腹腔镜脾切除术的临床应用

目的 探讨腹腔镜脾切除术（ＬＳ）的安全性和有效性。方法 从１９９６年４月至１９９９年７月,进行了１３例ＬＳ,其中１２例为原发性或继发性脾功能亢进,１例为脾囊肿,结果 １３例ＬＳ全部完成,无一例需中转行开腹手术,平均手术时间３．２小时,平均失血３８０ｍｌ。１例术后次日需再次腹腔镜探查,清除脾窝积血,平均术后住院６．２天,结论 ＬＳ安全,有效,切实可行,适用于脾体积正常至中度肿大有脾切除指征的血液疾病     

Experience with laparoscopic splenectomy

BACKGROUND/PURPOSE: The laparoscopic splenectomy (LS) often is adopted to treat children affected by hematologic diseases. Many of the pitfalls of LS are related to the 2 steps-dissection and extraction. Although various methods have been adopted, the conversion rate still is too high during the learning curve period. The authors analyse their experience in 54 laparoscopic splenectomies performed by their teams in 3 European countries. METHODS: From 1995 to 1999, 54 children underwent laparoscopic splenectomy, 4 of whom also underwent a concomitant cholecystectomy. There were 29 girls and 25 boys with ages ranging between 4 and 19 years (median, 8.1 years). All patients underwent an elective laparoscopic splenectomy: Thirty children had hereditary spherocytosis, 13 had an idiopathic thrombocytopenic purpura, 10 were affected by a beta thalassemia, and 1 child had sickle cell disease. RESULTS: Mean operating time was 140 minutes (range, 100 to 250 minutes). Hospital stay ranged from 2 to 6 days (median, 3 days). In 7 patients the spleen was removed through a 7-cm minilaparotomy; in another 46 cases the spleen was captured into an extraction bag, fragmented, and then removed through the umbilical or left orifice. There was one conversion to open surgery because of a camera failure during the operation. CONCLUSIONS: On the basis of our experience we believe that the operating time of LS is still too long compared with open surgery, and the extraction phase still not simple enough. A perfect control of hemostasis is fundamental because severe complications can arise from even a slight bleeding episode. It also is very important to search for and remove any accessory spleens. In our series this occurred in 7 patients, one of whom had 3 accessory spleens. The laparoscopic approach is today a good alternative to open splenectomy.     

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.     

脾叶动脉相关的腹腔镜下脾脏大体解剖的临床应用研究

目的:腹腔镜下对与脾叶动脉相关的脾脏大体解剖观察,研究腹腔镜脾切除术(LS)时脾蒂血管的最佳处理方式,并探讨腹腔镜治疗部分性脾栓塞术脾脏疾病的可行性。方法:对30例完全腹腔镜脾切除时对脾切迹分布、脾叶动脉阻断后脾供血界面变化、脾叶动脉处理方式进行归纳分析。结果:30例LS观察脾切迹分布:脾前缘切迹一个6例,占20%;二个13例,占43.3%;三个11例,占36.7%。脾叶动脉阻断后脾供血界面:分界清晰28例,占93.3%;分界模糊2例,占6.7%。界面分布在脾切迹所在平面或其延长线上,而与之相对的脾门区基本无二级血管,为脾叶动脉血管间隙。LS需要结扎、夹闭的脾叶动脉数:二支19例,占63.3%;三支7例,占23.3%;四支4例,占13.3%。腹腔镜下脾蒂血管处理方法:电凝+超声刀分离、钛夹+线结扎脾叶动脉23例,占76.7%;超声刀分离+Endo-G IA 6例,占20%;超声刀分离、线结扎+L igaSure 1例,占3.3%。30例LS中无术中凶险出血,无术中副损伤,无中转开腹。结论:LS时用电凝+超声刀分离、钛夹+线结扎脾叶动脉的“二级脾蒂离断术”处理脾蒂血管安全可靠,更符合我国医疗消费水平。应用腹腔镜行脾脏叶动脉或段动脉结扎,对临床上需要行部分性脾栓塞术(PSE)疾病的治疗将是一种新的微创治疗方法。     

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.     

