Splenectomy in haematologic diseases. Clinical indications and surgical technique

After the introduction of corticosteroids fifty years ago the indications for splenectomy in benign haematological diseases became more controversial, also due to the morbidity and mortality associated at that time with open splenectomy. The advent of minimally invasive techniques has provided safe procedures for removal of the spleen in cases of benign as well as malignant haematological disease. Laparoscopic splenectomy has been performed for spleens of normal size or larger size or weight. In this study the indications in haematological diseases and the results after splenectomy are analysed. From June 1998 to December 2004 107 patients with benign or malignant haematological disease were referred to our unit for splenectomy. Splenomegaly was defined as a spleen diameter > 15 cm and weight > 400 g and was present in 53% of cases in this series. Open splenectomy was carried out in 30 cases and laparoscopic splenectomy in 77. Operating time, blood loss, conversion rate, need for transfusion, complications, length of hospital stay and operative morbidity were analysed for both open and laparoscopic procedures. In the laparoscopic splenectomy group the outcomes after removal of spleens < 15 cm and > 15 cm were compared. Clinical results after splenectomy in haemolytic anaemia and idiopathic thrombocytopenic purpura are reported. In the open splenectomy group the spleens were larger and heavier, hence the operating time was greater than in the laparoscopic splenectomy group. The mean age of patients in the open group was 65 years as against 43 years in the laparoscopic group. Morbidity was 23% in the open group and 10% in the laparoscopic group. Mortality was nil in both groups. The overall conversion rate in the laparoscopic group was 2.6% owing to extensive adhesions and bleeding in 2 large spleens measuring > 27 cm and weighing > 2 kg (conversion rate for larger spleens: 6.2%). Spleens > 15 cm were associated with greater blood loss (p < 0.01), longer operating times and a longer hospital stay. No cases of overwhelming post-splenectomy infection were registered in either group. The healing rate for idiopathic thrombocytopenic purpura after splenectomy was 87%, while for haemolytic anaemia it was 100%. In this study splenomegaly was associated with malignant haematological disease occurring in patients aged 65 on average in whom an open splenectomy was generally carried out. Benign diseases occurred in patients aged 43 on average in whom laparoscopic splenectomy was the preferred procedure. Conversion rate, morbidity and length of hospital stay were comparable with those of other series. Laparoscopic splenectomy can be considered the gold standard procedure for benign disease in young patients and also as a safe procedure in selected cases of malignant haematological disease.     

101 laparoscopic splenectomies for the treatment of benign and malignant hematologic disorders

BACKGROUND: Laparoscopic splenectomy (LS) is the surgical approach of choice for patients with hematologic disorders requiring splenectomy. Patients with idiopathic thrombocytopenic purpura (ITP) have normal to slightly enlarged spleens and benefit the most from LS. METHODS: We reviewed the perioperative outcomes in 101 patients who underwent LS between May 1996 and December 2002. Patients were divided into three groups--ITP, other benign, and malignant hematologic disorders--and compared. RESULTS: The ITP patients (n = 48) had significantly smaller spleens and operative times compared with the other groups. Splenomegaly in the other benign (n = 23) and malignant hematologic disorders (n = 30) groups was responsible for higher open conversion rates and greater need for hand-assisted laparoscopic splenectomy (HALS). CONCLUSIONS: Laparoscopic splenectomy and HALS can be performed with good results for benign and malignant hematologic disorders. The benefits of HALS are similar to LS, so there should be a low threshold for HALS in patients with large spleens.     

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.     

