Laparoscopic splenectomy in β-thalassemia major patients

Background: Splenectomy is indicated in patients with thalassemia major when they develop hypersplenism with subsequent need for increased transfusions. Extreme splenomegaly is considered a restrictive factor for laparoscopic splenectomy in these patients. Methods: Laparoscopic splenectomy was undertaken in 12 β-thalassemia major patients with massive splenomegaly. The devascularization of the organ was performed with serial ligations of the splenic vessels starting from the lower pole of the organ. The spleen was extracted from the abdominal cavity through a 5-cm incision in the left iliac fossa, which incorporated two port sites. Results: The procedure was concluded laparoscopically in 10 cases, while two patients were converted due to difficulty in controlling bleeding from branches of the splenic vein. The patients tolerated the procedure well and had a postoperative hospital stay of 3–6 days. Conclusions: From our limited initial experience it seems that laparoscopic splenectomy in the difficult setting of thalassemia major patients is feasible, but extreme care is required in order to avoid hemorrhagic complications. Received: 21 March 1997/Accepted: 10 August 1997     

Laparoscopic management of accessory spleens in immune thrombocytopenic purpura

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

Pediatric laparoscopic splenectomy

Background: Lateral laparoscopic splenectomy in adults, first reported in 1991, was begun with children in 1993. Methods: The authors reviewed records of 59 patients 2 to 17 years old who underwent laparoscopic splenectomy by the lateral approach between 1994 and 1998 at four medical centers. Patients received prophylactic penicillin or vaccinations preoperatively. Results: Of the 59 patients, 51 required splenectomy for one of the following conditions: idiopathic thrombocytopenic purpura, hereditary spherocytosis, or sickle-cell disease. Splenomegaly was found in 86% of the patients, and ten accessory spleens were resected. No deaths or infection occurred, and only three patients had perioperative complications: acute chest crisis, small diaphragmatic injury, and intraoperative hemorrhage. One operation was converted to a minilaparatomy because of difficulty with specimen extraction. Conclusions: Pediatric laparoscopic splenectomy is safe and effective, resulting in little blood loss, rapid recovery, and a good cosmetic outcome. Received: 12 February 1999/Accepted: 24 September 1999/Online publication: 8 May 2000     

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     

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.     

A new surgical strategy for cirrhotic patients with hepatocellular carcinoma and hypersplenism

Background: Hepatectomy for cirrhotic patients with hypersplenism is a high-risk operative procedure. We report herein a new strategy for high-risk patients with hepatocellular carcinoma (HCC). Methods: Six cirrhotic patients with HCC and hypersplenism received a partial hepatectomy after first undergoing a laparoscopic splenectomy. We then compared the variables for these patients before splenectomy and before hepatectomy. Results: The platelet count and the white blood cell count were found to be significantly elevated before hepatectomy. The ammonia value decreased significantly before hepatectomy. The albumin value tended to be elevated before hepatectomy. Furthermore, the Child's classification of all patients improved significantly before hepatectomy. However, other variables—such as the indocyanine green dye excretion test at 15 min and the bilirubin value—did not change after splenectomy. For hepatectomy patients who first underwent a laparoscopic splenectomy, operation time ranged from 265 to 440 min (average time, 361 min), and blood loss ranged from 500 to 2,200 ml (median volume, 1,300 ml). Four of six patients did not require any blood transfusion; furthermore, no patient needed a platelet-rich plasma transfusion. All but one patient, who suffered postoperatively from an intractable duodenal ulcer, had an uneventful postoperative course. Conclusion: Partial hepatectomy after an initial laparoscopic splenectomy is a new and effective choice of treatment for cirrhotic patients with HCC and hypersplenism. Received: 1 May 1998/Accepted: 30 June 1999     

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.     

