Splenic artery embolization before laparoscopic splenectomy. An update

Role of plasma von Willebrand factor antigen in prediction of esophageal varices in pediatric and adolescent patients with portal hypertension

Background

Ruptured esophageal varices (EVs) are a leading cause of death in Portal hypertension (PHT), it has been a big concern of research to screen EVs through non-invasive approaches. This study aimed to evaluate the role of plasma von Willebrand factor antigen (VWF-Ag) assay for early detection of EVs in patients with portal hypertension. This was a cross-sectional study, done on 47 portal hypertensive children and adolescents who were collected from the Pediatrics Hepatology Clinic, Children Hospital, Ain Shams University. All patients were subjected to comprehensive history taking, thorough clinical examination, routine investigations, abdominal ultrasound, upper GI endoscopy, and measurement of plasma VWF-Ag level. The patients were divided based on their endoscopic findings into two groups; a varices group which included 37 patients, and a non-varices group which included 10 patients.

Results

VWF-Ag rise significantly in patients with EVs, revealing a direct positive association with the degree of EVs.

Conclusion

The plasma VWF-Ag can be applied as a non-invasive evidence of the presence and grading of EVs.

Comparison of three embolic materials at partial splenic artery embolization for hypersplenism: clinical, laboratory, and radiological outcomes

Purpose

To compare effectiveness of three widely used embolic agents in partial splenic embolization (PSE) by analyzing their clinical, laboratory, and radiological outcomes within one year of follow-up.

Materials and methods

This retrospective study examined 179 patients who underwent PSE to manage hypersplenism secondary to cirrhosis. Patients were divided into 3 groups according to embolic agent used. Group 1 (gelatin sponge) included 65 patients, group 2 (embospheres) included 58 patients, and group 3 (PVA) included 56 patients. Clinical, laboratory, and radiological outcomes were compared between groups.

Results

The technical success rate was 100% in all groups. Pain as a major complication was lower in the gelatin sponge group (20%) compared to the embosphere group (31%) and PVA group (32.3%). Major complications other than pain were found in 20.1%; 24.6% in gelatin sponge group, 15.5% in embosphere group and 19.6% in PVA group (p = 0.045). WBCs and platelet counts showed a significant increase after PSE in all groups. Entire splenic volume as measured by computed tomography after PSE showed no significant difference among the 3 groups; however, the volume of infarcted spleen was significantly lower in the gelatin sponge group compared to other two groups (p = 0.001). The splenic span was significantly reduced one-year post-procedure in three groups (p = 0.006), and it was significantly less in embosphere and PVA groups compared to gelatin sponge group (p < 0.05). Recurrent bleeding was higher in gelatin sponge group (p < 0.05).

Conclusions

Permanent embolic materials achieved better laboratory and radiological outcomes than gelatin sponge particles in PSE of cirrhotic hypersplenism patients. However, permanent particles were associated with greater abdominal pain.

Splenic marginal zone lymphoma treated with laparoscopic splenectomy: A case report

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The authors present a case of splenic marginal zone lymphoma (SMZL), which was successfully treated with laparoscopic splenectomy.

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SMZL is a rare subtype of indolent B cell lymphoma, and good prognosis is expected by splenectomy alone.

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Laparoscopic splenectomy is safe and feasible with splenic artery embolization preoperatively, especially in cases with large splenomegaly as seen in our case.

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Careful postoperative follow-up is required since some patients develop aggressive transformation, and result in worse prognosis.

Introduction

Splenic marginal zone lymphoma (SMZL) is rare subtype of malignant lymphoma that is classified as a low-grade B cell lymphoma. Splenectomy is usually chosen for both diagnosis and treatment, which often leads to the resolution of abdominal symptoms and cytopenia.

Case presentation

We presented the case of a 73-year-old woman who complained of spontaneous perspiration and fatigue. She was referred to our hospital for further treatment of enlarged intraabdominal lymph nodes and splenomegaly. The level of soluble Interleukin-2 receptor was elevated, and malignant lymphoma was suspected. Endoscopic ultrasound fine-needle biopsy of intraabdominal lymph node revealed B cell lymphoma. For a definitive diagnosis, as well as treatment, laparoscopic splenectomy was successfully performed. The histopathological finding was compatible with SMZL. The patient was discharged without any complications and observed to have no recurrence at eight months postoperatively.

Conclusion

Patients with SMZL is usually expected to have good prognosis with splenectomy. However, careful follow-up is required for aggressive transformation can occur and result in worse prognosis.

Massive splenomegaly due to B-cell lymphoma: A case report

INTRODUCTION

Massive splenomegaly is indicated by spleen weight exceeding 1000 g and largest spleen dimension greater than 20 cm Poulin et al. (1998). In many cases, splenectomy is the treatment of choice for massive splenomegaly because it releases the pressure on adjacent organs and also provides a definitive histopathological diagnosis of the underlying cause Iriyama et al. (2010), Radhakrishnan (2018).