Laparoscopic splenectomy: analysis of 60 consecutive cases

The purpose of the study was to analyze the results of 60 patients who were candidates for laparoscopic splenectomy. Over the period from May 1994 to May 2001, 60 patients were candidates for splenectomy. Laparoscopy was contraindicated in 3 cases because of ASA III and marked splenomegaly (2 cases) and previous gastric resection (1 case). The procedure was indicated for benign disease in 38 cases and for malignant disease in the remainder. Fifty-three procedures were completed laparoscopically (92.9%). Conversion proved necessary in 4 patients (6.7%) due to large incisional hernia, perisplenic abscess, bleeding of major splenic vessels at the hilum and marked splenomegaly (2 cases of lymphoma). The mean operative time was 200 min for the malignancies and 110 min for the benign conditions (P < 0.05). Major morbidity occurred in 5 cases (8.7%). No deaths were registered. The mean postoperative hospital stay was 7.5 days for patients with malignancies and 5.2 days for patients with benign disease (P < 0.05). Laparoscopic splenectomy was safe and effective in patients with benign disease, even in cases of marked splenomegaly. The morbidity rate was significantly higher in lymphoma patients than in patients with benign haematological disorders.     

Elective splenectomy in haematological disorders.

We report on 106 elective splenectomies performed for haematological disorders between March 1979 and January 1986. The most common indications were immune thrombocytopenic purpura (30 patients) and Hodgkin's disease (19 patients). However, staging laparotomy is no longer performed routinely for patients with Hodgkin's disease and the reasons for this are discussed. Other indications for splenectomy included splenic pain (13 patients), autoimmune haemolytic anaemia (12 patients), hereditary spherocytosis (11 patients) and hypersplenism (9 patients). The overall morbidity and mortality was 48% and 5% respectively. The most common postoperative complication was thrombocytosis (defined as a platelet count greater than 800 X 10(9)/l) and occurred in 26 patients. This review confirms that splenectomy continues to have an important role in the management of certain haematological disorders.     

Splenectomy for massive splenomegaly. Apropos of 36 cases

Thirty-six splenectomies for splenomegaly exceeding 1000 grams are reported. The enlargement of the spleen most often was related with a malignant disease (n = 32). Cytopenia was the main indication in 14 cases, and splenectomy was contemplated for diagnosis (n = 12), initial treatment (n = 6), or due to pain (n = 3) or spontaneous rupture (n = 1). Ten patients (27.8%) had an associated surgical treatment. One patient died postoperatively (2.8%) and 12 patients presented with 14 complications (33%) usually with a rapidly favorable evolution. In 11 of 12 cases (91.6%), the operation allowed establishing the diagnosis in cases of splenomegaly with an unknown origin. Lastly, it was always effective to relieve pain and in most cases improved cytopenia. The authors conclude that the patients with massive splenomegaly are improved by splenectomy, although it most often is merely a palliative treatment in cases of malignant hemopathy.     

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.     

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.     

Robotic Splenectomy: What is the Real Benefit?

Background

The laparoscopic approach to a difficult splenectomy requires a longer total operative time and is frequently associated with an increased risk of bleeding and a high conversion rate.

Methods

A total of 418 elective splenectomies were registered in the Department of General Surgery and Liver Transplantation of Fundeni Clinical Institute between January 1995 and June 2012, of which 299 splenectomies (212 laparoscopic and 77 robotic) were performed by a single surgical team and retrospectively documented. The effect of the learning curve and the relative complexity of each type of procedure were analyzed using the Minimally Invasive Splenectomy Score, which further allowed categorizing the splenectomies as simple or difficult. Statistical analyses using the CUSUM algorithm of the intra- and postoperative parameters of the laparoscopic and robotic approaches, for both the simple and the difficult splenectomies, were performed.

Results

The results of the statistical analyses clearly indicated that there was a learning curve effect for laparoscopic splenectomy but not for robotic splenectomy. When compared with the laparoscopic approach in difficult splenectomies, the robotic approach had a shorter total operative time (84.13 vs. 97.2 min), less blood loss (30.88 vs. 156.9 ml), and decreased risk of hemorrhagic complications during surgery.

Conclusions

Laparoscopic splenectomy remains the approach of choice for simple splenectomies in the surgical treatment for common indications. The robotic system is particularly beneficial in difficult splenectomies (i.e., partial splenectomy, splenectomy in liver cirrhosis, splenic tumors, or malignant hemopathies).     

