Laparoscopic management of accessory spleens in immune thrombocytopenic purpura

Background: A disparity exists between the incidence of accessory spleens reported in the open (15–30%) versus the laparoscopic (0–12%) literature. This disparity implies that a percentage of laparoscopic patients will require a reoperation for accessory splenectomy. We present our experience with the laparoscopic management of accessory spleens discovered after primary splenectomy for idiopathic thrombocytopenic purpura (ITP). Methods: Seventeen patients who underwent primary splenectomy for ITP were reviewed (1 open, 16 laparoscopic). In the laparoscopic group, the incidence of accessory spleens was 3 in 16 (19%). In 1 of these 3 patients, the accessory spleen was found and removed at the initial operation, whereas in 2 of the 16 patients (13%), the accessory spleens were missed. A third patient, whose initial operation was open, presented with recurrent thrombocytopenia after primary splenectomy. After recurrent thrombocytopenia developed, radio nuclide spleen scans were performed showing accessory spleens in all three patients. These three patients underwent accessory splenectomy using a four-port laparoscopic approach. Results: Laparoscopic accessory splenectomy was successfully performed in all three patients. Location of accessory spleens correlated with the spleen scan in each case. Mean operation time was 180 min. There were no conversions to open surgery and no complications. All patients were discharged from the hospital on postoperation day 1. The three patients had a good clinical response and were weaned effectively from their steroid medications. Conclusions: Patients undergoing a laparoscopic splenectomy for chronic ITP have a higher probability of requiring a reoperation for a missed accessory spleen. To minimize missing an accessory spleen, a systematic search should be made at the beginning of the laparoscopic operation. We have found that preoperation imaging with heat-treated erythrocyte scans is valuable for locating accessory spleens before reoperation. When reoperation for accessory splenectomy is necessary, a laparoscopic approach is safe and effective. Received: 22 July 1998/Accepted: 13 October 1998     

Laparoscopic versus open splenectomy in children

BACKGROUND: The authors have reviewed their initial experience with laparoscopic splenectomy (LS) to identify the indications, success rate, and complications associated with this procedure compared with a series of children undergoing open splenectomy (OS) during the same time period. METHODS: The records of 51 children who underwent splenectomy from 1993 through 1998 were reviewed retrospectively. RESULTS: Thirty-five patients aged 1 to 17 years (mean, 9.4 years) underwent LS for the following indications: ITP (n = 20), sickle cell disease or thalassemia (n = 6), hereditary spherocytosis (n = 5), other hematologic disorders (n = 4). Seventeen patients aged 2 to 17 years (mean, 11.8 years) underwent OS during the same time period for ITP (n = 4), sickle cell disease or thalassemia (n = 4), hereditary spherocytosis (n = 5), and other indications (n = 4). Concomitant cholecystectomy was performed in 4 of 35 LS and 4 of 17 OS. Accessory spleens were identified in 10 of 35 LS and 2 of 17 OS cases. Eleven spleens were enlarged in the LS group, and 8 were enlarged in the OS group. One LS required conversion to an open procedure because the spleen did not fit in the bag. No other cases were converted. Median estimated blood loss was 50 mL for both the LS and OS groups. The only intraoperative complication in the LS group was a splenic capsular tear, which had no effect on the successful laparoscopic removal of the spleen. No patient in either group required a blood transfusion. The LS patients had a shorter length of hospital stay (1.8 +/- 1 versus 4.0 +/- 1 day, P = .0001). Total hospital charges were not significantly different. Follow-up ranged from 6 to 40 months. One LS patient died 47 days postoperatively from unrelated causes. Two LS patients had recurrent ITP; accessory spleens were found in one and resected laparoscopically. CONCLUSION: LS in children can be performed safely with a low conversion rate (2.9%) and is associated with a shorter hospital stay and comparable total hospital cost when compared with OS.     

