Outcome of laparoscopic splenectomy based on hematologic indication

BACKGROUND: Laparoscopic splenectomy is the procedure of choice for elective splenectomy at the Cleveland Clinic Foundation. Although the literature clearly documents the technical feasibility and safety of laparoscopic splenectomy, little data exists concerning the results of this procedure based on the hematologic indication for splenectomy. We sought to examine the clinical experience with laparoscopic splenectomy in a single institution, with particular attention to morbidity and clinical outcomes based on hematologic disease process. METHODS: This study retrospectively reviewed a consecutive series of laparoscopic splenectomies performed for nontraumatic, splenic pathology at the Cleveland Clinic Foundation from August 1995 to January 2001. Patient demographics, operative indications, morbidity, mortality, and clinical outcome were evaluated. Hematologic diagnostic groups were compared using Fisher's exact tests and Wilcoxon rank-sum tests. RESULTS: A total of 147 laparoscopic splenectomies were performed. Seven patients (5%) required conversion to open splenectomy. Indications for splenectomy included idiopathic thrombocytopenic purpura (ITP) in 65 patients, hematologic malignancy in 43 patients, autoimmune hemolytic anemia (AIHA) in 9 patients, thrombotic thrombocytopenic purpura (TTP) in 9 patients, splenomegaly in 5 patients, splenic cyst in 4 patients, splenic abscess in 3 patients, hereditary spherocytosis in 2 patients, splenic artery aneurysm in 2 patients, Felty's syndrome in 1 patient, myelofibrosis in 1 patient, and other in 3 patients. Accessory spleens were identified in 20 patients (14%). Postoperative complications occurred in 23 (16%) patients. Patients with ITP had significantly shorter operation times (134 vs 163 min; p = 0.001), decreased estimated blood loss (126 vs 307 ml; p = 0.001), decreased length of hospital stay (2.8 vs 4.6 days; p < 0.001), and less chance of conversion (0 vs 7; p = 0.02) than patients with any other diagnosis. A mean follow-up period of 20 +/- 14 months showed an 85% rate of remission for ITP, 89% for TTP, and 89% for AIHA. Patients with malignant disease had significantly larger spleens (822 vs 313 g; p < 0.001), more estimated blood loss (380 vs 168 ml; p = 0.04), and longer operative times (170 vs 142 min; p = 0.009), as compared patients treated for benign disease. However, the length of hospital stay (4.3 vs 3.6 days; p = 0.06) and complication rates (19% vs 14%; p = 0.08) were not significantly different between the two groups. CONCLUSIONS: When performed for ITP, laparoscopic splenectomy resulted in shorter operations, minimal blood loss, earlier discharge, no conversions, and excellent remission rates, as compared with other hematologic indications. Despite larger spleens, more blood loss, and longer operations in patients with hematologic malignancies, morbidity and length of hospital stay still were similar to those associated with benign indications for laparoscopic splenectomy. In conclusion, laparoscopic splenectomy is safe and efficacious for a multitude of benign and malignant hematologic indications, and our data compares favorably to those for open series.     

Conversion factors for laparoscopic splenectomy for immune thrombocytopenic purpura

Background: Since 1994, 27 patients at our institution have undergone laparoscopic splenectomy for immune thrombocytopenic purpura (ITP). Laparoscopic splenectomy was completed in 22 of these patients. We sought to identify factors that precluded successful laparoscopic splenectomy in the remaining 5 patients. Methods: Retrospective review of 27 patients with ITP undergoing laparoscopic splenectomy was performed at Duke University Medical Center from August, 1994 to September, 1997. Results: Laparoscopic splenectomy was performed in 16 women and 11 men with a mean age of 47.2 years. Five (18%) of these procedures were converted to open splenectomy. There was no significant difference in age, ASA score, gender, weight, height, or splenic size between the converted and laparoscopic groups. However, preoperative and postoperative platelet counts were significantly higher in the laparoscopic group than in the converted group (p < 0.001). Operative times also were significantly longer for the laparoscopic group than for the converted group (p < 0.001). Adherent adjacent structures, associated comorbidities, and technical errors prohibited laparoscopic completion in five patients. Technical errors with subsequent bleeding required conversion in two patients. A thickened greater omentum blanketing the splenic capsule and a densely adherent pancreatic tail extending well into the splenic hilum prevented laparoscopic completion in two patients. Increased peak airway pressures greater than 60 mmHg after pneumoperitoneum necessitated conversion in the remaining patient, who had a previous history of pulmonary insufficiency. Regardless of surgical approach, all patients achieved a therapeutic response after splenectomy. Splenectomies completed laparoscopically resulted in a significantly shorter length of hospital stay (p < 0.01). Conclusions: Densely adherent adjacent structures, technical errors, and cardiopulmonary instability may preclude successful completion of laparoscopic splenectomies. Thorough preoperative evaluation with an emphasis on the cardiopulmonary system may elicit a cohort of individuals with ITP who are unlikely to undergo laparoscopic splenectomy successfully. This cohort also may include individuals with preoperative platelet counts less than 35,000 mm⁻³. Received: 15 April 1998/Received: 15 January 1999     