腹腔镜脾切除术44例临床分析

目的：总结腹腔镜脾切除术的经验体会。方法：2006年9月至2009年10月行腹腔镜脾切除术44例,其中外伤性脾破裂出血6例,特发性血小板减少性紫癜3例,自身免疫性溶血性贫血1例,脾囊肿4例,脾血管瘤2例,脾淋巴管瘤1例,脾错构瘤2例,肝硬化门脉高压脾功能亢进25例。均采用二级脾蒂离断法。结果：43例成功完成腹腔镜手术,1例行开腹手术。手术时间55~240min,平均（126.40±52.43）min,术中出血30~1 000ml,平均（221.7±214.43）ml,术后住院5~15d,平均6.5d,1例脾错构瘤由于术后短时间引流量多,引流液色红而再次行腹腔镜探查,发现为取脾时意外撕裂大网膜导致出血,腹腔镜下成功止血。术后无死亡病例。结论：腹腔镜二级脾蒂离断法脾切除术安全、可行、微创、经济。     

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.     

Simple method of laparoscopic splenectomy

Background  Although laparoscopic splenectomy was introduced in 1991, it has not become a standard procedure for splenectomy like laparoscopic cholecystectomy for gallstone disease. The reasons for this may include difficulty in grasping the spleen and difficulty with controlling hemorrhage. Here we present a simple method of laparoscopic splenectomy. Methods  We performed laparoscopic splenectomy in 46 patients from 1994 to 2006. Our procedure had four main features: (1) adoption of a lateral position so that gravity assists with the spleen, (2) exposure of the operative field using two cherry dissectors, (3) only dividing the upper part of the gastrosplenic ligament, and (4) stapling the splenic hilus together with the lower part of the gastrosplenic ligament. Results  Among 46 patients undergoing laparoscopic splenectomy, none of them were converted to open splenectomy. Three patients had postoperative intraperitoneal bleeding from the stapled stump of the splenic artery. In 28 patients during the most recent 3 years, the mean operating time was 71 min and only one patient had postoperative bleeding (hemostasis was achieved laparoscopically). Conclusion  Exposure of the operating field using cherry dissector and stapling of the splenic hilus together with the lower part of the gastrosplenic ligament are key points of our method of laparoscopic splenectomy.     

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP)

Background: Although the short-term benefits of laparoscopic splenectomy (LS) have been well documented, long-term follow-up data of patients who have undergone LS for ITP are scarce. We report our long-term follow-up data in patients who underwent LS for idiopathic thrombocytopenic purpura (ITP). Methods: Data were obtained from a prospectively collected computer database of 52 patients who underwent LS between October 1992 and December 2000 for medically refractory ITP. Patients and their referring hematologist were contacted, and follow-up information was obtained for 45 patients. Results: Fifty-two patients (27 women and 25 men) underwent LS for ITP. Median operative time was 160 min (range, 70–335); and median blood loss was 100 cc (range, 20–1500). There were seven cases of intraoperative hemorrhage (13.7%), resulting in one conversion. A second case was converted due to inadequate working space in a patient with a 26-cm spleen. Accessory spleens were found in 17 patients (32.7%). Postoperative complications occurred in three patients (5.9%). There were no deaths. Median length of hospital stay was 2 days (range, 1–12). Follow-up data were obtained in 45 patients (86.5%), with a median follow-up of 51 months. Six patients did not respond to surgery initially, and another two patients developed recurrent disease, for a remission rate of 82.2%. Nine patients underwent a damaged red blood cell scan. This group included the two patients who suffered recurrences. A positive scan was obtained in three patients (33%), one of whom was a patient with recurrent disease. This patient underwent an uneventful laparoscopic excision of residual splenic tissue but continues to require intermittent steroids to maintain platelet counts. The two other patients with a positive scan remain in remission. Conclusions: Laparoscopic splenectomy for ITP is safe and associated with low morbidity and a short hospital stay. Long-term follow-up showed that remission rates of ITP following LS are comparable to those reported in the literature on open surgery.     