An 18-year review of open and laparoscopic splenectomy for idiopathic thrombocytopenic purpura

BACKGROUND: Laparoscopic splenectomy has become the preferred surgical procedure for the management of idiopathic thrombocytopenic purpura (ITP). However, there studies have directly compared the incidence of recurrent ITP secondary to missed accessory spleens in open versus laparoscopic splenectomy. METHODS: Open and laparoscopic splenectomies performed for ITP at 4 sites over 18 years were analyzed. The incidence of recurrent disease secondary to missed accessory spleens was compared between the open and laparoscopic splenectomy groups. RESULTS: A total of 105 splenectomies (54 open/51 laparoscopic) were performed. Accessory spleens were identified in 6 laparoscopic and 6 open cases (P = .57). Recurrent disease occurred in 27.6% of open and 14.6% of laparoscopic cases (P = .222). There were no cases of recurrent ITP secondary to a missed accessory spleen in either group. CONCLUSIONS: The incidence of missed accessory spleens causing recurrent disease is similar when splenectomy is performed either open or laparoscopically.     

Trends in laparoscopic splenectomy for massive splenomegaly

HYPOTHESIS: During the past 10 years, expertise with minimally invasive techniques has grown, leading to an increase in successful laparoscopic splenectomy (LS) even in the setting of massive and supramassive spleens. DESIGN: Retrospective series of patients who underwent splenectomy from November 1, 1995, to August 31, 2005. SETTING: Academic tertiary care center. PATIENTS: Adult patients who underwent elective splenectomy as their primary procedure (n = 111). MAIN OUTCOME MEASURES: Demographics, spleen size and weight, conversion from LS to open splenectomy, postoperative length of stay, and perioperative complications and mortality. Massive splenomegaly was defined as the spleen having a craniocaudal length greater than 17 cm or weight more than 600 g, and supramassive splenomegaly was defined as the spleen having a craniocaudal length greater than 22 cm or weight more than 1600 g. RESULTS: Eighty-five (77%) of the 111 patients underwent LS. Of these 85 patients, 25 (29%) had massive or supramassive spleens. These accounted for 40% of LSs performed in 2004 and 50% in 2005. Despite this increase in giant spleens, the conversion rate for massive or supramassive spleens has declined from 33% prior to 1999 to 0% in 2004 and 2005. Since January 2004 at our institution, all of the massive or supramassive spleens have been removed with a laparoscopic approach. Patients with massive or supramassive spleens who underwent LS had no reoperations for bleeding or deaths and had a significantly shorter postoperative length of stay (mean postoperative length of stay, 3.8 days for patients who underwent LS vs 9.0 days for patients who underwent open splenectomy; P<.001). CONCLUSIONS: Despite conflicting reports regarding the safety of LS for massive splenomegaly, our data indicate that with increasing institutional experience, the laparoscopic approach is safe, shortens the length of stay, and improves mortality.     

Accessory spleens--diagnostic and therapeutic problem of the laparoscopic splenectomy in idiopathic thrombocytopenic purpura patients

The preoperative detection of accessory spleens (AS) is essential in ITP patients. The aim of this study was to evaluate the reasons of failure and long-term results of laparoscopic splenectomy (LS) in patients with idiopathic thrombocytopenic purpura (ITP). Thirty-four ITP patients (27 females and 7 males) underwent LS between June 1998 and January 2001. Computed Tomography (CT) and sonography (US) were performed preoperatively to evaluate the size of the spleen and to detect the presence of possible accessory spleens which were found in two cases. AS were seen during laparoscopy in three cases. During follow-up (median time = 23 months), in three patients a low platelet count was seen after 5 months, 1.5 and 1.8 years pop. In all these cases scintigraphy was performed, which revealed in one case the residual accessory spleen. In the two other patients, inspite of thrombocytopenia no residual spleens were found. The authors conclude that laparoscopic splenectomy is a safe and effective procedure in patients with ITP. The problem of accessory spleens can be managed by careful videoscopic examination of the abdominal cavity during splenectomy. The use of the preoperative imaging techniques for detection of accessory spleens is limited by the insufficient sensitivity of the examination.     

