Laparoscopic splenectomy: an evolving technique

Background: The success of laparoscopic cholecystectomy has favored the application of this technique in abdominal surgery. Laparoscopic splenectomy (LS) suffers from several technical problems for mobilization and manipulation of a solid organ. Lateral approach has been proposed as an alternative to the anterior approach which facilitates LS. The aim of this paper is to compare the results of LS using and anterior or lateral approach. Methods: Between February 1993 and May 1995, 27 LS were performed (group I, Ant-LS, n: 10; group II, Lat-SL, n: 17). LS was indicated in 19 patients for treatment of an idiopathic purpura, for spherocytosis in four; for AIDS-related thrombocytopenia in two; and for autoimmune anemia and leucopenia in two. Gallstones were associated in two cases and an ovarian cyst in another. Results: LS was completed in 8 patients of group I (80%) and 17 of group II (100%). Operative time (236±21 min vs 159±71 min p<0.003), number of trocars (4.5±0.5 vs 4±0.5, p<0.02), transfusion requirements (60 vs 17%, p<0.04) and mean stay (6.5±3.6 days vs 4±2 days, p<0.05) were significantly lower in the group of LS with a lateral approach. Conclusions: The lateral approach significantly facilitates the performance of LS compared with the anterior approach.Presented as a free paper in the 4th Congress of the EAES, Luxembourg, 14–17 June 1995     

Laparoscopic splenectomy and nephrectomy in a rat model

Background: In experimental studies on the effects of laparoscopic procedures on tumor biology, a localized tumor model is desirable. The spleen and the kidney are preferable, because these organs are amenable to tumor placement and subsequent removal. This study describes the technique of laparoscopic splenectomy and nephrectomy in the rat model. Methods: Pneumoperitoneum was established by CO₂ insufflation. Laparoscopic splenectomy involved two-handed dissection, intracorporeal ligation, and division of gastrosplenic attachments and hilar and short gastric vessels. Laparoscopic nephrectomy was done by intracorporeal ligation and division of the renal vessels and the ureter after mobilization of the kidney. Results: Laparoscopic splenectomy was performed in six rats; laparoscopic nephrectomy was done in six rats. Operative time ranged from 45 to 90 min for splenectomy and from 40 to 65 min for nephrectomy. Postoperatively, two rats died from hemorrhage. Necropsy of the rats after 10 days revealed adhesion in three rats after splenectomy and in four rats after nephrectomy. Inflammatory processes were found around the silk ligatures in all rats after splenectomy; in two rats wound infections occurred at the port sites. Conclusions: Laparoscopic splenectomy and nephrectomy in the rat proved technically feasible and may provide new localized tumor models suitable to be used in further studies on the oncological effects of laparoscopic surgery.     

腹腔镜脾切除术十年经验总结

目的 总结10年来行腹腔镜脾切除术(LS)的临床经验,探讨LS的安全性和有效性.方法 从1996年4月至2006年3月连续进行了135例LS,119例为原发性和继发性脾功能亢进,16例为其他脾疾病,其中48例为巨脾.结果 135例LS中因出血转行开腹脾切除术3例(2.2%),1例术后5 h需作小切口开腹止血,3例术后8～18 h需再次腹腔镜探查和清除脾窝积血.平均手术时间2.3 h,平均失血160 ml,平均术后住院6.5 d.结论 LS安全、有效、切实可行,适用于有脾切除指征的原发性和继发性脾功能亢进或其他脾疾病.     

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目的探讨腹腔镜脾切除术(laparoscopic splenectomy，LS)和腹腔镜辅助脾切除术(laparoscopic assisted splenectomy，LAS)的优缺点。方法1994～2003年共实施脾切除术43例，其中采用LAS行脾切除术13例，完全在腹腔镜下行脾切除术30例，切除副牌6例，4例同时行腹腔镜胆囊切除术。结果手术均获成功，LS术后切口感染1例，并发DIC 1例，平均手术时间160min，术中失血平均120mL，术后平均住院5．4d。LAS平均手术时间132min，术中平均失血90mL，术后平均住院8．6d。结论LS和LAS均安全可行，LAS手术时间短，术中出血少，但病人住院时间长。LS费时费事，术中出血多。     

Laparoscopic splenectomy: a selected retrospective review

Previous investigators have suggested that laparoscopic splenectomy should be the procedure of choice for the treatment of benign hematologic disorders unresponsive to medical therapy. To evaluate the safety and utility of laparoscopic splenectomy for a variety of splenic disorders, we reviewed our collective experience at 2 institutions. We studied our 8-year experience by retrospective chart review. Patient demographic data, splenic pathology, intraoperative events, concomitant procedures, and all adverse perioperative events were recorded. A total of 131 patients had laparoscopic splenectomy, and there were 8 conversions to open surgery. Pathology included 63 with idiopathic thrombocytopenic purpura (ITP), 23 malignancies, 12 thrombotic thrombocytopenic purpura (TTP), 10 autoimmune hemolytic anemia (AIHA), and 23 others. Accessory spleens were noted in 21 patients (16%). Concomitant surgical procedures included 12 hepatic biopsies, 4 distal pancreatectomies, 4 cholecystectomies, and 7 others. Mean operative time was 170 minutes. There were 16 major complications in 16 patients and 2 deaths. Median postoperative length of stay was 3 days. Conversions, due mostly to bleeding, are related to splenic pathology and medical comorbidity and are not temporally related to surgical experience (learning curve). The morbidity, mortality, and conversion rates were low. Laparoscopic splenectomy permits an appropriate abdominal exploration and is associated with a short hospital stay. It is the procedure of choice for most indications for splenectomy.     