PRESENTATION OF CASE

Herein we present a clinical case of disseminated diffuse large B - cell lymphoma, clinical stage IV, with massive splenomegaly. A 53 - year old man complaining of unintentional major weight loss, palpable abdominal mass in the left hemiabdomen and cervical lymphadenopathy, was admited to Department of abdominal surgery, UMC Ljubljana. Abdominal CT scan showed massive spleen, enlarged retroperitoneal and upper mediastinal lymph nodes and cervical lymphadenopathy. Splenectomy was performed and spleen was sent on histological analysis. Operation and postoperative course were uneventful. Spleen specimen weighed 5034 g (6% of patient body weight) and measured 33 × 24 × 10 cm. Histological and immunohistochemical analysis set the diagnosis of diffuse large B - cell lymphoma. Patients received 5 cycluses of R-CHOP chemotherapy and 2 cycluses of prophylactic intrathecal chemotherapy postoperatively.

DISCUSSION

Splenomegaly in combination with weight loss and malaise is very suggestive of underlying neoplastic condition and therefore requires further diagnostic investigations Han et al. (2008). Splenectomy in combination with adjuvant chemotherapy is the treatment of choice in case of spleen infiltration rith tumorous cells of B-cell lymphoma. However there are other possibilities in diagnosing and treatment of massive splenomegaly, including percutaneous image guided splenic needle biopsy and splenic artery embolisation prior to splenectomy.

CONCLUSION

Our aim with this case report is to present splenectomy in conjuction with chemotherapy as a safe option of treatment for massive splenomegaly due to B-cell lymphoma infiltration.

Childhood Visceral Leishmaniasis: Distinctive Features and Diagnosis of a Re-emerging Disease. An 11-year Experience From a Tertiary Referral Center in Athens, Greece

BACKGROUND

Visceral leishmaniasis (VL) remains a public health issue in Greece. The aim of this study was to describe the clinical and epidemiologic characteristics of pediatric VL in our region as well as to evaluate the laboratory findings and the diagnostic techniques that are applied.

METHODS

We retrospectively reviewed the medical records of all children diagnosed with VL in an 11-year period at a tertiary public hospital in the region of Athens. Demographic features, clinical information and laboratory findings were accessed.

RESULTS

A total of 43 cases were recorded during 2005-2015. Median age of the patients was 3.7 years. Pallor (100%), fever (98%), hepatosplenomegaly (55.8%) and appetite loss (32.6%) were the most common presentations of the disease. The predominant laboratory abnormalities were anemia (100%), thrombocytopenia (90.7%), elevated inflammatory markers (86.1%) and decreased albumin/globulin (A/G) ratio (72.1%). Four patients developed secondary hemophagocytic lymphohistiocytosis syndrome, whereas in 3 others abdominal ultrasound showed splenic nodules. Bone marrow aspiration detected Leishmania parasites in 92.7% of cases and the rapid rK39 strip test indicated anti-Leishmania antibodies in 97.1% of children. In addition, all patients in whom indirect immunofluorescent antibody test was implemented had positive results.

CONCLUSIONS

VL still affects children in our area. Fever, splenomegaly, anemia and appetite loss are the typical findings in children. Noninvasive techniques (immunofluorescent antibody test, rK39) in combination with bone marrow microscopy are useful in the diagnosis of pediatric VL.

Indications and outcome of splenectomy in hematologic disease

Splenectomy is part of the therapeutic arsenal for benign or malignant hematological disorders that constitute the main indication for elective splenectomy. With the development of minimally invasive approaches, and in particular, laparoscopy, as well as the advent of monoclonal antibody therapy, the indications and the outcomes of splenectomy for hematologic disease have changed in recent years. Nonetheless, splenectomy has its place in hemoglobinopathies and hemolytic diseases, improves thrombocytopenia in refractory immune thrombocytopenic purpura, can reverse sequelae linked to voluminous splenomegaly secondary to myelofibrosis, or can be used for diagnostic purposes or for splenomegaly in lymphoproliferative syndromes.

Surgery for massive splenomegaly

BACKGROUND

Splenectomy for massive splenomegaly (spleen weight more than 1·5 kg) is commonly believed to be hazardous and to provide poor palliation. The aim of this cohort study was to investigate these issues and examine the many definitions of massive splenomegaly to see whether a better tool might be proposed for preoperative evaluation of these patients.

METHODS

Morbidity and long-term outcomes were assessed in consecutive patients. Relief of pressure-volume-related symptoms and sustainable independence from transfusion in patients were used to ascertain the impact of splenectomy.

RESULTS

Splenectomy was performed in 56 patients, mainly for non-Hodgkin's lymphoma and myeloproliferative diseases. Median spleen weight was 2·3 (range 1·5-6·0) kg. Mortality at 180 days was zero, and the postoperative complication rate was 25 per cent (17 complications in 14 patients). At 2 years, relief of pain was maintained in 33 of 34 patients, with sustained independence from transfusion in 15 of 19 patients with anaemia and nine of 11 with thrombocytopenia. Spleen weight correlated negatively with BMI (P = 0·036).

CONCLUSION

Splenectomy for massive splenomegaly is safe and provides effective palliation. Provisional cut-off points relating to spleen size and BMI help to identify patients benefiting from a splenectomy, even those in a critical state.

Outcomes of partial splenic embolization in patients with massive splenomegaly due to idiopathic portal hypertension

AIM

To determine the outcomes of partial splenic embolization (PSE) for massive splenomegaly due to idiopathic portal hypertension (IPH).

