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

Retrospective investigation of patients undergoing splenectomy: Our 8-year clinical experience in a single center

OBJECTIVE

Elective splenectomy is often performed due to hematological diseases. In this study, we aimed to investigate the splenectomy procedures performed in our clinic under emergency and elective conditions by analyzing the surgical techniques applied, surgical indications, and the clinical and demographic data of the patients, while seeking to discuss this subject, which holds a significant place in general surgical practice, in light of current literature.

METHODS

Patients who underwent splenectomy surgery in the general surgery clinic of a tertiary care hospital between September 2016 and September 2024 were included in the study. Clinical and demographic data of the patients were collected retrospectively through the hospital information management system records.

RESULTS

The mean age of 89 patients included in the study was 41.0±18.8 years (18-76 years). The male/female ratio was 1.3/1. The most common indication for splenectomy was trauma (38.2%). This was followed by mass (29.2%), splenomegaly (14.6%), and immune thrombocytopenic purpura (ITP) (14.6%). Of the patients, 62.9% underwent open surgery, while 37.1% were operated on using the laparoscopic technique. Of the patients, 57.3% underwent elective surgery, while emergency surgery was planned for 42.7%.

CONCLUSION

While splenectomy is a life-saving intervention in emergency conditions, it has become the most important treatment in some hematological diseases. Firstly, accurate surgical indication and the selection of an appropriate surgical technique tailored to the patient are of critical importance. There are still controversial issues in the current literature regarding the indications for splenectomy and the surgical technique to be applied.

A Simple Technique of Tunnel Constructing for Occluding Splenic Vessels During Laparoscopic Splenectomy in Patients with Cirrhosis

Purpose: Dissecting and ligating the splenic artery is crucial for bleeding control during laparoscopic splenectomy (LS). However, for patients with portal hypertension from liver cirrhosis, it is difficult for identification and ligation because the splenic vessel is circuitous and dilated. The aim of this study was to describe a simple technique of constructing a tunnel behind the tail of the pancreas for occluding the splenic vessels during LS in patients with portal hypertension. Materials and Methods: The clinical data of 61 patients who underwent LS from April 2016 to January 2017 were retrospectively analyzed. In 27 patients, the tunnel construction (TC) behind the tail of the pancreas approach was performed owning to difficulty in dissecting and ligating the splenic artery (TC group), including 17 patients who received the TC method directly and 10 patients who received the TC method after trying to dissect the splenic artery. The remaining 34 patients underwent traditional ligating of the splenic artery (LA group). The peri- and postoperative outcomes of operative time, blood loss, conversion rate, postoperative oral diet intake, postoperative hospital stay, and postoperative complication rate of the two groups were analyzed. All the operations were completed by the same group of surgeons. Results: All 61 operations were successfully completed. Compared with patients in the LA group, patients in the TC group had less blood loss (120.37 ± 40.74 mL versus 162.65 ± 87.47 mL; t = -2.317, P = .024). There was no statistical difference of operative time, conversion rate, complication rate, postoperative hospital stays, and follow-up between the two groups. Conclusions: The technique of constructing a tunnel behind the tail of the pancreas for occluding the splenic vessels was effective and safe in those patients whose splenic artery was difficult to dissect and ligate.

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.

Laparoscopic splenectomy for massive splenomegaly: the "splenic no-touch" technique for hilar control by anterior lienorenal approach

PURPOSE

Laparoscopic splenectomy is challenging in patients with massive splenomegaly. The paper describes a technique that overcomes the difficulties one faces while dealing with a massive spleen laparoscopically.

METHODS

We describe our splenic no-touch technique through the anterior lienorenal approach in patients undergoing laparoscopic splenectomy for massive splenomegaly during a 10-year period from January 2010 to January 2020.

RESULTS

During the study period, 14 patients underwent laparoscopic splenectomy for massive splenomegaly. Of these, 13 patients had successful laparoscopic completion of the procedure. One patient required conversion for bleed. There were no pancreatic tail injuries during splenic hilar stapling in any patient. The median operative time was 170 minutes (140-225). The median blood loss was 50 mL (20-600). Two patients required blood transfusions. There was no other morbidity or mortality. The median postoperative stay was 2 days.

CONCLUSION

The splenic no-touch technique using the anterior lienorenal approach for laparoscopic splenectomy is safe and feasible in patients with massive splenomegaly. Preoperative imaging enables optimal port placement and procedure ergonomics.

A laparoscopic approach to address massive splenomegaly, symptomatic cholelithiasis, and a planned postoperative pregnancy: A case report

We report long-term follow-up of a patient who underwent a tailored laparoscopic procedure for symptomatic cholelithiasis, massive splenomegaly, and a planned pregnancy. There were no complications, and the patient remained symptom-free at the 5-year follow-up. We supplemented our case report with national surgical data demonstrating the safety of laparoscopic splenectomy.