Laparoscopic versus open pediatric splenectomy for massive splenomegaly

Laparoscopic splenectomy (LS) has rapidly evolved into the technique of choice compared with open splenectomy (OS) because of the advantages of the minimally invasive approach. Splenomegaly increases the technical difficulties of LS. LS for massive splenomegaly has generally been found to fail in adults and children. With improvements in laparoscopic technique and accumulation of laparoscopic experience, however, concerns about completing the procedure in pediatric cases with even massive splenomegaly have been lowered. A retrospective review (April 1997-October 2009) of databases at 2 institutions identified 145 children undergoing splenectomy, 79 laparoscopic and 66 open. We defined splenic margin below the umbilicus or anteriorly extending over the midline as massive splenomegaly. By this definition, 22 cases of pediatric laparoscopic and 17 cases of open splenectomies for massive splenomegaly were performed. Perioperative and follow-up data of laparoscopic pediatric splenectomies were compared with those of open splenectomies, including operative time, bleeding, spleen size, complications, and hospital stay. There were no deaths, wound infections, or instances of pancreatitis. No accessory spleen was missed by laparoscopic; accessory spleens were missed in 2 patients in open splenectomies. The complication rate of laparoscopic versus open was 13.6% versus 41.2%. No subsequent surgery was necessary for dealing with complications both in laparoscopic and open series. Laparoscopic pediatric splenectomy for massive splenomegaly is a feasible, effective, and safe procedure and is associated with low morbidity and a short hospital stay.     

Laparoscopic splenectomy has become the gold standard in children

Splenectomy is frequently required in children with various hematologic disorders. The reported advantages of laparoscopic splenectomy (LS) include less pain, shorter hospital stay, and improved cosmesis. This report evaluates the outcome of children undergoing LS at a single children's facility. One hundred twelve children underwent LS by the lateral approach between August 1995 and February 2001. Indications for LS were hereditary spherocytosis in 58, idiopathic thrombocytopenic purpura in 21, sickle cell disease in 19, and other conditions in 14. LS alone was completed in 89 children and LS and cholecystectomy (LSC) in 20. Three required conversion to open splenectomy. Accessory spleens were identified in 19. Complications included ileus (four), acute chest syndrome (four), bleeding (two), pneumonia (one), and diaphragm perforation (one). There was no mortality. An accessory spleen was missed in one child with recurrent anemia. Average operative time for LS was 106 minutes and for LSC 135 minutes. Operative time for LS decreased with experience but the difference was not significant. Average length of stay was 1.51 days (range 1-11) and was longer in sickle cell disease (2.47 days) versus hereditary spherocytosis (1.29 days) and idiopathic thrombocytopenic purpura (1.16 days). We conclude that LS is safe and effective in children with hematologic disorders and is associated with minimal morbidity, zero mortality, and a short length of stay.     

Accessory spleens: preoperative diagnostics limitations and operational strategy in laparoscopic approach to splenectomy in idiopathic thrombocytopenic purpura patients

Aim The preoperative detection of accessory spleen (AS) is still a very important and serious problem. The aim of the study was to assess the reasons for failure and the long-term results of laparoscopic splenectomy (LS) in patients with idiopathic thrombocytopenic purpura (ITP).Method Fifty-eight ITP patients underwent LS between June 1998 and December 2002. There were 42 women and 16 men. Preoperatively, we performed computed tomography (CT) and sonography to evaluate the size of the spleen and possibly to recognize the presence of the accessory spleens, which were found preoperatively in three cases.Results Intraoperatively, ASs were found in the course of laparoscopy in six cases overall, three preoperatively false negative. During follow-up (median time 31 months), in three patients the low platelet count was recognized, respectively after 5 months and 1.5 and 1.8 years. In all those cases scintigraphy was performed and in one case the residual accessory spleen, missed both in preoperative examination and during laparoscopy, was revealed. In two other patients, in spite of thrombocytopenia, no residual spleens were found.Conclusion We conclude that the problem of accessory spleens can be managed by careful videoscopic examination of the abdominal cavity during splenectomy, while the use of preoperative imaging techniques in detection of accessory spleens is still limited by the insufficient sensitivity of the examination.     