Laparoscopic nephrectomy in childrenrid=""id=""Presented in poster format at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Antonio, Texas, USA, 24–27 March 1999

Background: Laparoscopic nephrectomy in the adult population is reported with increased frequency. We present our initial experience with laparoscopic nephrectomy in children. Methods: Over a 2-year period, 11 nephrectomies were performed in nine children aged 16 months to 16 years (mean, 6.5 years). All patients were referred due to complications of a nonfunctioning kidney. Seven patients had recurrent urinary tract infections, and two had refractory hypertension. Two patients underwent bilateral laparoscopic nephrectomy. The operation was performed using four access ports measuring 3.5 to 10 mm. Results: All kidneys were removed successfully using a laparoscopic technique. The average length of the operation was 163 min per kidney (range, 90–420). The estimated blood loss was <10–150 ml (mean, 45). No patient required transfusion. Seven patients were discharged home by postoperative day 2. The two patients with the longest operating times were discharged home on postoperative days 4 and 5 due to delay in return of bowel function. Narcotic use was minimal, and all patients enjoyed a rapid return to full activity. Conclusion: Laparoscopic nephrectomy is a viable alternative to open nephrectomy in children. Further experience with this technique is required to establish its efficacy and reduce the operating time Received: 29 April 1999/Accepted: 29 August 1999/Online publication: 17 April 2000     

Port site tumor recurrence rates in a murine model of laparoscopic splenectomy decreased with increased experiencerid=""id=""Presented at the sixth International Congress of the European Association of Endoscopic Surgery (E.A.E.S.), Rome, Italy, 5 June 1998

Background: The etiology of port site tumor recurrences following laparoscopic surgery for cancer remains unknown. A recent study from our laboratory using a murine splenic tumor model suggests that it is poor surgical technique (i.e., crushing of the tumor) rather than the CO₂ pneumoperitoneum that is responsible for these tumors. However, in that experiment, no intraabdominal procedure was carried out. We subsequently performed a preliminary study in which we compared the rate of port site tumor recurrences after laparoscopic-assisted splenectomy (LAS) vs open splenectomy (OS) using the murine splenic tumor model. In this study, we found significantly more port and incisional tumors after laparoscopic splenectomy. The reasons for this finding are unclear. Further analysis of the data showed that the incidence of port tumors in the LAS group decreased dramatically from the first to the second trial, suggesting that the experience of the surgeon may play a role. The purpose of the current study was to carry out further trials to determine if the lower rate of port tumor recurrence in the laparoscopic group will persist with increased surgical experience. Methods: Splenic tumors were established in female Balb/C mice (n= 128) via a subcapsular injection of a 0.1-cc suspension containing 10⁵ C-26 colon adenocarcinoma cells via a left flank incision at the initial procedure. Seven days later, the animals with isolated splenic tumors (95%) were randomized to one of two groups—open splenectomy (OS) or laparoscopic-assisted splenectomy (LAS). Three ports were placed in similar locations in all animals. The OS mice underwent an open splenectomy via a subcostal incision and anesthesia for 20 min. The LAS mice underwent laparoscopic mobilization of the spleen using a three-port technique, followed by an extracorporeal splenectomy via a subcostal incision. Seven days after splenectomy, the mice were killed and inspected for abdominal wall tumor implants. The experiment was carried out in four separate trials. Results: When the results of the four trials were combined, there was no significant difference in the incidence of animals with at least one port tumor recurrence between the OS vs the LAS group (25% vs 35.2%; p= 0.30, power = 0.91). However, the overall incidence of port site tumors (number of ports with tumors/total number of ports for each group) was significantly higher in the laparoscopic-assisted group than in the open group (18.5% vs 9.5%; p= 0.03). It was noted that the incidence of port tumor recurrence (PTR) in the LAS group dropped significantly from the first to the latter three trials (second, third, and fourth trials combined) (36.1% vs 13.5%; p < 0.006) while it did not change significantly in the OS group. In the latter three trials, there was no significant difference in the number of animals with PTR between the LAS and the OS group (13.5% vs 9.8%; p= 0.43). Conclusions: Overall, there was no significant difference between the OS and the LAS groups in number of animals with port tumor recurrence or subcostal wound tumor recurrence. However, there were more port tumors in the laparoscopic-assisted group. The reasons for these findings are unclear. The laparoscopic mobilization was quite difficult; it required excessive splenic manipulation, which may have liberated tumor cells from the primary lesion and facilitated port tumor formation. With increased experience, less manipulation was required to complete the mobilization. Of note, the incidence of port tumors in the LAS group decreased significantly from the first to the subsequent three trials; therefore, it is possible that surgical technique is a factor in port tumor formation. The CO₂ pneumoperitoneum may also be a factor, but this seems less likely. Received: 10 September 1999/Accepted: 4 April 2000/Online publication: 9 August 2000     