Optimal teaching environment for laparoscopic splenectomy

BACKGROUND: Traditional surgical teaching depends on graduated acquisition of skill learned in residency. The introduction of minimal access techniques after residency training has created a new paradigm dependent on animate course experiences and limited preceptor training. The outcome of performance of a new skill "learned" in these settings has not been assessed. The purpose of this study was to test the benefit of an animate course compared with a precepted operating room experience in learning to perform a laparoscopic splenectomy. METHODS: All attending surgeons who had taken a 1-day course to learn laparoscopic splenectomy (n = 37) and those who had undergone an intraoperative preceptorship (in their hospital) by the lead author (n = 15) were polled to ascertain their previous experience with laparoscopy and with laparoscopic splenectomy since the intervention. The course included lectures, operative videos, and an animal lab. Statistical differences were measured using a t test. RESULTS: Thirty-two of the 37 (86.5%) taking the course and all 15 of the precepted surgeons responded. There was no difference between the groups regarding prior laparoscopic experience (P = 0.73), laparoscopic training during residency (P = 0.74), academic or private practice (P = 0.48), or follow-up since the intervention (P = 0.36). The participants graded the courses (1 to 5, 5 = excellent) at an average of 4.72. Fourteen of 15 precepted surgeons have performed laparoscopic splenectomy as compared with 2 of 32 taking courses (nonprecepted surgeons; P <0.0001). The number of laparoscopic splenectomies performed totaled 112 for precepted surgeons and 4 for nonprecepted surgeons (P = 0.0003). The nonprecepted surgeons performed significantly more open splenectomies than laparoscopic (95 versus 13 respectively, P = 0.02). Reasons quoted not to proceed with laparoscopic splenectomy included waiting for the perfect patient, concern of hilar management, and splenic size. CONCLUSION: Surgeons precepted in their own operating room performed a laparoscopic splenectomy more readily than those gaining experience from a course only (93% versus 6%, respectively) despite no difference in their preintervention experience and having the opportunity to do so. The expectation of the eventual performance of advanced laparoscopic techniques depends on a precepted experience.     

Laparoscopic subtotal splenectomy in the treatment of hereditary spherocytosis

Clinical manifestations of hereditary spherocytosis, the most common red blood cell membrane disorder, can be controlled by splenectomy. However, concerns regarding exposure of patients to a life long risk for overwhelming infections have restricted its use, especially ?n children. Subtotal splenectomy, as long as 80% to 90% of the enlarged spleen is removed, is a logical alternative. Subtotal splenectomy was effective ?n decreasing the hemolytic rate, while maintaining the phagocytic and immune function of the spleen. This surgical procedure should be considered ?n transfusion-dependent infants and children whit hereditary spherocytosis and ?n older patients whit erythrocyte membrane defects. Based on our experience ?n laparoscopy (120 laparoscopic splenectomies) and open subtotal splenectomy (5 cases) we performed 2 laparoscopic subtotal splenectomies in patients with hereditary microspherocytosis with good short term results. We have had no problem with blood loss and no transfusions were needed. The procedure can be performed safely and easily with all the traditional advantages of a minimally invasive approach. In order to evaluate the long term clinical benefit a minimal follow-up of 5 years is needed.     

Hand-assisted laparoscopic splenectomy versus open splenectomy for massive splenomegaly: 20-year experience at a Canadian centre

Background

Multiple techniques for splenectomy are now employed and include open, laparoscopic and hand-assisted laparoscopic splenectomy (HALS). Concerns regarding a purely laparoscopic splenectomy for massive splenomegaly (> 20 cm) arise from potentially longer operative times, higher conversion rates and increased blood loss. The HALS technique offers the potential advantages of laparoscopy, with the added safety of having the surgeon’s hand in the abdomen during the operation. In this study, we compared the HALS technique to standard open splenectomy for the management of massive splenomegaly.