Laparoscopic excision of accessory spleen

BACKGROUND: Laparoscopic splenectomy has become an accepted procedure in the management of several hematologic diseases. Less clear is the effectiveness of laparoscopic excision of accessory spleens after initial splenectomy in the management of recurrent hematologic disease. We report here our early experience of this technique. METHODS: All patients who underwent laparoscopic excision of accessory spleens (LEAS) after initial splenectomy were reviewed for preoperative studies, technical success, and effects on either platelet count or hemoglobin level. RESULTS: In 5 patients LEAS was attempted. Two patients had initial open splenectomies, and 3 had initial laparoscopic splenectomies. Hematologic diagnoses were immune thrombocytopenic purpura (3), chronic lymphocytic leukemia-induced thrombocytopenia (1), and autoimmune hemolytic anemia (1). All patients underwent preoperative damaged red blood cell scintigraphy, which demonstrated functioning splenic tissue, and abdominal computed tomography scans, which demonstrated a nodule in 4 of 5 patients. LEAS was technically successful in 4 patients, with the 1 failure also being the patient in whom the computed tomography scan could not demonstrate the accessory spleen. However, only 2 of the 4 patients after LEAS had durable hematologic responses to surgery, despite follow-up damaged red blood cell scintigraphy showing no residual functioning splenic tissue. CONCLUSION: LEAS can be technically successful when the accessory spleen is demonstrated on both damaged red blood cell scintigraphy and computed tomography scan; therefore, adequate visualization in both studies is required. However, hematologic response to excision may be less effective than with the initial splenectomy. Further study is needed to determine the causes of these outcomes.     

Results of laparoscopic and open splenectomy for nontraumatic diseases

The medical records of patients who had undergone splenectomy for nontraumatic diseases of the spleen between 1997 and 2000 were reviewed. The aim of the study was to evaluate the short-term outcomes of open and laparoscopic splenectomies and to determine whether some well-known benefits of laparoscopic surgery could be observed in patients who underwent laparoscopic splenectomy for nontraumatic splenic diseases. The data of 44 patients were available for analysis and included 20 patients (45.5%) who underwent laparoscopic splenectomy and 24 patients (54.5%) who underwent open splenectomy. Various parameters were reported for open and laparoscopic procedures separately, including associated surgical procedures, spleen weight, postoperative mortality and morbidity rates, perioperative blood transfusions, use and length of abdominal drainage, accessory spleen removal, operative times, length of hospital recovery, and hematologic parameters on admission to and discharge from the hospital. Laparoscopic splenectomy was successfully completed in all 20 considered patients with no conversion to open splenectomy. The supine position and four trocars were adopted in all patients. Accessory spleens were found in four (9.0%) patients: two (4.5%) during open splenectomy and two (4.5%) during laparoscopic splenectomy. The postoperative mortality rate was 2.7% (a case of myocardial infarction). The morbidity rate was 9% (four patients), but no postoperative complications occurred after laparoscopic splenectomy. A significant statistical difference was shown by the increase in platelet counts after open versus laparoscopic splenectomy. The open and laparoscopic mean operative times (73.70 +/- 13.42 minutes and 78.42 +/- 14.63 minutes, respectively) were comparable. These times were comparable also considering patients who underwent only splenectomy. Mean recovery time was shorter after laparoscopic splenectomy (3.95 +/- 0.60 days) than after open splenectomy (7.0 +/- 1.68 days). After open procedures, however, the mean recovery time was shorter in uncomplicated cases (6.68 +/- 1.49 days) than in the open group as a whole. Authors conclude that many well-known advantages of the laparoscopic approach. especially those related to its low invasiveness, can be observed in patients requesting splenectomy for nontraumatic diseases of the spleen, without lowering the efficacy of this operation. They suggest that such advantages can be entirely displayed when selection criteria of the patients are applied.     

Laparoscopic splenectomy for treatment of patients with idiopathic thrombocytopenic purpura

BACKGROUND: Laparoscopic splenectomy (LS) is one of the advanced laparoscopic procedures that benefit most from minimally invasive surgery. This study was undertaken to compare the operating time, blood loss, length of hospital stay, and platelet count response for patients with idiopathic thrombocytopenic purpura (ITP) undergoing open splenectomy (OS) versus LS. METHODS: We performed OS in 20 cases before 1992 and LS in 14 cases after 1993 for the treatment of ITP. RESULTS: The operating time was significantly shorter for OS than for LS (126 +/- 52 min versus 203 +/- 83 min, p < 0.01). Blood loss was less for OS than for LS (321 +/- 264 ml versus 524 +/- 648 ml, p = 0.287). None of the patients who underwent LS were converted to open surgery. Accessory spleens were found in four OS patients (20.0%) and four LS patients (28.6%). The postoperative hospital stay was significantly longer for OS patients than for LS patients (15.2 +/- 5.8 days versus 8.9 +/- 2.9 days, p < 0.0005). No significant difference was noted in the long-term results of splenectomy. CONCLUSIONS: Compared with OS, LS required more operating time, had the potential to cause greater blood loss, had a comparable incidence of accessory spleen and response rate, and appeared to shorten the postoperative stay.     