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.     

经脐单孔腹腔镜下二级脾蒂离断法行脾切除的临床应用

目的:探讨经脐单孔腹腔镜下二级脾蒂离断法行脾切除的临床应用价值。方法:回顾分析2012年6月至2013年8月为30例患者行腹腔镜下二级脾蒂离断法脾切除术的临床资料。将患者分为单孔腹腔镜组与三孔腹腔镜组,对比分析两组患者术中、术后情况。结果:术后无严重并发症发生。单孔腹腔镜组2例中转单手辅助腹腔镜手术;13例门静脉高压性脾功能亢进患者加行腹腔镜胃底贲门周围血管离断术,发现副脾3例,并予以切除。三孔组5例门静脉高压性脾功能亢进患者加行腹腔镜胃底贲门周围血管离断术,发现副脾1例,并予以切除。单孔组手术时间略长于三孔组,差异有统计学意义(P<0.05);术后镇痛时间、术后排气时间及出院时间单孔组明显短于三孔组,差异有统计学意义(P<0.05);两组患者术中出血量差异无统计学意义(P>0.05)。术后患者均康复出院,随访2~13个月,无不适症状。结论:经脐单孔腹腔镜下二级脾蒂离断法行脾切除术由腹腔镜技术经验丰富的团队开展是安全、可行的,具有患者创伤小、术后疼痛轻、康复快等优点,手术切口微小,美观效果较好。     

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.     

A cause for conversion of laparoscopic splenectomy: splenic candidiasis

Laparoscopic splenectomy (LS) is now considered the procedure of choice for removal of the spleen in several hematologic and traumatic splenic conditions. Perisplenitis is still considered a relative contraindication. We report a rare case of isolated splenic candidiasis treated by laparoscopic splenectomy. The technical challenges of the laparoscopic approach in cases of perisplenitis are outlined. Because of dense adhesions to the diaphragm, the LS was converted to open splenectomy, and the procedure was completed through a small subcostal incision. This case report suggests the need for and effectiveness of splenectomy in patients whose fungal infection is suspected to be localized to the spleen. Laparoscopic removal of the spleen in these cases is very difficult to accomplish because of the risk for diaphragm injuries and the technical problems encountered.     

Laparoscopic splenectomy

Background: Intraoperative bleeding is the main complication and main cause of conversion to open surgery during laparoscopic splenectomy (LS). We present the advantages of the lateral approach and the use of the ultrasonic shears (US) for achieving a safer vascular control. Methods: We have performed a total of 48 LS using several approaches. In our initial experience 10 patients underwent surgery with an anterior approach. In the second series of 18 patients, we used a manually assisted procedure. In the last 20 patients, we employed a technique with a full lateral position. Only three ports have been used. The major part of the dissection was conducted from behind, thus allowing a safer vascular control. The division of short gastric vessels and lower pole vessels was performed using US. The main vascular pedicle was stapled. The spleen was removed through a short Pfannenstiel incision. There were 9 males and 11 females with a mean age of 36 years (range, 18–71 years). Fourteen had immune thrombocytopenic purpura (ITP); two had an HIV-infection-related purpura; two had an autoimmune hemolytic anemia; and two had a spherocytosis. Results: All the 20 LS were completed. The average splenic weight was 274 g (range, 162–1,400 g). In all but one patient, the intraoperative blood loss was less than 60 ml, and was none in six patients (average, 51 ml). In our initial series of 10 patients surgically treated with an anterior approach, the average blood loss was 180 ml, and it was 230 ml in the series of hand-assisted procedures. The average operative time was 127 min (range, 70–220 min), including the time required by the change of position and the Pfannenstiel incision. There was no mortality. All but one patient had an uneventful postoperative course. The HIV-infected patient had a severe postoperative pancreatitis. In those patients with an uncomplicated course, the average postoperative stay was 4.3 days (range, 2–8 days). Conclusions: The lateral position with a posterior approach to splenic vessels allows for safe vascular control. The use of US results in a gain of time and safety. The average intraoperative bleeding of this series is much lower than that observed in our previous experience and in other published series.     