Methods

We reviewed all splenectomies performed at 5 hospitals in the greater Vancouver area between 1988 and 2007 for multiple demographic and outcome measures. Open splenectomies were compared with HALS procedures for spleens larger than 20 cm. Splenectomy reports without data on spleen size were excluded from the analysis. We performed Student t tests and Pearson χ² statistical analyses.

Results

A total of 217 splenectomies were analyzed. Of these, 39 splenectomies were performed for spleens larger than 20 cm. We compared the open splenectomy group (19 patients) with the HALS group (20 patients). There was a 5% conversion rate in the HALS group. Estimated blood loss (375 mL v. 935 mL, p = 0.08) and the mean (and standard deviation [SD]) transfusion rates (0.0 [SD 0.0] units v. 0.8 [SD 1.7] units, p = 0.06) were lower in the HALS group. Length of stay in hospital was significantly shorter in the HALS group (4.2 v. 8.9 d, p = 0.001). Complication rates were similar in both groups.

Conclusion

Hand-assisted laparoscopic splenectomy is a safe and effective technique for the management of spleens larger than 20 cm. The technique results in shorter hospital stays, and it is a good alternative to open splenectomy when treating patients with massive splenomegaly.     

Laparoscopic splenectomy and lymph node biopsy for hematologic disorders.

OBJECTIVE: The authors audit the introduction of laparoscopic splenectomy and laparoscopic intra-abdominal lymph node biopsy and compare outcomes with a parallel cohort of patients undergoing open splenectomy. SUMMARY BACKGROUND DATA: Laparoscopic splenectomy was first reported in 1992. It was introduced into clinical practice at the Royal Brisbane Hospital in 1991. Between June 1991 and March 1994, 24 patients have undergone laparoscopic splenectomies and 23 patients have had laparoscopic intra-abdominal lymph node biopsies. METHODS: Laparoscopic splenectomy was performed using a four- or five-port technique. The splenic hilum was secured using a linear stapler cutter, and the spleen was removed after placing it in a laparoscopic bag. Lymph node biopsy was performed using a three- or four-port technique, depending on the site and size of the lymphadenopathy. RESULTS: Laparoscopic splenectomy was completed in 22 patients (92%). Median hospital stay was 3 days (range 2-7 days) and morbidity occurred in two patients (8%). Lymph node biopsy was completed laparoscopically in 21 of 23 patients (91%), with morbidity in two cases (9%). Median hospital stay was 2 days (range 1-6 days), with a diagnostic accuracy of 90%. Comparison with open splenectomy revealed that the laparoscopic approach took significantly longer to perform (p = 0.0002), but resulted in a significantly shorter hospital stay (p = 0.0005). CONCLUSIONS: Both laparoscopic splenectomy and laparoscopic lymph node biopsy currently are used as the treatments of choice for hematologic disease in our institution.     

Laparoscopic splenectomy in the management of benign and malignant hematologic diseases.

OBJECTIVES: The use of laparoscopy to treat malignant hematological diseases is not completely accepted. Our aim was to analyze operative and postoperative results of laparoscopic splenectomy performed for benign versus malignant hematological disorders. METHODS: Between 1994 and 2003, 76 consecutive patients underwent laparoscopic splenectomy. The first 38 cases were performed by using an anterior approach, whereas in the remaining 38 cases a semilateral position was used. RESULTS: Baseline characteristics showed that patients with malignant diseases were significantly older (56.9 vs 32.6 years, P < 0.001). Seventy-two (94.7%) procedures were completed laparoscopically. Conversion was required in 4 cases (5.2%). Mean operative time was 138.5 minutes for benign and 151.0 minutes for malignant diseases, (P > 0.05, ns). The hand-assisted technique was used in 3 patients with massive splenomegaly. Pathologic features showed that spleen volume was higher in patients with malignant diseases (mean interpole diameter 18.1 cm vs 13.7 cm, P < 0.001). Massive splenomegaly (interpole diameter over 20 cm, weight over 1000 g) was present in 13 patients (17.1%); 9 had malignant diseases. Overall perioperative mortality was 1.3% and major postoperative complications occurred in 6 patients (7.8%). Postoperative splenoportal partial thrombosis was identified in 9.7% of patients. CONCLUSIONS: Laparoscopic splenectomy is a well-accepted, less-invasive procedure for hematological disorders. Neoplastic diseases or splenomegaly, or both, do not seem to limit the indications for a minimally invasive approach after the learning curve.     