Laparoscopic splenectomy in children.

BACKGROUND: Laparoscopic splenectomy is being performed more commonly in children, although its advantages are not clear. We sought to determine whether laparoscopic splenectomy was superior to open splenectomy. METHODS: The records of all pediatric patients undergoing splenectomy without significant comorbidities over a 12-year period were examined. The patients were divided into those undergoing laparoscopic splenectomy and those undergoing open splenectomy. Demographics, operative time, estimated blood loss, spleen size, length of stay, and total charges were compared between the groups. RESULTS: Eighty-one (58%) children underwent laparoscopic splenectomy, and 59 (42%) children underwent open splenectomy. The groups were similar in age and sex; hereditary spherocytosis was more common in the LS group. Operating time was longer in the laparoscopic splenectomy group (231 +/- 10 min vs 138 +/- 9 min; P<0.001), but blood loss and complication rates were similar. Twelve (15%) conversions were necessary primarily due to spleen size. Although children undergoing LS had a shorter length of stay (2.4 +/- 0.1 vs 4.1 +/- 0.3 days; P<0.001), they incurred higher charges (dollars 21199 +/- 664 vs dollars 15723 +/- 1737; P<0.002). CONCLUSION: Laparoscopic splenectomy is a safe procedure in children, resulting in shorter hospital stay, which may translate into earlier return to activity and a smaller burden on the child's caretakers.     

Laparoscopic splenectomy: outcomes and lessons learned from over 200 cases

BACKGROUND: In this study of laparoscopic splenectomy (LS), we evaluate prospectively gathered perioperative patient data and review lessons learned in the evolution of this procedure. METHODS: At 2 university medical centers between November 1993 and March 2000, there were 203 patients (122 female patients and 81 male patients) who underwent LS after preoperative evaluation. RESULTS: LS was successfully completed in 197 patients (97%). The mean operative time was 145.5 minutes and the length of stay averaged 2.7 days with 143 (70.4%) staying less than 48 hours. The most common indication was idiopathic thrombocytopenic purpura (ITP). Six patients required conversion to open splenectomy (OS), with only 2 conversions in the last 163 cases. No deaths were attributed to the procedure. Complications occurred in 19 patients (9.3%). Thirty accessory spleens were identified in 25 patients (12.3%). Seventeen patients (8.4%) underwent concomitant procedures, most commonly cholecystectomy. CONCLUSIONS: LS by the lateral approach is both safe and feasible in patients of all ages.     

Laparoscopic splenectomy for ITP

Background: A comparison of safety, efficacy, and cost of laparoscopic splenectomy (LS) vs open splenectomy (OS) for idiopathic thrombocytopenic purpura (ITP) was performed. Methods: The records of 49 consecutive patients who underwent splenectomy for ITP (31 LS and 18 OS) at a large metropolitan teaching hospital between 3/91 and 8/95 were reviewed. Morbidity, mortality, hospital stay, operative time, blood loss, time to oral fluid intake, direct costs, and operating room (OR) costs were analyzed. Results: Age, sex, comorbidity, and spleen size were similar in both groups. LS was successful in 94% of patients in whom it was attempted. Operative times showed a learning curve for LS, with average times for the last ten cases (94 ± 35 min) significantly shorter than for the first ten (p= 0.01) and also shorter than for OS (103 ± 45 min). Postsurgical hospital stay was 2.9 ± 1.3 days for LS and 6.9 ± 3.0 days for OS (p < 0.001). Patients tolerated an oral diet 1.2 ± 0.5 days after LS and 3.2 + 0.7 days after OS (p < 0.001). Direct hospital cost was $5,509 ± 3,636 for LS and $9,031 ± 12,752 for OS. In the LS group, six patients (21%) had accessory spleens identified and removed, compared with two patients (11%) in the OS group. Platelet counts did not respond in two (7%) patients in the LS group, but no accessory spleens were identified by nuclear scan. One major complication occurred in the LS group. There were no cases of splenosis or mortality in either group. Conclusions: LS is a safe and effective treatment for ITP, with significantly shorter postoperative hospital stay than OS. Received: 26 March 1996/Accepted: 11 May 1996     