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.     

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.     

Splenic artery embolization before laparoscopic splenectomy in children

Background This study assessed the safety and utility of preoperative splenic artery embolization before laparoscopic splenectomy in children. Methods Five young girls with a mean age of 13.2 years underwent laparoscopic splenectomies at the authors’ institution from August 1998 to April 2003. Three of the patients had idiopathic thrombocytopenic purpura, and two had hereditary spherocytosis. Preoperative splenic artery embolization was performed the day before the surgery in all cases. The laparoscopic splenectomy was performed using traditional laparoscopic procedures and standard laparoscopic instruments with the patient in the right semilateral position. Results The mean spleen weight was 252.6 g, and the mean length was 11.6 cm. All the patients reported postembolic pain, but not to a level unmanageable by intravascular narcotics. There were no severe complications in the splenic artery embolization. The laparoscopic splenectomies were completed in a mean of 211 min, with a mean estimated blood loss of 9 ml. None of the operations required conversion to traditional open laparotomy, and none of the patients died or experienced operative complications. Conclusion The authors concluded that splenic artery embolization is safe and useful as an adjuvant procedure performed before elective laparoscopic splenectomy in children.     

预结扎脾动脉腹腔镜巨脾切除术12例分析

目的:探讨预结扎脾动脉腹腔镜巨脾切除术的方法和疗效。方法:为12例巨脾伴脾功能亢进患者行腹腔镜脾切除术。术中预结扎脾动脉,超声刀解剖脾周韧带,Endo-GIA离断脾蒂。结果:12例患者均顺利完成手术,无中转开腹及并发症发生。术后血小板、白细胞均明显上升。结论:随着超声刀、Endo-GIA等先进器械的应用,预结扎脾动脉腹腔镜巨脾切除术已成为治疗巨脾、脾功能亢进的有效术式。     

Laparoscopic accessory splenectomy for recurrent idiopathic thrombocytopenic purpura

BACKGROUND: Splenectomy has 50% to 70% long-term efficacy for immune thrombocytopenic purpura (ITP). In some patients, relapse is due to the presence of residual accessory splenic tissue. METHODS: A 44-year-old male had ITP since 1983 with splenectomy in 1985. He had a transient response, but then developed severe thrombocytopenia refractory to multiple modalities for 20 years. An accessory spleen was first visualized in 2000. RESULTS: A laparoscopic accessory splenectomy was performed without difficulty. The patient had an initial response with a significant increase in platelet count. Although over time the thrombocytopenia recurred, there has been a long-term benefit in that the patient is on much lower doses of prednisone to maintain an adequate platelet count. CONCLUSION: The finding of accessory splenic tissue after prior splenectomy may be an increasingly common problem in patients with recurrent ITP. Although reported response rates for resection of residual splenic tissue vary, the availability of a safe, less morbid, minimally invasive approach makes the decision to operate easier.     

Splenic artery embolization using contour emboli before laparoscopic or laparoscopically assisted splenectomy

The present study assessed preoperative splenic artery embolization using spherical embolic material, super absorbent polymer microspheres (SAP-MS), before laparoscopic or laparoscopically assisted splenectomy. Distal splenic artery embolization using 250 to 400 microm SAP-MS was performed in nine cases with ITP and in seven cases with the other diseases with splenomegaly. Laparoscopic or laparoscopically assisted splenectomies, including a hand-assisted procedure and the procedure involving left upper minilaparotomy, were done 2 to 4 hours after embolization. Conversion to traditional laparotomy was not required in any of the 16 cases, while conversion to 12-cm laparotomy was required in one case with massive splenomegaly. Mean operating time was 161 minutes, and mean intraoperative blood loss was 290 mL. No major postoperative complications were identified, and only one patient reported postembolic pain before surgery. Preoperative splenic artery embolization using painless embolic material, SAP-MS, would be effective for easy and safe laparoscopic or laparoscopically assisted splenectomy.     