METHODS

In this prospective study, we evaluated the characteristics and prognosis of consecutive patients with IPH who underwent PSE for all indications at a single medical center between June 2009 and January 2015. The inclusion criteria were: presence of hypersplenism, massive splenomegaly, and resultant pancytopenia. The exclusion criteria were: presence of other diseases causing portal hypertension. During the post-PSE period, the patients were hospitalized. All patients underwent abdominal computed tomography imaging 4 wk post-PSE to determine total splenic and non-infarcted splenic volumes.

RESULTS

A total of 11 patients, with median age of 33.27 ± 4.8 years, were included in the study. Mean spleen size was 22.9 cm (21-28 cm), and severe hypersplenism was diagnosed in all patients before PSE. Post-PSE, leukocyte and platelet counts increased significantly, reaching peak levels in the second week with gradual decreases thereafter. Liver function tests did not exhibit significant changes during post-intervention follow-up. All patients developed post-embolization syndrome, and one patient experienced serious complications; all complications were successfully treated with conservative therapy and no death occurred.

CONCLUSION

Our findings showed that PSE has a lower complication rate than previously-reported surgical complication rates, which supports this intervention as a viable alternative for high-risk operable patients with severe hypersplenism.

Factors associated with significant liver necroinflammation in chronic hepatitis B patients with cirrhosis

We determined the association between various clinical parameters and significant liver necroinflammation in patients with chronic hepatitis B (CHB) related cirrhosis. Two hundred patients with CHB related cirrhosis were recruited in the final analysis. Clinical laboratory values and characteristics were obtained from the medical record. We performed analyses of the relationships between independent variables and significant liver necroinflammation by using binary logistic regression analysis and discriminant analysis. Significant liver necroinflammation (grade≥2) was found in 58.0% (80/138) of antiviral therapy patients and 48.4% (30/62) of non antiviral therapy patients respectively. Also, there were some significant differences in serum hepatitis B surface antigen (HBsAg), serum hepatitis B e antigen (HBeAg) and serum hepatitis B virus (HBV) DNA between antiviral therapy and non antiviral therapy patients. After that, aspartate aminotransferase (AST), total bilirubin (TBIL), total bile acid (TBA), prothrombin time (PT), aspartate aminotransferase to platelet ratio index (APRI) and serum HBV DNA were confirmed as independent predictors of significant liver necroinflammation in CHB patients with cirrhosis by univariate analysis and multivariate analysis (p = 0.002, 0.044, 0.001, 0.014, 0.01 and 0.02 respectively). Finally, receiver operating characteristic (ROC) curve analysis and discriminant analysis validated that these six variables together have strong predictive power to evaluate significant liver necroinflammation.

Perioperative spleen embolization as a useful tool in laparoscopic splenectomy for simple and massive splenomegaly in children: a prospective study

OBJECTIVE

The purpose of this prospective study is to evaluate the efficiency of perioperative spleen embolization prior to laparoscopic splenectomy indicated for hypersplenism.

METHODS

We conducted a prospective study exploring a technique combining ultra-selective perioperative embolization and splenectomy. Between January 2008 and March 2013, 16 splenectomies were performed in children suffering from hypersplenism due to varying hematologic diseases. Spleen embolization was performed by an interventional radiologist in the operating room (OR) just before splenectomy and during the same general anesthesia. Ages varied from 3 to 17 years. Spleen volume was measured by preoperative ultrasound. One patient underwent a laparotomy because of suspected adhesions due to previous surgery. All other operations were performed laparoscopically.

RESULTS

One complication arose from embolization: a perforation of the splenic artery. After immediately placing a platinum coil proximal to the perforation, the splenectomy was carried out as usual. Fourteen children (87.5 %) had splenomegaly, of which eight (50 %) had massive splenomegaly. There were no deaths, no conversions to laparotomy, no reoperations and none of these patients had to be transfused.

CONCLUSIONS

Perioperative spleen embolization performed in the OR by an interventional radiologist makes laparoscopic splenectomy a safer procedure. We propose a preoperative method for spleen measurement that is adapted to children: simple and massive splenomegaly is defined through patient body weight and a preoperative ultrasound. We conclude that spleen size is no more a limiting factor for laparoscopic splenectomy in children.

Visceral Leishmaniasis in Southwestern Iran: A Retrospective Clinico-Hematological Analysis of 380 Consecutive Hospitalized Cases (1999-2014)

Visceral Leishmaniasis (VL) is an endemic parasitic disease and remains as a major health concern in southwestern Iran. The current study describes clinico-hematological, epidemiological and therapeutic features of VL cases, admitted to university-affiliated hospitals, during 1999–2014 in Fars province, southwestern Iran. A total of 380 VL cases were recorded during a 16 years period, giving an average annual admission of 23.75 cases/year in which 217 (57.1%) were male and 163 (42.9%) were female. Mean age of the patients was 3.7 years. The majority of the cases (91.5%) were ≤ 5 years old. Bone-marrow aspiration detected Leishmania amastigotes only in 26.6% of cases. Fever (98.1%), abdominal protrusion (65.1%) and hepatosplenomegaly (63.7%) were the most common clinical presentations of the patients. Pancytopenia was noted in 43.1, anemia in 87.3 and thrombocytopenia in 64% of cases. Increase in the level of AST (aspartate aminotransferase), ALT (alanine aminotransferase), alkaline phosphatase, LDH (lactate dehydrogenase) and CRP (C-Reactive Proteins) were seen in 84.9, 53.6, 44.4, 72.5 and 83.1% of cases, respectively. Mortality was noted in 5.3% of cases. Deranged haemato-biochemical parameters including total and direct bilirubin, PLT (platelet) and pancytopenia were significantly contributed to mortality from VL. Moreover, clinical features such as severe splenomegaly as well as bacterial infections were meaningfully contributed to death from VL. The majority of patients (74.9%) were treated with meglumine antimoniate. Amphotericin B was administrated in 59 of cases, 11 of them were initially treated with meglumine antimoniate with a shift to amphotericin B, because of treatment failure. Findings of the current study demonstrated that VL is present in southwest of Iran with a fairly continual rate during the last 16 years period. Deranged haemato-biochemical parameters along with severe splenomegaly contributed to mortality from VL.