Laparoscopic versus open splenectomy: a comparative study

Laparoscopic splenectomy (LS) is gaining wide acceptance as a safe, effective alternative to open splenectomy (OS) in the treatment of hematologic disorders in adult and pediatric patients, with low conversion rates and complications. The aim of this retrospective case-control study was to compare two cohorts of patients, with similar characteristics, who underwent OS or LS in a single institution. The medical records of the initial 20 consecutive patients who underwent LS were reviewed and compared with a control group of 28 patients undergoing OS, matched for age, gender, diagnosis, splenic size and weight, and American Society of Anesthesiologists score. Data were collected regarding operative time, blood loss, blood transfusions, pathologic findings, accessory spleen detection, complications, ileus duration, and postoperative hospital stay. Nineteen patients underwent attempted LS. One procedure (5%) was converted to OS for uncontrolled hilar bleeding. Accessory spleens were detected in two cases in the LS group compared with four cases in the OS group (14%). Mean operative time was 165 minutes (range: 100-240 minutes) for LS and 114 minutes (75-180 minutes) for OS (P < 0.001). In the LS group a regular diet was tolerated 36 hours (range: 24-48 hours) after surgery compared with 72 hours (range: 48-96 hours) for the OS group (P < 0.001), and mean postoperative hospital stay was 4.1 days (range: 3-8 days) for LS, compared with 8.1 days (range: 5-12 days) for OS (P < 0.001). No differences were observed in blood loss, complication rates, or transfusion requirements. Compared with OS, LS requires more operative time (showing a learning curve), is comparable in blood loss, transfusion requirements, complication rates, and detection of accessory spleens and appears to be superior in terms of return of bowel function and hospital stay.     

Laparoscopic splenectomy for hematologic disorders: experience with the first fifty patients

BACKGROUND: Splenectomy is increasingly being performed by various minimal access surgical modalities for select hematologic disorders. METHODS: A retrospective analysis was performed on the first 50 patients on whom laparoscopic splenectomy (LS) was attempted. The data studied included indications for surgery, patient demographics, intraoperative parameters, and patient outcomes. A total laparoscopic approach (TLS) was employed in 38 patients and a hand-assisted technique (HALS) was used in 12 patients with massive splenomegaly. Eight patients had concomitant surgical procedures: 7 patients underwent laparoscopic cholecystectomy and 1 patient received a kidney transplant. The most common indications for LS were idiopathic thrombocytopenic purpura (ITP) (50%) and hereditary spherocytosis (24%). RESULTS: LS was successfully completed in 48 patients (96%). Thirty-four patients (68%) required perioperative blood or platelet transfusions. The mean spleen diameter was 17.1 cm (range, 11.2-28.4 cm) on imaging study and mean intact splenic weight was 1019 gm. The mean operative time was 188 minutes (range, 90-340 minutes) in the TLS group and 171 minutes (range, 120-240 minutes) in the HALS group. The mean intraoperative blood loss was 306 mL (range, 40-640 mL) in the TLS group and 163 mL (range, 100-300 mL) in the HALS group. The mean postoperative hospital stay was 3.2 days (range, 2-5 days). CONCLUSION: TLS is safe and feasible in patients with nonpalpable spleens. A concomitant laparoscopic procedure for treating coexisting abdominal pathology may be performed without additional morbidity. The HALS technique may be preferable in patients with splenomegaly (palpable spleens), as it appears to offer intraoperative advantages for retraction, dissection, hemostasis, and organ retrieval.     