What we learned from the experience of laparoscopic splenectomy in patients with idiopathic thrombocytopenic purpura (ITP)--single surgeon experiences

From October 1994 to December 2004, 50 cases of laparoscopic splenectomy (LS) have been carried out by a single surgeon for treating patients with idiopathic thrombocytopenic purpura (ITP). This study was performed to analyze a single surgeon's experiences of LS in ITP and discuss lesions that we have learned and the technical changes based on perioperative outcomes of LS. It seems that strict right lateral decubitus is definitively the position of choice because it ensures good exposure of splenic vascular structure in hilum. We also found that a flexible scope or 45-degree angled telescope, not to mention a 30-degree one, allowed for optimal vision, and made laparoscopic procedures easy and secure. We could control the vascular structure safely by just applying 5-mm laparoscopic clips without using harmonic scalpel or endo-GIA. When delivering spleen, it maybe easy and safe way to remove the plastic pouch with spleen fragmented through the umbilical port after changing the patient's position to supine again.     

Single-incision laparoscopic splenectomy with innovative gastric traction suture

Laparoscopic splenectomy is now the gold standard for patients with idiopathic thrombocytopenic purpura (ITP) undergoing splenectomy. There are a few reports in literature on single-incision laparoscopic (SIL) splenectomy. Herein, we describe a patient undergoing SIL splenectomy for ITP without the use of a disposable port device. We report a 20-year-old female patient with steroid-refractory ITP having a platelet count of 14,000/cmm who underwent a SIL splenectomy. Dissection was facilitated by the use of a single articulating grasper and a gastric traction suture and splenic vessels were secured at the hilum with an endo-GIA stapler. She made an uneventful postoperative recovery and was discharged on the second postoperative day. She is doing well with no visible scar at 8-month follow-up.     

The ascendance of laparoscopic splenectomy

The application of laparoscopic techniques for abdominal procedures has been achieved with varying success. The general acceptance of laparoscopic splenectomy (LS) may be hindered by its infrequent performance and difficulty in manipulating the spleen. A retrospective review of splenectomies performed for primary splenic pathology was done to assess the role and outcome of LS. One hundred fifty LSs were performed from July 1995 through September 1999. Over that time period the proportion of LS performed increased steadily from 17 to 75 per cent of all splenectomies. The primary indications for splenectomy included immune thrombocytopenic purpura in 75 (50%), lymphoma/leukemia 36 (24%), and splenomegaly 19 (13%). There were 86 females and 64 males. Immediately before operation 36 patients (4%) had a platelet count <50,000/ mL, and 24 patients (16%) a hemoglobin <10 mg per cent. The mean operative time was 161 minutes with an average blood loss of 138 cm3 (<50-800). The mean morcellated weight of the entire group was 411 g (33-3300) indicating generally large splenic size. In the 37 patients with splenomegaly the mean weight was 735 g (293-3300). There were two conversions to open splenectomy. Two patients with hematologic malignancy, splenomegaly, and cytopenias died from overwhelming post-splenectomy sepsis (1.3%). Morbidity occurred in 14 (9%) with the most common complication being pancreatitis in seven (5%). The median length of postoperative stay was 2.4 days (range 1-5). In summary LS has rapidly replaced the open approach for nearly all elective splenectomies in adults and children. When performed with the patient in the lateral position it can be accomplished with minimal morbidity, even in complex patients, including those with splenomegaly.     

Elective splenectomy in the elderly patient

This report reviews 10 years' experience with elective splenectomy in patients over 55 years of age. Of 55 patients, 25 were over the age of 65. The majority of splenectomies (41) were performed for hematological disorders exclusive of lymphoma, but including ITP, hypersplenism (both primary and secondary), Felty's syndrome and myeloid metaplasia. Sixty-eight per cent of these patients responded to splenectomy with sustained elevation of platelet counts while 70 per cent responded to sustained elevation of leukocyte counts. Sixteen of the hematological patients received a preoperative trial of steroid therapy in an attempt to alleviate leukopenia or thrombocytopenia with a 37.5 per cent (6 of 16) success rate. There was no correlation between the response to preoperative steroid therapy and response to splenectomy. These data correspond favorably to previous published material in the younger aged patients. There was no difference in the postoperative complication rate related to drainage or nondrainage of the splenic bed. However, eight other complications occurred for a morbidity rate of 14.5 per cent in addition to complications related to drainage of the splenic bed (8%). A 9 per cent (5 of 55) mortality rate was related to the patients' pre-existing diseases and appears acceptable in light of hematological response rate and quoted mortality rates for splenectomy over age 65.     