Laparoscopic splenectomy for massive splenomegaly

BACKGROUND: Laparoscopic splenectomy (LS) is the preferred operative approach for diseases involving normal-sized spleens. Our experience with laparoscopic splenectomy in the setting of massive splenomegaly is presented. METHODS: A prospective review of patients undergoing LS for massive splenomegaly was conducted. Massive splenomegaly (MS) in adults was defined as a craniocaudal length >or=17 cm or a morcellated weight >or=600 g. In children, spleens measuring fourfold larger than normal for age were considered massive. RESULTS: Forty-nine patients with MS were treated with LS. The most common primary diagnoses were lymphoma and leukemia. Mean splenic length was 20 cm (15 to 27 cm), with weights ranging from 600 to 4,750 g. Twelve patients with supermassive splenomegaly (length >22 cm) required a hand-assisted laparoscopic approach. There were no conversions to open surgery. Mean operating time was 171 minutes (90 to 369). Mean blood loss was 114 cc (<30 to 600 cc). Average length of stay was 2.3 days (1 to 16). Minor postoperative complications occurred in 3 patients. CONCLUSIONS: Laparoscopic splenectomy in the setting of splenomegaly is safe and appears to minimize perioperative morbidity. In patients with supermassive splenomegaly, a hand-assisted laparoscopic approach may be required.     

Laparoscopic ventral hernia repair

Introduction: Effective surgical therapy for ventral and incisional hernias is problematic. Recurrence rates following primary repair range as high as 25–49%, and breakdown following conventional treatment of recurrent hernias can exceed 50%. As an alternative, laparoscopic techniques offer the potential benefits of decreased pain and a shorter hospital stay. This study evaluates the efficacy of the laparoscopic approach for ventral herniorrhaphy. Methods: A retrospective review was performed for 100 consecutive patients with ventral hernias who underwent laparoscopic repair at our institutions between November 1995 and May 1998. All patients who presented during this period and were candidates for a mesh hernia repair were treated via an endoscopic approach. Results: One hundred patients underwent a laparoscopic ventral hernia repair. There were 48 men and 52 women. The patients were typically obese, with a mean body mass index (BMI) of 31 kg/m². Each had undergone an average of 2.5 (range; 0–8) previous laparotomies. Forty-nine repairs were performed for recurrent hernias. An average of two patients (range; 1–7) had previously failed open herniorhaphies; in 20 cases, intraabdominal polypropylene mesh was present. There were no conversions to open operation. The mean size of the defects was large at 87 cm² (range; 1–480). In all cases, the mesh (average, 287 cm²) was secured with transabdominal sutures and metal tacks or staples. Operative time and estimated blood loss averaged 88 min (range; 18–270) and 30 cc (range; 10–150). Length of stay averaged 1.6 days (range; 0–4). There were 12 minor and (two) major complications: cellulitis of the trocar site (two), seroma lasting >4 weeks (three), postoperative ileus (two), suture site pain > 2 weeks (two), urinary retention (one), respiratory distress (one), serosal bowel injury (one), and skin breakdown (one) and bowel injury (one). Both of the latter complications required mesh removal. With an average follow-up of 22.5 months (range; 7–37), there have been (three) recurrences. Conclusion: The laparoscopic approach to the repair of both primary and recurrent ventral henias offers a low conversion rate, a short hospital stay, and few complications. At 23 months of follow-up, the recurrence rate has been 3%. Laparoscopic repair should be considered a viable option for any ventral hernia. Received: 11 February 1999/Accepted: 15 March 2000/Online publication: 28 April 2000     