Effect of spleen size on splenectomy outcome

BACKGROUND: Laparoscopic splenectomy (LS) is gaining acceptance as an alternative to open splenectomy (OS). However, splenomegaly presents an obstacle to LS, and massive splenomegaly has been considered a contraindication. Analyses comparing the procedure with the open approach are lacking. The purpose of this study was to analyze the effect of spleen size on operative and immediate clinical outcome in a series of 105 LS compared with a series of 81 cases surgically treated by an open approach. METHODS: Between January 1990 and November 1998, 186 patients underwent a splenectomy for a wide range of splenic disorders. Of these patients, 105 were treated by laparoscopy (group I, LS; data prospectively recorded) and 81 were treated by an open approach (group II, OS analyzed retrospectively). Patients also were classified into three groups according to spleen weight: group A, <400 g; group B, 400-1000 g; and group C, >1000 g. Age, gender, operative time, perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia, length of stay, and morbidity were recorded in both main groups. RESULTS: Operative time was significantly longer for LS than for OS. However, LS morbidity, mortality, and postoperative stay were all lower at similar spleen weights. Spleens weighing more than 3,200 g required conversion to open surgery in all cases. When LS outcome for hematologic malignant diagnosis was compared with LS outcome for a benign diagnosis, malignancy did not increase conversion rate, morbidity, and transfusion, even though malignant spleens were larger and accessory incisions were required more frequently. Postoperative hospital stay was significantly longer in malignant than in benign diagnosis (5 +/- 2.4 days vs. 4 +/- 2.3 days; p < 0. 05). CONCLUSIONS: In patients with enlarged spleens, LS is feasible and followed by lower morbidity, transfusion rate, and shorter hospital stay than when the open approach is used. For the treatment of this subset of patients, who usually present with more severe hematologic diseases related to greater morbidity, LS presents potential advantages.     

Use of laparoscopic splenectomy in developing countries: analysis of cost and strategies for reducing cost

BACKGROUND: In general, laparoscopic surgery is more expensive than open surgery. However, recent reports showed lower overall cost. PATIENT AND METHODS: Fourteen patients underwent laparoscopic splenectomy (LS) and 15 patients open splenectomy (OS). Patients were evaluated with regard to blood loss, complication rate, length of hospital stay, operative time, presence of accessory spleens, hospital cost, and total cost. For the OS group, there was no laparoscopic instrument cost, and the total cost was equal to the hospital cost. In the LS group, total cost was calculated by adding the hospital cost to the cost of laparoscopic instruments. RESULTS: The postoperative hospitalization was shorter in the LS group than the OS group (3.4 vs. 7.5 days), but the operating time was significantly longer for the LS group. The mean hospital cost was calculated as US $1,055 in the LS group and $1,664 in the OS group. The overall total cost was $1,664 for the OS group and $2,064 for the LS group. In the LS group, less morbidity and shorter postoperative hospital stay resulted in lower hospital cost. CONCLUSION: The cost for laparoscopic instruments is the main factor responsible for the high total cost of LS. Resterilization of disposable laparoscopic instruments is feasible and a more economic way of treatment compared with splenectomy with totally disposable laparoscopic instruments and has costs comparable to those of open surgery.     

Laparoscopic surgery of the spleen: state of the art

INTRODUCTION: Laparoscopic splenectomy (LS) offers superior visualization and access to the spleen and avoids the major laparotomy incision necessary in open splenectomy (OS). This review summarizes the current knowledge of laparoscopic techniques for splenectomy from the perspective of surgeons whose combined experience now totals 340 cases. BACKGROUND AND DISCUSSION: While LS has been applied across the spectrum of splenic diseases, it is most indicated in treatment of a benign hematologic condition with a normal or slightly enlarged spleen as seen in autoimmune thrombocytopenic purpura (ITP), autoimmune deficiency syndrome-related ITP, hemolytic anemia, or spherocytosis. Both anterior and lateral approaches have been used for LS. While benefits of the anterior approach include access to the splenic artery along the superior border of the pancreas within the lesser sac, thus securing vascular control early in the procedure, the lateral approach allows for improved exposure of and access to the splenic pedicle. Also, mechanics and sequence of dissection are enhanced and more intuitive to the surgeon using the lateral approach, and the tail of the pancreas is more easily identified. Potential perioperative complications of LS include hemorrhage, injury to the tail of the pancreas, and deep vein thrombosis. The most common criticisms facing LS are the potential for missed accessory spleens, longer operating time, and greater operating room costs compared to OS. However, while LS requires a longer operating time than OS, studies indicate shorter postoperative hospital stays for LS versus OS patients in comparable cases, which can, in turn, reduce the total hospital cost for the procedure. CONCLUSION: Although LS continues to pose certain technical challenges--such as management of the massive spleen, specimen extraction, and identification of remotely located accessory spleens--its advantages over OS in terms of faster postoperative recovery, shorter hospital stay, and equivalent or lower perioperative morbidity are now well established. Indications for LS and more laparoscopic spleen-conserving surgery are likely to broaden.