Efficacy and surgical procedures of preoperative splenic artery embolization for laparoscopic splenectomy of a massive splenomegaly: A case report

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The combination of embolization of the splenic artery and continuous epinephrine infusion to reduce the spleen volume was highly effective.

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New technique of laparosopic splenolectomy for massive splenomegaly.

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Spleen volume started to decrease immediately after the onset of intravenous infusion of low-dose epinephrine.

Here, we describe the case of a 58-year-old woman diagnosed with massive splenomegaly with a malignant lymphoma that had a maximum diameter of 24 cm. Splenectomy was indicated because of thrombocytopenia and abdominal distention. Therefore, a balloon catheter was inserted preoperatively through the splenic artery for embolization and continuous infusion to reduce the spleen volume. It enabled easy handling of the spleen and minimized bleeding. The volume of the spleen was estimated at 1896 g through the skin incision, as measured by volumetric computed tomography; thus, laparoscopy seemed difficult. However, the surgery was successfully performed only with laparoscopic surgery, and the volume of the resected spleen was 1020 g. This preoperative preparation is an effective alternative to laparoscopic removal of a huge splenomegaly.

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.

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 Versus Open Splenectomy for Portal Hypertension

Background. Laparoscopic splenectomy has become the gold-standard procedure for normal to moderately enlarged spleens. However, the safety of laparoscopic splenectomy for patients with portal hypertension remains controversial. We carried out this systematic review to identify the feasibility and safety of laparoscopic splenectomy in treating portal hypertension. Data sources. A systematic search for comparative studies that compared laparoscopic splenectomy with open splenectomy for portal hypertension was carried out. Studies were independently reviewed for quality, inclusion and exclusion criteria, demographic characteristics, and perioperative outcomes. Conclusion. Although laparoscopic splenectomy is associated with longer operating time, it offers advantages over the open procedure in terms of less blood loss, lower operative complications, earlier resumption of oral intake, and shorter posthospital stay. Therefore, laparoscopic splenectomy is a safe and feasible intervention for portal hypertension.

Laparoscopic splenectomy: perioperative management, surgical technique, and results

Since their introduction in the early 1990s, minimally invasive techniques have gained widespread acceptance because of the significant benefits that patients are able to experience. Some of these benefits include reduced postoperative pain, earlier return to normal activity, and improved cosmesis when compared with open surgery. For these reasons, since its first description by Delaitre and Maignien in 1991, laparoscopic splenectomy (LS) has been increasingly utilized for a safe surgical removal of the spleen with nearly equivalent or superior short- and long-term outcomes when compared with the open approach. In this technical report, we aim to describe our preoperative and postoperative management of patients undergoing LS and to illustrate our preferred surgical technique, its rationale, and our results.

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.

Laparoscopic splenectomy for splenomegaly using a homemade retrieval BAG

INTRODUCTION

Operating on an enlarged spleen via the laparoscopic approach presents several challenges. A homemade bag may facilitate retrieval of the enlarged spleen assisted by a laparoscope and save medical expense.

AIM

To assess the feasibility and safety of laparoscopic splenectomy for moderate or massive splenomegaly using our technique and a homemade retrieval bag.

MATERIAL AND METHODS

Fifty patients underwent laparoscopic splenectomy for moderate or massive splenomegaly which was defined as the major axis exceeding 17 cm by abdominal computed tomography. A homemade retrieval bag made from a commercial sterile infusion container which costs about US$ 1-2 per piece was used for spleen retrieval. Two transabdominal sutures for suspension of the retrieval bag were made to aid specimen removal in this technique.

RESULTS

There were 31 males and 19 females with mean age of 56 ±11 years. Laparoscopic splenectomy was successfully completed in 49 of these 50 patients. Overall, mean operative time was 149 ±31 min (range: 100-252 min). Median estimated blood loss was 189 ±155 ml (range: 50-920 ml). There were 12 minor complications but no mortality. Time to discharge after surgery ranged from 3 to 9 (mean: 4.7 ±1.7 days). The average splenic weight was 729 ±74 g (range: 632-930 g).

CONCLUSIONS

Our preliminary results indicate that laparoscopic splenectomy is feasible and safe for moderate or massive splenomegaly and may be a well-tolerated alternative to open splenectomy. Not only is the cost of our homemade retrieval bag low, but also it is easy to make and ready to use.