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.     

腹腔镜脾切除术16例报告

目的:总结腹腔镜脾切除术的手术经验.方法:回顾分析2004~2010年为16例患者施行腹腔镜脾切除术的临床资料.患者取半右侧卧位,术中可灵活调整;用钝头器械显露术野,游离脾周韧带、处理脾蒂时灵活应用多种器械,用宫腔吸引刮匙协助取出标本.结果:14例手术获得成功,2例中转开腹,手术时间平均(124±52) min,术中出...     

Laparoscopic splenectomy: size matters

BACKGROUND: Laparoscopic surgery is arguably the treatment of choice for patients undergoing elective splenectomy; however, for those patients with massive splenomegaly, laparoscopic surgery may prove difficult. PATIENTS AND METHODS: 6 years' experience of elective splenectomy was reviewed, in particular looking at the outcome of laparoscopic splenectomy in relation to the degree of splenomegaly. RESULTS: The conversion rate for laparoscopic splenectomy on patients with spleens weighing less than 1 kg was 0% whereas the conversion rate for those with spleens weighing more than 1 kg was 60%. In addition, a good correlation between both operative time and intra-operative blood loss in relation to splenic weight was observed. Open splenectomy on patients with spleens weighing more than 1 kg reduced the operative time and intra-operative blood loss without affecting hospital stay. CONCLUSIONS: Laparoscopic splenectomy is the method of choice for elective splenectomy in patients with splenic weight estimated to be < 1 kg; however, the operation takes longer, there is a high risk of conversion and there is an increase in blood loss/morbidity associated with massive splenomegaly (spleen > 1 kg) if splenectomy is attempted laparoscopically.     

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 in children: experience in a single institution

PURPOSE: To assess the safety and effectiveness of laparoscopic splenectomy in children. MATERIALS AND METHODS: Hospital records of 63 patients who underwent laparoscopic splenectomy between 1998 and 2005 were reviewed retrospectively. In 16 patients concomitant cholecystectomy was performed. All procedures were performed by the same surgeon. The indications for splenectomy were hereditary spherocytosis (n = 35), idiopathic thrombocytopenic purpura (n = 22), autoimmune hemolytic anemia (n = 3), and other diseases (n = 3). Details of operative technique were reviewed and their implications on intraoperative complications are analyzed. The postoperative course and long-term results were assessed. RESULTS: There were 35 girls and 28 boys, whose average age was 11.3 years (range, 3.9-19.5 years). There were 7 conversions, mainly at the beginning of the series. A mild degree of intraoperative bleeding was observed in 23 (36.5%) cases. In two cases (3%) severe bleeding led to conversion. Postoperatively, 1 patient required blood transfusion and 1 patient had signs of mild general infection that was treated conservatively. There was no mortality in this series. The mean operation time was 134 minutes for splenectomy and 174 minutes for splenectomy and cholecystectomy. Operative time did not significantly diminish at the end of the 7-year study period. CONCLUSION: Laparoscopic splenectomy in children performed by an experienced team proved to be safe and effective with minimal side effects and should be recommended as a procedure of choice in children who require splenectomy.     

Laparoscopic colon surgery in a rat model

The effects of laparoscopic colectomy on immune function require further study. Because the rat has been widely used to investigate the immune system we studied the feasibility of laparoscopic sutured colon anastomoses in a rat model. We used a low-pressure CO₂ pneumoperitoneum, a 2.7-mm 30° wide-angle arthroscope and video system, and microotologic forceps and scissors to perform two-handed dissection and suturing of the rat colon. The procedures included laparoscopic division of the colon and colostomy (group A,n=3), laparoscopic closure of a colotomy (group B,n=4), and complete laparoscopic division and reanastomosis of the colon (group C,n=4). One anesthetic death occurred in group C. Necropsy performed 1–15 days postoperatively revealed no anastomotic leaks and two anastomotic strictures. Laparoscopic sutured colon anastomosis in the rat is feasible and may provide a new model for the physiologic study of laparoscopic colon surgery.     

