteristics or preoperative status. However, the patients treated with LC and LS required significantly longer operative time, shorter postoperative stay as well as shorter time of return to the first oral intake, and suffered less intraoperative blood loss as well as fewer postoperative surgical infections than the patients treated with traditional open procedures (group 1 vs group 3, P < 0.05 for all). The patients treated with LC and LS showed no significant differences in the intraoperative and postoperative variables from those treated with LS alone (group 1 vs group 2). All patients showed significant improvements in the haematological responses (preoperative period vs postoperative period, P < 0.05 for all). None of the patients treated with LC and LS presented with any gallstone-associated symptoms following discharge, while the patients treated with the traditional open procedures expressed complaints of discomfort related to their surgical incisions.

CONCLUSION: Consecutive LC and LS is an appropriate treatment option for liver cirrhosis patients with gallstones and hypersplenism, especially for those with Child-Pugh A and B.

Splenectomy for massive splenomegaly: long-term results and risks for mortality

OBJECTIVE

To evaluate long-term outcomes after splenectomy for massive splenomegaly in a series of 222 consecutive patients.

BACKGROUND

Splenectomy for massive splenomegaly (>1500 g) provides palliation but is associated with a high rate of perioperative complications in a population of patients with advanced hematological malignancies. Predictive factors for survival and whether the palliative goals are achieved in the long-term are not well defined.

METHODS

Patients with various hematological disorders who underwent splenectomy between 1998 and 2009 were followed until death or for at least 2 years. Linear and logistic regression analyses were used to ascertain the impact of demographical factors, diagnoses, and preoperative transfusion parameters on the postoperative survival.

RESULTS

Splenectomy for massive splenomegaly was performed most commonly for non-Hodgkin lymphoma (48%) and myeloid metaplasia (31%). Mean ± standard deviation splenic weight was 2731 ± 1393 g (range, 1500-13,085 g). Average operating time was 115 minutes, with a range from 46 to 346 minutes. Thirty-day mortality was 1.8%, and the complication rate was 20%. The most common complications were hemorrhage (9%) and portal venous thrombosis (9.9%). Relief from pressure-related symptoms was achieved in 98.5%, and durable remission of anemia and thrombocytopenia persisted in half of the patients at 2 years. Sex, age, and intraoperative blood loss were not significantly associated with survival. Preoperative need for red blood cell and platelet transfusions were the most significant risk factors associated with decreased survival.

CONCLUSIONS

Splenectomy for massive splenomegaly can be performed safely and offers durable palliation. Preoperative transfusion requirement is an indicator of hematological disease severity and predictor of decreased survival.

Postoperative outcomes after laparoscopic splenectomy compared with open splenectomy

OBJECTIVE

To evaluate 30-day postoperative outcomes in laparoscopic (LS) versus open splenectomy (OS).

SUMMARY BACKGROUND DATA

LS has generally been associated with lower rates of postoperative complications than OS. However, evidence mainly comes from small studies that failed to adjust for the confounding effects of the underlying indication or clinical condition that may have favored the use of one technique over the other.

METHODS

A retrospective cohort study of patients undergoing splenectomy in 2008 and 2009 using data from the American College of Surgeons National Surgical Quality Improvement Program database (n = 1781). Retrieved data included 30-day mortality and morbidity (cardiac, respiratory, central nervous system, renal, wound, sepsis, venous thromboembolism, and major bleeding outcomes), demographics, indication, and preoperative risk factors. We used multivariate logistic regression to assess the adjusted effect of the splenectomy technique on outcomes.

RESULTS

A total of 874 (49.1%) cases had LS and 907 (50.9%) had OS. After adjusting for all potential confounders including the indication and preoperative risk factors, LS was associated with decreased 30-day mortality [OR (odds ratio): 0.39, 95% CI: 0.18-0.84] and postoperative respiratory occurrences (OR: 0.46, 95% CI: 0.27-0.76), wound occurrences (OR: 0.37, 95% CI: 0.11-0.79), and sepsis (OR: 0.52, 95% CI: 0.26-0.89) when compared with OS. Patients who underwent LS also had a significantly shorter total length of hospital stay and were less likely to receive intraoperative transfusions compared with patients who underwent OS.