A modified laparoscopic splenectomy for massive splenomegaly in children with hematological disorder: a single institute retrospective clinical research

PURPOSE

With the optimal acceptance of its clinical advantages, laparoscopic splenectomy (LS) emerged as a gold standard procedure as compared with open splenectomy (OS). However, it is still controversial and even counted as contraindication for massive splenomegaly. Here, we aim to summarize the experiences, characteristics and trends of modified LS for massive splenomegaly in children with hematological disorders.

METHODS

Retrospective series of 57 pediatric patients with massive splenomegaly who underwent splenectomy from March 2007 to December 2011 were designated for this clinical analysis. The main outcome measures were dealt by statistics. For 30 cases of LS, we strictly adhered to the principle of using only three trocars to operate and initial ligation of the splenic artery, followed by retrieving the piecemeal of spleen through an accessory incision of 2-3 cm at 12 mm trocar port site.

RESULTS

Of the 57 pediatric patients, 27 underwent OS and 30 underwent LS, respectively. Despite the operative time being shorter for OS than for LS (P < 0.001), the blood loss was lower in LS than in OS (P < 0.001); the time required for oral intake as well as duration of hospital stay was lower in LS than in OS (P < 0.001). Post-operatively, 7 (25.9 %) complications occurred in OS and 3 (10 %) in LS. The conversion rate of LS to OS was 13.33 % in four cases till 2009.

CONCLUSIONS

Despite the conflicting reports regarding the safety of LS for massive splenomegaly, we demonstrated that our modified laparoscopic splenectomy in the treatment of children with massive splenomegaly in hematological diseases seemed to achieve the fundamental goal of less invasion; it was safe and feasible.

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.

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.

A two-step control of secondary splenic pedicles using ligasure during laparoscopic splenectomy

OBJECTIVE

We modified the LigaSure vessel sealing into a two-step technique without using Endo-GIA stapler for the secondary splenic pedicle control in laparoscopic splenectomy (LS). This study evaluated the efficacy and safety outcomes of this technique.

METHODS

Patients (n = 105) scheduled for elective LS were consecutively and prospectively enrolled, including 24 males and 81 females, with a mean age of 43.6 (range 11-75) years. Following the mobilization of the spleen, the splenic inflow was interrupted by applying a Hem-o-lock clip. LigaSure was used to seal and transect the secondary splenic pedicles adjacent to the pancreatic tail and subsequently in proximity to the spleen.

RESULTS

Of 105 patients, 103 patients (98.1%) underwent successful LS, whereas two patients (1.9%) required the conversion to laparotomy. The mean operative time was 100 min, whilst the mean volume of blood loss was 500 mL. No clinically significant morbidities or mortality occurred following LS. An average of 8,000 RMB (range: 6900 to 9000; 1 USD = 6.5 RMB) was saved by using this two-step technique.

CONCLUSION

Secondary splenic pedicles can be successfully controlled in LS by using a two-step technique with the LigaSure vessel sealing system in an economically favorable way.

Laparoscopic splenectomy: standardized approach

Laparoscopic splenectomy was first reported in 1991-1992 by several groups. The impact and role of laparoscopy for splenectomy can be considered as significant as that for gallbladder disease, achalasia, esophageal reflux, and adrenal disease. In many centers, the laparoscopic approach is now routine for most cases of elective splenectomy. The laparoscopic approach is associated with reduced morbidity, especially pulmonary, wound, and infectious complications. This article reviews a standardized approach to laparoscopic and hand-assisted splenectomy and covers indications, operative strategy, and complications. Several special considerations, including massive splenomegaly, postsplenectomy thrombosis of the portosplenic venous system, and accessory spleens are also discussed.

Outcome of laparoscopic splenectomy with preoperative splenic artery embolization for massive splenomegaly

BACKGROUND

Laparoscopic splenectomy (LS) has become a safe and feasible procedure for cases involving spleens of normal size. Only a few publications report on the outcome of LS with preoperative splenic artery embolization (SAE) for massive splenomegaly. The authors present their experience in patients with massive splenomegaly who underwent laparoscopic-assisted splenectomy (LAS) or hand-assisted laparoscopic splenectomy (HALS) following SAE.

METHODS

A retrospective review of patients with massive splenomegaly undergoing LAS or HALS after preoperative SAE during the years 2004 to 2006 at the authors' institution was performed. Patients with a craniocaudal spleen length of 20 cm or greater were included in the study irrespective of their primary diagnosis. The data collected included information on patient demographics, operative details, rates of conversion to open procedures, perioperative blood transfusions, and postoperative complications. Routine Doppler ultrasound of the abdomen was performed on postoperative days 7 and 30 to screen for portal vein thrombosis (PVT).

RESULTS

A total of 19 patients were identified. The median spleen length was 23 cm, and the median spleen weight was 1,740 g. Nine patients underwent LAS, and 10 underwent HALS. The median operative time was 130 min, and the median hospital stay was 6 days. There were no conversions to open laparotomy. The median estimated blood loss was 200 ml. One patient required reoperation 24 h after LAS due to bleeding, and PVT developed in three patients postoperatively.

CONCLUSIONS

In the setting of massive splenomegaly, LAS or HALS with preoperative SAE is safe and has a low conversion rate. Postoperative imaging surveillance for PVT should be performed routinely in this patient population.