Laparoscopic splenectomy in children

To determine the safety and efficiacy of laparoscopic splenectomy (LS) in children, a retrospective review of our preliminary experience using LS was compared to results in patients who previously underwent open splenectomy (OS). From July 1993 to January 1995, we performed eight LS procedures in six children with hereditary spherocytosis (HS) and two with immune thrombocytopenic purpura (ITP). Laparoscopic cholecystectomy was simultaneously done in one case with HS. There were 4 males and 4 females who ranged in age from 5 to 15 years—an average age of 8.8 years. Two cases in the early series required a counterincision because of bleeding. Eleven patients who previously underwent OS in our department were used to compare demographics, operative courses, and surgical outcomes. The ages, genders, diseases, body weights, and spleen weights were comparable between LS group and OS groups. The operative time for the LS group was statistically longer than for the OS group (226±24 min vs 101±8 min, P<0.001). The estimated blood loss in the LS group was similar to that of the OS group (100±39 ml vs 73±11 ml, P=0.97). There were no peri- or postoperative complications in two groups. The postoperative hospital stay of LS group was statistically shorter than that of the OS (6.8±0.6 days vs 10.4±0.5 days, P<0.001). LS provided better cosmesis and minimized trauma in children over OS. LS appears to be a safe and effective procedure in children, and is useful in the management of pediatric patients with HS or ITP.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Laparoscopic splenectomy through a lateral access

The investigation included 35 patients with diseases of blood and spleen pathology (30) and wounds and traumas of the abdomen with injuries of that organ (5), treated by laparoscopic splenectomy through a lateral access. The technique and stages of the operation and advantages of the lateral access are described. The laparoscopic splenectomy was shown to be possible in 90% of cases if patients were selected with special reference to the main disease, size and degree of pathological alterations in the spleen. An adequate approach to selections of patients with injuries of the organ allowed to make operations in more than a third of the patients and casualties. When using the lateral access laparoscopic splenectomy is thought to be more convenient, gives better visualization of the anatomical structures and reduces risk of injury of adjacent organs, thus resulting in less frequency of complications and conversions.     

Laparoscopic splenectomy using a wall-lifting procedure

A laparoscopic splenectomy using a hanger wall-lifting procedure is herein described. The patient is placed in the right lateral position. The left lower chest and left abdominal wall are then lifted by three wires in two directions, left laterally and vertical to the abdominal wall. The view of the operative field thus obtained is excellent. The lifting wires and bars do not hinder the movement of the forceps, since the angles of the instruments to approach the spleen are different from those of the wires. A laparoscopic splenectomy using this wall-lifting procedure avoids the usual complications associated with pneumoperitoneum while still being technically comparable to a procedure with pneumoperitoneum. Received: 7 October 1998/Accepted: 22 February 1999     

Laparoscopic splenectomy: ligasure versus EndoGIA: a comparative study

BACKGROUND: Laparoscopic splenectomy (LS) is considered the gold standard for the treatment of hematologic disease of the spleen. Intraoperative bleeding is the main complication and main cause of conversion during LS. In this paper, we present our experience with 112 LS procedures, comparing two different techniques and instruments for spleen dissection and hilar vascular control. METHODS: We have performed a total of 112 LS procedures in 9 years in two affiliated university hospitals. There were 48 males and 64 females (median age, 32.8 years). Indications were as follows: idiopathic thrombocytopenic purpura (ITP) in 42 patients, hereditary spherocitosis in 28, 6 with beta-talassemia, 1 with hemolitic anemia, 27 with lymphoma, 2 with leukemia, 3 with splenic cysts, and 3 PPT cases. Associated procedures were present in 25 cases (17 cholecystectomy and 4 liver/lymphnodal biopsies + lysis of adhesions). Patients were divided in two groups according to the method of dissection and hilar section (group 1, endostapler + monopolar coagulation with 38 patients; group 2, the Ligasure Vessel Sealing System (Valleylab, Boulder, CO) with 74 patients). RESULTS: Groups were well matched according to age, indications, spleen sizes, and procedures associated. Conversion rates (10 cases, 9%; 5 in each group), postoperative hospital stay (median 4 days in each group), and intra- and postoperative complications were similar in the 2 groups without any mortality in each group, while intraoperative blood loss (loss of 100 mL in 55 patients in group 2, 78%; and in 21 patients in group 1, 52%), transfusion rates (8 patients in group 1 versus 4 patients in group 2), and operative mean time (150 minutes in group 1 versus 125 minutes in group 2) were minor in the Ligasure Vessel Sealing System group, with a statistical significance. CONCLUSIONS: The approach to spleen dissection and hilum section was safe and efficacy in each case, otherwise the use of Ligasure results in a gain of time. Furthermore the average intraoperative bleeding and average transfusion rates of this series were lower in group 2.     

内结扎法腹腔镜巨脾切除联合选择性贲门周围血管离断术

目的总结腹腔镜下内结扎法巨脾切除联合选择性贲门周围血管离断术的经验。方法采用丝线结扎结合超声刀或LigaSure，进行腹腔镜巨脾切除和选择性贲门周围血管离断术治疗门静脉高压症并发食管胃底静脉曲张6例。结果6例手术全部镜下顺利完成，术中出血量80-200ml，平均130ml，无输血，无中转开腹，手术时间150-210min平均190min。无并发症，术后5天恢复正常活动。术后随访3—10个月，平均8个月，无再发出血。结论应用内结扎法腹腔镜巨脾切除联合选择性贲门周围血管离断术治疗门静脉高压症安全有效，出血少，微创。