Laparoscopic splenectomy in patients with hematologic malignancies

BACKGROUND: Although laparoscopic splenectomy (LS) for benign hematologic disease is well accepted, its role in hematologic malignancies is not clearly defined. This study examined the efficacy and feasibility of LS for hematologic malignancies. METHODS: Records were reviewed from patients who underwent LS at two university hospitals. Charts from 77 open splenectomies for malignancy (OM) during the same period were also reviewed. RESULTS: Fifty-three patients underwent LS, 22 for hematologic malignancies (LM) and 31 for benign hematologic disorders (LB). Median splenic weight was greater in the LM group (930 g) than in the LB group (164 g, P = 0.001). LM was associated with longer operations and greater blood loss than was LB. LM had a 41% conversion rate. Morbidity, mortality, and transfusion rates were similar. Median hospital stay was shorter for LM (4 days) than for OM (6 days, P = 0.001). CONCLUSIONS: LS is feasible in hematologic malignancies but is associated with increased operative time and blood loss and a high conversion rate. Morbidity and mortality, however, was similar. Shorter hospital stays for LM compared with OM may translate into earlier recovery and initiation of antineoplastic therapy.     

Laparoscopic splenectomy: a surgeon’s experience of 302 patients with analysis of postoperative complications

Background

This study aimed to evaluate the operative and clinical outcomes in a series of 302 consecutive laparoscopic splenectomies and to analyze the risk factors of postoperative complications.

Methods

The study retrospectively reviewed 302 consecutive patients who underwent laparoscopic splenectomy. The patients were classified into three disease groups: benign spleen-related disease (group 1, n = 196), malignant spleen-related disease (group 2, n = 42), and portal hypertension (group 3, n = 64). The three groups were compared in terms of perioperative data. Postoperative complications were classified into three complication groups according to the Clavien–Dindo Classification of Surgical Complications and Severity: no complication, mild complications, and severe complications. Multivariate logistic regression was used to analyze the independent risk factors of postoperative complications.

Results

The patients in group 1 were younger and had a higher body mass index, a lower American Society of Anesthesiology (ASA) score, and a smaller spleen than the patients in groups 2 and 3. Fewer patients in group 1 required hand-port assistance than in the other two groups. Group 1 had shorter operative times, required fewer transfusions, presented a lower incidence of complications, and had shorter postoperative stays than groups 2 and 3. In the analysis of complications, high ASA score was an independent risk factor for the occurrence of complications. Both high ASA score and larger spleen size were independent risk factors for the occurrence of severe complications. Compared with total laparoscopic splenectomy, the data including the hand-assisted cases showed a reduction in odds ratio for both the occurrence of complications and the occurrence of severe complications.

Conclusions

The treatment of malignant spleen-related disease and portal hypertension with laparoscopic splenectomy is more challenging than the treatment of benign disease. High ASA score is an independent risk factor for the occurrence of complications, whereas high ASA score and larger spleen size are both independent risk factors for the occurrence of severe complications. The appropriate introduction of the hand-assisted technique may facilitate the laparoscopic procedure and reduce postoperative complications.     