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

BACKGROUND/PURPOSE

This study was conducted retrospectively to examine whether laparoscopic splenectomy is an effective procedure for patients with splenomegaly due to portal hypertension in comparison to patients with a normal-sized spleen.

METHODS

From September 1994 to May 2005, we performed laparoscopic splenectomy in 50 patients at Wakayama Medical University Hospital, Japan. Of these, 17 patients with splenomegaly due to portal hypertension and 17 patients with idiopathic thrombocytopenic purpura (ITP) with normal-size spleen were enrolled in this study, in which we compared the surgical outcome between patients with splenomegaly due to portal hypertension and those without splenomegaly (ITP group).

RESULTS

The mean operative time (splenomegaly due to portal hypertension vs ITP; 171 vs 165 min; P = 0.7433) and estimated blood loss (248 vs 258 ml; P = 0.5396) were similar in the two groups. There were two patients with complications (11.8%) in the patients with splenomegaly due to portal hypertension and five patients with complications (29.4%) in those with ITP. All patients with splenomegaly due to portal hypertension showed appropriate increases in the platelet count following surgery. No perioperative mortality occurred.

CONCLUSIONS

We concluded that laparoscopic splenectomy was an effective procedure for splenomegaly due to portal hypertension, with findings being similar to those observed in patients with a normal-sized spleen (such as patients with ITP).

Laparoscopic splenectomy for blunt trauma: a safe operation following embolization

BACKGROUND

Embolization of the injured spleen from blunt trauma reduces the risk of continued or delayed hemorrhage in patients being treated with nonoperative management (NOM). Splenectomy is required in some patients following embolization due to continued bleeding or infarction with abscess formation. Laparoscopic splenectomy for blunt trauma can be done safely in patients following embolization.

METHODS

A retrospective chart review was conducted on patients undergoing splenectomy following embolization due to blunt trauma at two level I trauma centers. Minimally invasive techniques were compared to laparotomy for operative time, operative blood loss, and postoperative length of stay.

RESULTS

Eleven of 46 patients required splenectomy following embolization, eight for continued bleeding and three for abscess formation. Four of these patients had their spleens removed laparoscopically, three for continued bleeding and one for abscess formation. Patients undergoing laparoscopic splenectomy for continued bleeding had slightly longer operative times, more blood loss but shorter postoperative stay than those undergoing laparotomy. (96 versus 76 min, 500 versus 300 cc, and 4.0 versus 7.0 days, respectively). Laparoscopic removal of the abscessed spleen took 270 min compared to 55 and 90 min for the open procedures but the postoperative hospital stay was only 6 days compared to 10 and 13 days. There were no serious complications in any patients.

CONCLUSION

Laparoscopic removal of the spleen following embolization for blunt trauma is safe and should be considered in patients that have persistent bleeding or are at risk for delayed bleeding, as well as patients in whom complications of infarction and abscess formation develop.

Effect of catheter-directed arterial embolization and laparoscopic endovascular stapling on stapled vessel integrity in a porcine model

Arterial embolization is a frequently performed adjunctive maneuver prior to laparoscopic splenectomy or nephrectomy to facilitate laparoscopic dissection and reduce intraoperative bleeding. However, little is known regarding the effect of laparoscopic stapling across thrombosed vessels with imbedded embolic materials. This study analyzed the stapled line integrity by comparing visceral arteries treated with either platinum coils or polyvinyl alcohol (PVA) particles. Using a porcine model, 30 visceral vessels including splenic and renal arteries were treated with either coil or PVA embolization, which was followed by laparoscopic stapling. Vessel integrity and bursting pressure analysis was performed using an in vitro flow circuitry. The mean bursting pressure of the coil and the PVA group was 158 +/- 56 and 350 +/- 34 mm Hg, respectively (p < .001). The lowest bursting pressure in the coil and the PVA group was 70 and 280 mm Hg, respectively. The highest bursting pressure in the coil and the PVA group was 225 and 420 mm Hg, respectively. The bursting pressure in the splenic artery between the PVA and the coil group was 345 +/- 29 and 150 +/- 54 mm Hg, respectively (p < .001). Significant difference in the bursting pressure in the renal artery was noted in the PVA and the coil group, which was 350 +/- 40 and 160 +/- 40 mm Hg, respectively (p < .001). Our findings showed that preoperative coil embolization followed by laparoscopic vessel stapling sustained a poor busting pressure. Such a practice appears to be unsafe based on our findings and should be performed with caution in a clinical setting.

Splenic Artery Embolization and Endovascular Stapler Integrity in a Porcine Model

Splenic artery embolization is often used before laparoscopic splenectomy in cases of splenomegaly to reduce blood loss and facilitate the procedure. The aim of this study was to examine the general reliability of endovascular staplers when fired at the site of embolization coil deployment using a porcine model. Ex vivo and in vivo experiments were conducted on porcine abdominal aortas, which are similar in diameter to those of the splenic artery in the human. When the endovascular staplers were fired across the porcine vessels at the area of embolization coil deployment ex vivo, the staple lines all failed. In contrast, in vivo, the staple lines remained intact with no bleeding despite resistance imposed by the intravascular coils. Despite consistent failure in the ex vivo studies, in vivo all staple lines held and permitted safe transection of the vessel. We presume that the hemostatic properties of the coils caused sufficient thrombosis in this model, which mimics the clinical situation, to permit division of the previously embolized splenic vessel.