Preoperative Splenic Artery Embolization for Massive Splenomegaly in Children: A Single Center Experience

Introduction: Massive splenomegaly in children can complicate minimally invasive splenectomy. Splenic artery embolization (SAE) before splenectomy has been shown to decrease splenic volume, reduce intraoperative blood loss, and decrease conversion rates in laparoscopic surgery. Our objective was to review our recent experience with immediate preoperative SAE in massive splenomegaly for pediatric patients using both laparoscopic and robotic techniques. Materials and Methods: We retrospectively reviewed preoperative SAE outcomes in pediatric patients with massive splenomegaly undergoing minimally invasive splenectomy between January 2018 and July 2021. Results: Four patients, 3 female, ages 5-18 years, had SAE immediately before minimally invasive splenectomy. Two cases were completed robotically, one laparoscopically, and one laparoscopic case required conversion to open. SAE time ranged from 69 to 92 minutes. Time between embolization and surgical start ranged from 26 to 56 minutes, with operative times from 153 to 317 minutes. Estimated blood loss ranged from <10 to 150 mL. Mean length of stay was 3.5 days (range 2-6). Postoperative complications included one patient with ileus and another with concurrent gastritis and urinary tract infection. Splenic size comparisons were difficult to perform due to morselization of the spleen; however, excised spleen weights, measurements, and surgeon's impression suggested decreased size of the spleen after SAE. There were no transfusions, postembolization complications, or deaths. Conclusion: SAE subjectively appears to decrease splenic distension, which should allow for easier manipulation and possibly better visualization of splenic hilar vessels during minimally invasive surgery. Immediate preoperative SAE is safe and feasible and should be considered in pediatric patients with massive splenomegaly.

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.

Pancreatic Fistula and Biochemical Leak after Splenectomy: Incidence and Risk Factors-A Retrospective Single-Center Analysis

Purpose

Postoperative pancreatic fistula (POPF) is a complication discussed in the context of pancreatic surgery, but may also result from splenectomy; a relationship that has not been investigated extensively yet.

Methods

This retrospective single-center study aimed to analyze incidence of and risk factors for POPF after splenectomy. Patient characteristics included demographic data, surgical procedure, and intra- and postoperative complications. POPF was defined according to the International Study Group on Pancreatic Surgery as POPF of grade B and C or biochemical leak (BL).

Results

Over ten years, 247 patients were identified, of whom 163 underwent primary (spleen-associated pathologies) and 84 secondary (extrasplenic oncological or technical reasons) splenectomy. Thirty-six patients (14.6%) developed POPF of grade B/C or BL, of which 13 occurred after primary (7.9%) and 23 after secondary splenectomy (27.3%). Of these, 25 (69.4%) were BL, 7 (19.4%) POPF of grade B and 4 (11.1%) POPF of grade C. BL were treated conservatively while three patients with POPF of grade B required interventional procedures and 4 with POPF of grade C required surgery. POPF and BL was noted significantly more often after secondary splenectomy and longer procedures. Multivariate analysis confirmed secondary splenectomy and use of energy-based devices as independent risk factors for development of POPF/BL after splenectomy.

Conclusion

With an incidence of 4.5%, POPF is a relevant complication after splenectomy. The main risk factor identified was secondary splenectomy. Although POPF and BL can usually be treated conservatively, it should be emphasized when obtaining patients’ informed consent and treated at centers with experience in pancreatic surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02531-7.

The usefulness of modified splenic hilum hanging maneuver in laparoscopic splenectomy, especially for patients with huge spleen: a case-control study with propensity score matching

BACKGROUND

Although Laparoscopic splenectomy (LS) have been proven to the standard operation for removal of spleen, the rate of conversion to open surgery is still higher than those of other laparoscopic surgeries, especially for huge spleen. In order to reduce the rate of conversion to open surgery, we had developed LS using modified splenic hilum hanging (MSHH) maneuver: the splenic pedicle was transected en bloc using a surgical stapler after hanging splenic hilum with an atraumatic penrose drain tube.

METHODS

Between January 2005 and December 2019, we retrospectively assessed 94 patients who underwent LS. MSHH maneuver was performed in 37 patients (39.4%). We compared the intra- and postoperative outcomes between patients with or without MSHH maneuver. To adjust for differences in preoperative characteristics and blood examination, propensity score matching was used at a 1:1 ratio, resulting in a comparison of 29 patients per group. Predictive factors of conversion from LS to open surgery were elucidated using the uni- and multi-variate analyses.