Laparoscopic splenectomy

Background: Laparoscopic splenectomy is currently the procedure of choice for elective splenectomy. This study reviews the initial 100 laparoscopic splenectomies completed at the Cleveland Clinic Foundation. Methods: A retrospective review of elective laparoscopic splenectomy was performed to assess clinical outcomes at the Cleveland Clinic Foundation. Patient demographics, preoperative diagnoses, operative characteristics, morbidity, and mortality were evaluated. Results: Of the 169 elective splenectomies completed over a 4-year period from 1995 to 1999, 100 were attempted laparoscopically. The proportions of all splenectomies attempted laparoscopically by year were 17%, 38%, 75%, and 72%. Nearly 70% of splenectomies were performed for idiopathic thrombocytopenic purpura or malignancy. Overall, the mean blood loss was 181 ml, and the mean operative time was 170 min. Splenomegaly occurred in 31% of the patients and accounted for longer operative times. Three patients required conversion to an open procedure. Postoperative complications were seen in 13% of the patients. One patient died in the postoperative period from staphylococcal sepsis, giving a mortality rate of 1%. Conclusions: Laparoscopic splenectomy currently is the procedure of choice for elective splenectomy at our institution. As compared with traditional open splenectomy, laparoscopic splenectomy results in minimal morbidity even in the setting of splenomegaly.     

Laparoscopic splenectomy: a personal series of 140 consecutive cases

Introduction

Laparoscopic splenectomy has emerged as a safe and effective treatment for a variety of haematological conditions. The objective was to review the results from a large personal series from the perspective of outcomes according to operative time, conversion to open operation, complications and mortality. The application of laparoscopic splenectomy to cases of splenomegaly without hand assistance is examined.

Patients and Methods

A retrospective review of 140 patients undergoing laparoscopic splenectomy at a single university hospital by one surgeon during 1994-2006. Case notes were reviewed and data collected on operative time, conversion to open procedure, morbidity and mortality. Particular reference was made towards the results of cases of splenomegaly.

Results

In total 140 laparoscopic splenectomies were performed with a complication rate of 15% and no mortality. The median operative time was 100 min and conversion to open procedure was necessary in 2.1%. Conversion for cases of splenomegaly was only 5.7%. The median hospital stay was 3 days.

Conclusions

Laparoscopic splenectomy is a safe procedure with acceptable morbidity. A laparoscopic approach for splenomegaly is feasible.     

The value of splenic preservation with distal pancreatectomy

HYPOTHESIS: Splenic-preserving distal pancreatectomy for benign or low-grade malignant disease is associated with decreased perioperative morbidity compared with conventional distal pancreatectomy with splenectomy. DESIGN: A retrospective review of a prospective database of patients. SETTING: Memorial Sloan-Kettering Cancer Center, New York, NY. PATIENTS: All patients (N = 211) undergoing distal pancreatectomy. MAIN OUTCOME MEASURES: Perioperative complications, length of postoperative stay, and overall survival times were analyzed. RESULTS: After excluding patients with adenocarcinoma and those who had other major organ resection, 125 patients underwent distal pancreatectomy for benign or low-grade malignant disease with splenectomy (n = 79) or splenic preservation (n = 46). Perioperative complications occurred in 39 (49%) of the 79 patients following splenectomy and 18 (39%) of the 46 patients following splenic preservation (P =.21). Perioperative infectious complications and severe complications were significantly higher in the splenectomy group (28% and 11%) compared with the splenic preservation group (9% and 2%) (P =.01 and.05), respectively. Length of hospital stay was 9 days (range, 5-41 days) following splenectomy and 7 days (range, 5-26 days) following splenic preservation (P<.01). No difference in length of surgery, units of blood transfused, or perioperative mortality was noted between groups. CONCLUSIONS: Splenic preservation following distal pancreatectomy for benign or low-grade malignant disease is safe and is associated with a reduction in perioperative infectious complications, severe complications, and length of hospital stay compared with conventional distal pancreatectomy with splenectomy. Therefore, splenic preservation should be considered in this group of patients.