Evaluation of the Amplatzer vascular plug for proximal splenic artery embolization

PURPOSE

Proximal splenic artery embolization is performed for splenic salvage in the setting of trauma or before splenectomy in patients with splenomegaly. Typically, this has been done with the use of metallic coils, but precise placement of the first deposited coil may be limited. The Amplatzer vascular plug (AVP) may be used to accomplish precise proximal splenic artery embolization.

MATERIALS AND METHODS

Fourteen patients had proximal splenic artery embolization performed with the AVP. Thirteen were performed to allow splenic salvage after blunt trauma and one was performed before splenectomy for massive splenomegaly. Devices ranging in diameter from 8 to 12 mm were placed through 5-F or 6-F guiding catheters. Desired AVP location was distal to the dorsal pancreatic artery and proximal to the most peripheral pancreatica magna branch. Test injections of contrast agent were performed after approximately 5 minutes and then at 3-5-minute intervals until occlusion was seen. If this was not noted by 15 minutes, an adjunctive closure method was chosen. Computed tomography (CT) follow-up was performed in all patients.

RESULTS

Device placement in the desired location was successful in all cases, with device repositioning required in two. Occlusion took an average of approximately 10 minutes. Additional coils placed in three patients could all be packed into a tight configuration. A second AVP was placed in one patient. There were no complications of the procedures. Follow-up CT images showed no evidence of migration or recanalization of any of the devices. Minimal artifact was noted from the AVP on CT.

CONCLUSION

In this preliminary series, use of the AVP allowed for precise proximal splenic artery embolization.

Partial splenic embolization

Partial splenic embolization (PSE) is a non-surgical procedure developed to treat hypersplenism as a result of hepatic disease and thus avoid the disadvantages of splenectomy. A femoral artery approach is used for selective catheterization of the splenic artery. Generally, the catheter tip is placed as distally as possible in an intrasplenic artery. After an injection of antibiotics and steroids, embolization is achieved by injecting 2-mm gelatin sponge cubes suspended in a saline solution containing antibiotics. PSE can benefit patients with thrombocytopenia, esophagogastric varices, portal hypertensive gastropathy, encephalopathy, liver dysfunction, splenic aneurysm, and splenic trauma. The contraindications of PSE include secondary splenomegaly and hypersplenism in patients with terminal-stage underlying disease; pyrexia or severe infections are associated with a high risk of splenic abscess after PSE. Complications of PSE include daily intermittent fever, abdominal pain, nausea and vomiting, abdominal fullness, appetite loss, and postembolization syndrome. Decreased portal-vein flow and a rapid increase in the platelet count after excessive embolization may cause portal-vein or splenic-vein thrombosis.

Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

Although laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas still remain controversial. To date, the indications that preclude laparoscopic splenectomy are not clearly defined. In view of this, the European Association for Endoscopic Surgery (EAES) has developed clinical practice guidelines for LS.

METHODS

An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. A consensus development conference using a nominal group process convened in May 2007. Its recommendations were presented at the annual EAES congress in Athens, Greece, on 5 July 2007 for discussion and further input. After a further Delphi process between the experts, the final recommendations were agreed upon.

RESULTS

Laparoscopic splenectomy is indicated for most benign and malignant hematologic diseases independently of the patient's age and body weight. Preoperative investigation is recommended for obtaining information on spleen size and volume as well as the presence of accessory splenic tissue. Preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections is recommended in elective cases. Perioperative anticoagulant prophylaxis with subcutaneous heparin should be administered to all patients and prolonged anticoagulant prophylaxis to high-risk patients. The choice of approach (supine [anterior], semilateral or lateral) is left to the surgeon's preference and concomitant conditions. In cases of massive splenomegaly, the hand-assisted technique should be considered to avoid conversion to open surgery and to reduce complication rates. The expert panel still considered portal hypertension and major medical comorbidities as contraindications to LS.

CONCLUSION

Despite a lack of level 1 evidence, LS is a safe and advantageous procedure in experienced hands that has displaced open surgery for almost all indications. To support the clinical evidence, further randomized controlled trials on different issues are mandatory.

Partial splenic embolization in the treatment of patients with portal hypertension: a review of the english language literature

This article reviews the existing literature on the use of partial splenic embolization in patients with portal hypertension. All articles published in the English language on splenic embolization or partial splenic embolization as a treatment for portal hypertension were identified with a PubMed search from 1973 through 2005. Partial splenic embolization appears to be efficacious in reducing episodes of variceal bleeding, improving hematologic parameters, enhancing hepatic protein synthesis, and reducing the severity of hepatic encephalopathy. Associated morbidity and mortality appear to be acceptable. The literature, however, is limited in quality. Given the potential benefits of partial splenic embolization, further investigation is warranted to allow evidence-based evaluation of its use.

Laparoscopic versus open splenectomy for massive splenomegaly: a comparative study

BACKGROUND

Despite the benefits of the laparoscopic approach to splenectomy, its application in patients with massive splenomegaly (splenic weight >or= 1000 g) remains controversial. In this study we evaluated the safety and feasibility of laparoscopic splenectomy for massive splenomegaly compared with open splenectomy.