RESULTS

After the propensity score matching, blood loss (268 ml vs. 50 ml), the rate of conversion to open surgery (27.6% vs. 0%), and postoperative hospital stays (15 days vs. 10 days) were significantly decreased in patients with MSHH maneuver, respectively. Among 94 patients, 19 patients (20.2%) underwent conversion to open surgery. In multivariate analysis, spleen volume (SV) and LS without MSHH maneuver were independent predictive factors of conversion to open surgery, respectively. Additionally, cut-off value of SV for conversion to open surgery was 802 ml (sensitivity: 0.684, specificity: 0.827, p < 0.001).

CONCLUSIONS

LS using MSHH maneuver seems to be useful surgical technique to improve intraoperative outcomes and reduce the rate of conversion from LS to open surgery resulting in shorten postoperative hospital stay.

Efficacy and safety of laparoscopic splenectomy for hypersplenism secondary to portal hypertension after transjugular intrahepatic portosystemic shunt

Background

Laparoscopic splenectomy (LS) being used after Transjugular intrahepatic portosystemic shunt (TIPS) has not been reported. This report aims to explore the feasibility, safety, and potential efficacy of LS after TIPS hypersplenism secondary to portal hypertension (PHT).

Methods

We retrospectively reviewed a series of six patients who underwent LS after TIPS for hypersplenism secondary to PHT between 2014 and 2020. The perioperative data and patients’ clinical outcomes were recorded.

Results

LS was successfully performed in all patients. Hypersplenism was corrected after LS in all six patients. Postoperative prothrombin time, prothrombin activity, international normalized ratio, and total bilirubin showed a trend toward improvement. The preoperative and 1-month postoperative albumin and activated partial thromboplastin levels showed no significant difference. Plasma ammonia level and thromboelastography indicators were ameliorated in two limited recorded patients. No postoperative complications such as subphrenic abscess, portal vein thrombosis, variceal bleeding, hepatic encephalopathy, and liver failure occurred during the 1-month follow-up period.

Conclusion

LS following TIPS is feasible, safe, and beneficial for patients with hypersplenism secondary to PHT. The following LS not only corrects the hypersplenism, but also has the potential to improve liver function.

Outcomes of Laparoscopic Splenectomy for Treatment of Splenomegaly: A Systematic Review and Meta-analysis

OBJECTIVES

To review the evidence regarding the outcomes of laparoscopic techniques in cases of splenomegaly.

BACKGROUND

Endoscopic approaches such as laparoscopic, hand-assisted laparoscopic, and robotic surgery are commonly used for splenectomy, but the advantages in cases of splenomegaly are controversial.

REVIEW METHODS

We conducted a systematic review using PRISMA guidelines. PubMed/MEDLINE, ScienceDirect, Scopus, Cochrane Library, and Web of Science were searched up to February 2020.

RESULTS

Nineteen studies were included for meta-analysis. In relation to laparoscopic splenectomy (LS) versus open splenectomy (OS), 12 studies revealed a significant reduction in length of hospital stay (LOS) of 3.3 days (p = <0.01) in the LS subgroup. Operative time was higher by 44.4 min (p < 0.01) in the LS group. Blood loss was higher in OS 146.2 cc (p = <0.01). No differences were found regarding morbimortality. The global conversion rate was 19.56%. Five studies compared LS and hand-assisted laparosocpic splenectomy (HALS), but no differences were observed in LOS, blood loss, or complications. HALS had a significantly reduced conversion rate (p < 0.01). In two studies that compared HALS and OS (n = 66), HALS showed a decrease in LOS of 4.5 days (p < 0.01) and increase of 44 min in operative time (p < 0.01), while OS had a significantly higher blood loss of 448 cc (p = 0.01). No differences were found in the complication rate.

CONCLUSION

LS is a safe approach for splenomegaly, with clear clinical benefits. HALS has a lower conversion rate. Higher-quality confirmatory trials with standardized splenomegaly grading are needed before definitive recommendations can be provided. Prospero registration number: CRD42019125251.

Rhinoplasty Assisted by Endoscopic Septoplasty: Precise Job and an Educational Tool

BACKGROUND

Septoplasty is a crucial step during rhinoplasty to correct the nose function and nasal aesthetics. The idea is not investigated regarding the educational purposes. Objective of the study is to evaluate the efficiency of endoscopic septoplasty during full job rhinoplasty and to observe its educational benefit.

METHODS

Twenty-seven patients who submitted for prospective study of endoscopic septorhinoplasty operation; the analysis involves 16 female patients and 11 males.

RESULTS

Endoscopic septoplasty during rhinoplasty showed an efficient illumination and visualization, which improved the precision and has an educational benefit during the reform of the posterior septum, isolated septal spurs, anterior septum, and middle turbinate attachments.

CONCLUSION

The procedure allows a precise septal job with excellent visualization of the anterior and posterior septum. It also has an intraoperative educational benefit and helps to soothe the time down of patient's recovery.