Is splenectomy after trauma an endangered species?

Nonoperative management of splenic trauma is now the most common treatment modality for splenic injuries and splenectomy has almost disappeared in some trauma centers. Splenectomy for cancer staging is infrequently performed suggesting that the indications for splenectomy continue to evolve. We evaluated a state database to assess a communitywide experience with splenic surgery. International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were used to determine the indication for splenic surgery. Indications for splenic surgery were listed as trauma (injury codes), medical (hematological diseases, neoplasms, or procedures in which the spleen might be removed contiguously like distal pancreatectomy), or incidental (noncontiguous procedures). Splenectomies for medical indications (n = 607, 43%) were more common than splenectomies for trauma (n = 518, 37%) or incidental splenectomies (n = 276, 20%). Splenectomy for medical reasons was associated with hematologic disease in 56 per cent, neoplastic disease in 34 per cent, and other diagnoses in 10 per cent of cases. Incidental splenectomies were most commonly associated with operations on the esophagus/stomach (32%) and colon (30%). Mortality rate and length of stay were greatest for incidental (14.4 +/- 0.9 days, 10.9% mortality) compared with trauma (11.0 +/- 0.5 days, 7.7% mortality) or medical (9.7 +/- 0.4 days, 4.8% mortality) splenectomies (all P < 0.05 versus incidental). Our results suggest that in the era of nonoperative management of splenic injuries, medical indications now represent the most common reason for splenectomy. As laparoscopic techniques for elective splenectomy become more common, the changing indication for splenectomy has important ramifications for surgical education and training.     

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.     

Laparoscopic subtotal splenectomy in hereditary spherocytosis

BACKGROUND: Clinical manifestations of hereditary spherocytosis can be controlled by splenectomy. The use of this procedure has been restricted due to concerns regarding exposure of patients to a lifelong risk of overwhelming infections. Subtotal splenectomy, which removes 85-90% of the enlarged spleen, is a logical alternative. In the first cases performed by laparoscopy we have chosen to preserve the upper pole. However, this technique showed some disadvantages, especially concerning the correct intraoperative evaluation of the splenic remnant volume. Therefore, we developed a new variant of the procedure by preserving the lower pole of the spleen. METHODS: Based on the authors' experience in laparoscopy (176 laparoscopic splenectomies), 10 laparoscopic subtotal splenectomies were performed in patients with hereditary microspherocytosis, preserving either the upper or the lower splenic pole. RESULTS: Patient age ranged between 5 and 35 years. The mean volume of the remnant spleen was 41.4 cm3. There were no complications, and no transfusions were needed. Follow-up for 1-30 months was available. CONCLUSIONS: Subtotal splenectomy appears to control hemolysis while maintaining splenic function. The laparoscopic approach is safe and effective and should be considered the procedure of choice in hereditary microspherocytosis. Laparoscopic subtotal splenectomy presents an advantage over open subtotal splenectomy, resulting in decreased blood loss, shorter hospital stay, no conversions, fewer operative and postoperative complications, and excellent remission rates. On the basis of our experience, the preservation of the lower pole of the spleen seems to be a first-line option for the optimal evaluation of the residual splenic mass.     

Laparoscopic Splenectomy for Idiopathic Thrombocytopenic Purpura: Outcome and Long-term Results

The technical feasibility of laparoscopic splenectomy (LS) has been recently established. However, data regarding the efficacy of the procedure with long-term follow-up of patients with idiopathic thrombocytopenic purpura (ITP) are scarce. The objective of this study was to determine retrospectively the immediate efficacy and the long-term results of a standardized laparoscopic procedure applied to patients with ITP refractory to medical treatment. Laparoscopic splenectomy was performed in 35 patients for ITP between May 1993 and May 1998. The lateral approach was used in the last 27 patients. Data were recorded retrospectively on that group. Twenty-six patients (96%) underwent successful LS. Mean operative time for the laparoscopic procedure was 90 minutes. There were no postoperative deaths. Postoperative complications developed in three patients. Thrombocytopenia resolved after surgery in 93% of patients, but 7 patients (25%) experienced relapse during a mean 28-month follow-up. At present no patient needs medical therapy to maintain a normal platelet count. Laparoscopic splenectomy is feasible and safe in patients with ITP. Long-term results of LS for ITP are comparable to those achieved with open splenectomy.     