MATERIALS AND METHODS

One surgeon applied the laparoscopic approach to splenectomy to all comers with massive splenomegaly, while other surgeons carried out the surgery through a laparotomy. The outcomes of the two approaches were compared on an intention-to-treat basis. Results of continuous variables are shown as medians.

RESULTS

Fifteen patients underwent laparoscopic splenectomy between 2000 and 2005, and 13 underwent open splenectomy between 1996 and 2003. The two groups were comparable for age, sex, American Society of Anesthesiologists score, and splenic weight (1.3 vs. 1.1 kg). There was one conversion (6.6%) to open surgery. Although laparoscopic splenectomy was associated with significantly longer operating time (175 vs. 90 minutes, P < 0.001), it carried lower postoperative morbidity and mortality (13.3 vs. 30.8% and 0 vs. 7.7%, respectively). Laparoscopic splenectomy was associated with significantly lower total dose (29 vs. 264 mg morphine-equivalent, P < 0.0001) and duration of opiate usage (1 vs. 4 days, P < 0.0001); duration of parenteral hydration (24 vs. 96 hours, P = 0.006) and more rapid resumption of oral diet (24 vs. 72 hours, P = 0.017); and a shorter postoperative hospital stay (3 vs. 10 days, P < 0.0001).

CONCLUSIONS

The laparoscopic approach to splenectomy for massive splenomegaly is feasible and safe. Despite a longer operating time, the postoperative recovery following laparoscopic splenectomy is smoother, with lower morbidity and shorter postoperative hospital stay compared with open splenectomy.

Sutureless and stapleless laparoscopic splenectomy using radiofrequency: LigaSure device

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Splenic arterial interventions: anatomy, indications, technical considerations, and potential complications

Splenic arterial interventions are increasingly performed to treat various clinical conditions, including abdominal trauma, hypersplenism, splenic arterial aneurysm, portal hypertension, and splenic neoplasm. When clinically appropriate, these procedures may provide an alternative to open surgery. They may help to salvage splenic function in patients with posttraumatic injuries or hypersplenism and to improve hematologic parameters in those who otherwise would be unable to undergo high-dose chemotherapy or immunosuppressive therapy. Splenic arterial interventions also may be performed to exclude splenic artery aneurysms from the parent vessel lumen and prevent aneurysm rupture; to reduce portal pressure and prevent sequelae in patients with portal hypertension; to treat splenic artery steal syndrome and improve liver perfusion in liver transplant recipients; and to administer targeted treatment to areas of neoplastic disease in the splenic parenchyma. As the use of splenic arterial interventions increases in interventional radiology practice, clinicians must be familiar with the splenic vascular anatomy, the indications and contraindications for performing interventional procedures, the technical considerations involved, and the potential use of other interventional procedures, such as radiofrequency ablation, in combination with splenic arterial interventions. Familiarity with the complications that can result from these interventional procedures, including abscess formation and pancreatitis, also is important.

Laparoscopic splenectomy: present status and future perspective

Laparoscopic splenectomy has become widely accepted as the approach of choice for the surgical treatment of benign and malignant hematologic diseases. Advances in technology have led to better outcomes for the procedure, and have allowed surgeons to apply the technique to disease processes that were at one time felt to be contraindications to laparoscopic splenectomy. However, challenges still remain. There is a steep learning curve associated with the procedure. The development of cost-effective laparoscopic simulators to target the skills required for laparoscopic splenectomy and other laparoscopic procedures is essential. The advent of devices which isolate and seal the large blood vessels that surround the spleen have reduced intra-operative bleeding and minimized conversions to open splenectomy. Improvements in optics and instrumentation, as well as robotic technology, will continue to define the frontier of minimally invasive surgery, and further facilitate the acceptance of laparoscopic splenectomy for the treatment of benign and malignant hematologic diseases.

Laparoscopic splenectomy and LigaSure

Laparoscopic splenectomy (LS) is a preferred choice, especially for hematologic diseases. We present the advantages of the use of LigaSure (energy-based equipment that works by applying a precise amount of bipolar energy and pressure to the tissue, achieving a permanent seal) for achieving a precise hemostasis, thus making the LS easier. We have performed LS using LigaSure on 10 patients (4 female, 6 male; mean age, 36 years [range, 16-58]) between December 2002 and August 2003. All patients had ITP. There were no conversion to open surgery. Mean dimensions of spleens were 99 x 49 mm (range, 85 x 36-118 x 60). Intraoperative blood loss was no more than 100 mL in any patients (range, 20-100; mean, 60). The average operative time was 93 minutes (range, 60-155). There were no complications in the postoperative period. The average postoperative stay was 4.3 days (range, 3-7). LS using LigaSure is a safe and time-sparing procedure with almost no complications in this small initial series.

Laparoscopic splenectomy: what barriers remain?

Conditions that once were considered either relative or absolute contraindications for laparoscopic splenectomy have become fewer and less significant in the overall assessment of candidates for this procedure. Advances in surgical technique, operative conduct, and instrumentation have made it feasible to perform splenectomy laparoscopically with good outcomes and minimal morbidity in a variety of different pathologic conditions. Obesity, malignancy, pregnancy, and splenomegaly are assessed here in detail.