Posterolateral approach

Laparoscopic splenectomy (LS) is effective and technically feasible for treating various hematological diseases, especially idiopathic thrombocytopenic purpura (ITP). An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is often difficult. A total of 13 patients with ITP underwent elective laparoscopic splenectomy. We utilized a laparoscopic posterolateral approach involving dissection of the suspensory ligaments at the lower pole, then dissection and division of the posterolateral attachments, followed by the dissection and ligation of all splenic branches near the splenic parenchyma. This procedure was completed in 11 of our 13 patients and converted to open surgery in the other two patients. Mean operative time was 3 h; mean postoperative stay was 3 days. No blood transfusion was required, and no complications were noted in the postoperative period. The posterolateral approach provides better visualization and control of branches of the splenic vein and artery in the splenic hilum. It also permits visualization and control of surgical hemorrhage through the operating ports. Received: 24 January 1997/Accepted: 28 October 1997     

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 in pediatric patients with hematologic diseases.

OBJECTIVE: The aim of this study was to evaluate our experience with laparoscopic splenectomy in pediatric patients with hematologic diseases. METHODS: A retrospective chart review was performed to analyze the following: indication for splenectomy, pre- and peri-operative management, surgical technique, complications, duration of hospitalization, and outcome. RESULTS: Eleven patients underwent laparoscopic splenectomy for the following indications: recurrent thrombocytopenia (<10,000) in seven with chronic immune thrombocytopenic purpura; anemia in two with hereditary spherocytosis; and hypersplenism in one and recurrent splenic sequestration in another with homozygous hemoglobin S. The six girls and five boys had a median age of 7 years. The median operative time was 180 minutes, and the median hospitalization was 72 hours. Among the patients with immune thrombocytopenic purpura (median platelet count, 153,000), those patients (n=3) with platelet counts of <100,000 did not suffer any bleeding complications. The patient with hypersplenism and homozygous hemoglobin S required a small incision in the left lower quadrant to facilitate removal of a 558-gram spleen. This patient also underwent cholecystectomy for cholelithiasis. The operative time was 295 minutes, and he was hospitalized for 5 days because of atelectasis. CONCLUSIONS: Laparoscopic splenectomy is a safe and effective procedure in children with hematological disorders.     

脾破裂手助腹腔镜切除术的应用

目的:探讨手助腹腔镜技术在脾破裂切除术中的应用。方法:用手助腹腔镜技术为15例外伤性脾破裂患者行脾切除术。结果:14例顺利完成手术,1例术中大出血中转开腹,平均手术时间105min,术中平均失血110ml,平均住院6.5d。结论:手助腹腔镜技术治疗外伤性脾破裂是安全可行的,适用于无脑、胸损伤,血液动力学稳定的患者。     

超声刀在腹腔镜脾切除术中的临床应用

目的:探讨腹腔镜结合超声刀在脾切除术中的临床应用价值。方法:应用腹腔镜结合超声刀行脾切除12例,其中脾亢4例,外伤脾7例,脾肿瘤1例,均在全麻下实施腹腔镜手术。结果:12例手术均获成功,手术平均时间150m in。无严重并发症发生,仅1例术后2周发生脾窝积液并感染,经手术引流痊愈。结论:腹腔镜结合超声刀行脾切除术具有较高的实用价值,在严格掌握手术适应证的基础上,腹腔镜行中等肿大以下脾切除术是可行的。