Splenosis in a port site after laparoscopic splenectomy

Splenosis, the autotransplantation of splenic tissue, is most commonly seen after traumatic splenic rupture and splenectomy. It also can occur during embryonic development. Intraperitoneal, intrathoracic, and retroperitoneal sites have been reported. Although the presence of the splenic tissue often is asymptomatic and an incidental finding, it may present with pain or be confused with various pathologies including neoplasia. Because most pediatric splenectomies are performed for hemolytic disorders, parenchymal disruption must be contained to avoid recurrent disease. We present a case in which the devascularized spleen was contained in a bag and fragmented in situ. Splenosis developed in the retrieval port site after laparoscopic splenectomy and cholecystectomy. Port-site splenosis needs to be considered in the differential diagnosis of port-site pain and a palpable nodule postsplenectomy.     

Splenic retrieval after laparoscopic splenectomy: a new bag

BACKGROUND: Laparoscopic splenectomy has become the gold-standard surgical approach for patients undergoing elective splenectomy. Little data exist concerning the technical difficulties of splenic retrieval. When the spleen is large, popular commercial retrieval bags are often too small to facilitate removal. The aim of this study was to compare our clinical experience utilizing two different retrieval bags, the Endocatch II (Autosuture, London, UK) and the developing E200 (Espiner Ltd., Bristol, UK). MATERIALS AND METHODS: We performed a retrospective review of all laparoscopic splenectomies performed at Hull Royal Infirmary, Kingston upon Hull, from March 1997 to July 2003. Patient demographics, morbidity, mortality, and clinical outcome had been entered prospectively into a database. Two patient groups were examined, depending on the type of retrieval bag utilized. Complications and instrument failure during splenic retrieval were analysed. RESULTS: A total of 83 laparoscopic splenectomies were performed. No retrieval bag was used in 8 cases (10%). The Endocatch retrieval bag was used for 45 (60%) patients and the E200 for 30 (40%) patients. The mean operative time for the former group was 65 minutes (range, 50-127 minutes) and for the latter, 120 minutes (range, 80-180 minutes) (P < 0.05). Bag-related complications were 2 (4%) perforations and 2 (4%) failures to deploy while using the Endocatch bag. CONCLUSION: The Endocatch bag is easy to deploy but is associated with perforation and cannot be used for large spleens. The E200 bag is more useful for large spleens but is associated with prolonged operative time due to poor maneuverability. Improved technology is still required.     

Steep learning curve of laparoscopic splenectomy

BACKGROUND AND PURPOSE: In 1992, Ochsner Foundation Hospital was among the first institutions in which laparoscopic splenectomy was performed. The aim of this study is to review our experience and discuss the lessons learned. METHODS: A retrospective review of 33 cases of laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP) (N = 22), autoimmune hemolytic anemia (AIHA) (5), thrombocytopenic purpura (TTP) (2), and other disorders (4) at Ochsner Foundation Hospital between 1992 and 1999 was conducted. Several measures, including rates of conversion to open splenectomy, were recorded and analyzed. RESULTS: Of the 33 cases, 26 (79%) were completed laparoscopically. Four were converted to an open procedure secondary to bleeding and three secondary to difficulty in dissection. Six conversions to open surgery were necessary during the first eight laparoscopic splenectomies and only one during our last 25 cases. Two patients required reoperations for bleeding. The average hospital stay after laparoscopic splenectomy was 2.3 days; eight patients stayed only 1 day. All of the TTP patients, 86% of the patients with ITP, and 40% of those with AIHA responded well to splenectomy. CONCLUSION: Laparoscopic splenectomy is a safe although complex procedure. Bleeding is the major complication but has been less common with experience. Even with today's technology, very large spleens are still extremely difficult to remove. With the short recovery and ready acceptance of patients and physicians, this technique is being used with increasing frequency. A significant learning curve exists for the safe completion of this challenging procedure.