CONCLUSIONS

LS is associated with more favorable postoperative outcomes than OS, irrespective of the indication for splenectomy or the patient's clinical status.

[Video-assisted surgery in children: current progress and future perspectives]

This review presents the evidence of video-assisted surgery in the pediatric population and discusses future progress in this field. Videosurgery minimizes the cosmetic impact and the pain induced by open procedures and has been in constant development in adults and children. Earlier training of surgeons and residents combined with advances in anesthetics and technology have expanded the use of videosurgery for more complex interventions. Although most feasible surgical procedures have been performed by laparoscopy, the literature has not yet defined it as the gold standard for most interventions, especially because of the lack of evidence for many of them. However, laparoscopy for cholecystectomy is now the preferred approach with excellent postoperative outcomes and few complications. Although no evidence has been demonstrated in children, laparoscopy has been shown to be superior in adults for gastroesophageal reflux disease and splenectomy. Laparoscopic appendectomy remains controversial. Nevertheless, meta-analyses have concluded in moderate but significant advantages in terms of pain, cosmetic considerations, and recovery for the laparoscopic approach. Laparoscopy is now adopted for undescended testes and allows both localization and surgical treatment if necessary. For benign conditions, videosurgery can be an excellent tool for nephrectomy and adrenalectomy. However, laparoscopy remains controversial in pediatric surgical oncology.

Laparoscopic splenectomy: experience of a single center in a series of 300 cases

BACKGROUND

Laparoscopic splenectomy (LS) has gradually become the technique of choice for surgical removal of the spleen. The aim of this study was to evaluate the efficacy of LS in a large cohort of patients from a single center.

METHODS

From March 1992 to June 2010, 300 patients underwent LS at our hospital for predominantly hematologic disorders. The first 92 cases were performed using an anterior approach, whereas in the remaining 208 cases a lateral approach with a four-trocar technique was used. Patient demographics, diagnosis, and outcomes were reviewed.

RESULTS

Spleen volume was similar between the anterior (350 ml) and the lateral (370 ml) approaches. The lateral approach was associated with shorter operative time (60 vs. 80 min), less blood loss (30 vs. 110 ml), and no conversion (0 vs. 2.2 %) compared to the anterior approach. Reoperations were required in three patients (1.0 %) because of bleeding, subphrenic abscess, and intestinal ischemia. Postoperative complications were significantly fewer for the lateral (4.8 %) than for the anterior (31.5 %) approach and the hospital stay was shorter (3.1 vs. 5.2 days) and there was less postoperative pain. Splenectomy for hematologic malignancies resulted in a higher morbidity rate, more postoperative pain, and longer hospital stay. Overall mortality rate was 0.3 %. No late complications were observed during the 1-5-year follow-up.

CONCLUSIONS

LS using the lateral approach with the placement of four trocars can be considered the procedure of choice for both benign and malignant diseases affecting the spleen. Extensive experience and technical standardization help to avoid surgical pitfalls, providing an adequate control of hemostasis, the excision of accessory spleens (AS), and the avoidance of parenchymal rupture.

Short- and long-term risks of splenectomy for benign haematological disorders: should we revisit the indications?

Splenectomy has represented a key treatment option in the treatment of many benign haematological diseases, including immune thrombocytopenia (ITP) and disorders associated with ongoing haemolysis (thalassaemia major and intermedia, sickle cell disease, and hereditary or acquired haemolytic anaemias). Improvements in surgical techniques have reduced perioperative complications and mortality. Preventive measures (new protein conjugate vaccines, antibiotic prophylaxis, and increased vigilance) are thought to greatly reduce the risk of overwhelming post-splenectomy infection (OPSI), although their implementation is inconsistent. Nevertheless, there is increasing documentation of the short- and long-term risks of splenectomy, which vary according to the underlying indication. Splenectomized patients are at increased risk of venous thromboembolism, particularly within the splenoportal system. The long-term thromboembolic risk is higher in haematological disorders associated with ongoing haemolysis, particularly in thalassaemia intermedia, which has led to a more conservative approach. In comparison, patients with ITP appear to be at lower risk of adverse effects of splenectomy, which maintains its place as the potentially most curative and safe second-line treatment. However, a splenectomy-sparing approach is also emerging for ITP, and recent guidelines recommend that this procedure is deferred until ≥ 12 months from ITP diagnosis, to allow sufficient time for possible remission.

Splenic hilum management during laparoscopic splenectomy

BACKGROUND

The division of the splenic hilum is the most delicate step during laparoscopic splenectomy. An incorrect approach could lead to a series of related complications. Aim of the study was to report authors' personal experience in a series of 107 laparoscopic splenectomies where the splenic hilum was approached by means of stapling device. A possible relationship between instruments used to divide the splenic artery and vein and complications was analyzed.

METHODS

Laparoscopic splenectomy was performed in 107 cases at authors' institution between 1998 and January 2011. In all the patients, splenic hilum was approached by means of vascular stapler.

RESULTS

Indications for the spleen removal mainly were hematologic disorders. Associated surgical procedures were performed in 32 cases. Among the 13 patients who required a conversion to open splenectomy, only in 3 cases the reason was related to the hilum management. Postoperative complications included portal vein thrombosis in 3 cases, pancreatic fistula in 1 case, and bleeding, requiring reintervention, in 2 cases.

CONCLUSIONS

The use of the stapling device is a safe and effective method to approach the splenic hilum during laparoscopic splenectomy. In experienced hands it showed a low rate of related complications.

Consecutive concomitant laparoscopic splenectomy and cholecystectomy: an Italian experience of 30 patients and proposition of a technique

INTRODUCTION

With recent advancements in the field of minimally invasive surgery, combined laparoscopic procedure is now being performed for treating coexisting abdominal pathologies during the same surgery. In some patients, spleen disorders are associated with gallbladder stones. Conventional surgery requires a wide upper abdominal incision for correct exposure of both organs. The aim of this study was to assess the feasibility and outcomes of concomitant laparoscopic treatment for coexisting spleen and gallbladder diseases.

MATERIALS AND METHODS

Thirty consecutive laparoscopic splenectomy (LS) plus laparoscopic cholecystectomy (LC) have been performed in our department between January 2000 and December 2009 (24% of 125 LS performed in this period). There were 11 female patients and 19 male patients, with a median age of 16.2 years (range: 4-55). Indications were hereditary spherocytosis for 22 cases, idiopathic thrombocytopenic purpura for 3 cases, thalassemia for 4 cases, and sickle cell disease for 1 case. Patients were operated on using right semilateral position, tilting the table from right to left, using a five-trocar technique in 25 cases and a four-trocar technique in the last 5 cases. Cholecystectomy was performed first, then splenectomy was achieved, and spleen was removed in an Endobag.

RESULTS

One patient required conversion to open procedure (3.3%) because of splenomegaly. Average operative time was 150 minutes (range: 90-240). Average length of stay was 3.5 days (range: 3-11). Mean blood loss was 60  mL (range: 30-500). Transfusion rate was 3.3%. Mean spleen size and weight were, respectively, 16.5  cm and 410  g. No perioperative mortality occurred in the series. We reported 3 cases of hemoperitoneum, of which one managed conservatively. The results using four trocars were comparable to those with five trocars.

CONCLUSION

With increasing institutional experience, concomitant laparoscopic splenectomy and cholecystectomy is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder diseases. The four-trocar technique guarantees good results.