Laparoscopic splenectomy

Background: The purpose of this study was to evaluate the outcome of patients undergoing laparoscopic splenectomy (LS) at the University of California, San Francisco. Methods: The medical records of the initial 52 unselected patients undergoing LS were reviewed and compared to 28 concurrently treated open splenectomy patients (OS). Results: Patients did not differ with regard to age, gender, body, or splenic weights. The operative time was longer in the LS patients (mean 196 vs 156 min), but the length of stay and duration of ileus were shorter in the LS group. For adult patients admitted exclusively for splenectomy, operative times did not differ between LS and OS and total hospital cost was less in the LS group (mean $8,939 vs $14,022). Six patients required conversion to OS, four occurring in the first 11 patients treated (overall conversion rate of 11%). Three patients died from complications related to their underlying disease. Two other major complications occurred. Complication rates and transfusion requirements did not differ between OS and LS patients. Conclusions: Laparoscopic splenectomy is a safe and effective alternative to open splenectomy for treatment of hematologic diseases in patients of all ages. Received: 16 April 1996/Accepted: 5 July 1996     

Laparoscopic vs open colectomy for sigmoid diverticulitis

Background: The aim of this prospective comparative study was to assess the outcome of laparoscopic and open colectomy for sigmoid diverticulitis in patients aged ≥75 years. Methods: From January 1993 to December 1998, all patients 75 years of age and older undergoing an elective colectomy for sigmoid diverticulitis were included in the study. The patients were divided into the following two groups: group 1 (n= 22) consisted of patients who underwent a laparoscopic procedure; group 2 (n= 24) consisted of patients who underwent an open procedure. Results: In group 1, there were 12 women and 10 men with a mean age of 77.2 years (range, 75–82); in group 2, there were 14 women and 10 men with a mean age of 78 years (range, 76–84) (p= 0.37). There was no difference between the groups in ASA classification. The operative time was shorter in group 2 (136 vs 234 mins). The postoperative period during which parenteral analgesics were required (5.4 vs 8.2 days, p= 0.001), postoperative morbidity (18% vs 50%, p= 0.02), postoperative length of hospital stay (13.1 vs 20.2 days, p= 0.003), and the inpatient rehabilitation (6 vs 15 patients, p= 0.01) were significantly shorter for group 1 than for group 2. There were no perioperative deaths. The conversion rate was 9% in group 1. Conclusion: The data from the present study suggest that laparoscopic colectomy for sigmoid diverticulitis can be applied safely to older patients with fewer complication, less pain, shorter hospital stay, and a more rapid return to preoperative activity levels than that seen with open colorectal resection. Received: 22 November 2000/Accepted: 22 February 2000/Online publication: 7 September 2000     

Laparoscopic vs conventional Nissen fundoplication

Background: Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study. Methods: Some 110 consecutive patients with prolonged symptoms of grade II–IV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups. Results: Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result. Conclusions: Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery. Received: 15 May 1996/Accepted: 10 September 1996     

Laparoscopic repair of rectal prolapse

Background: There have been few large series that have focused on the feasibility of the laparoscopic approach for rectal prolapse. This single-institution study prospectively examines the surgical outcome and changes in symptoms and bowel function following the laparoscopic repair of rectal prolapse. Methods: In a selected group of 34 patients (total prolapse, 28; intussusception, six), 17 patients underwent laparoscopic-assisted resection rectopexy and 17 patients received a laparoscopic sutured rectopexy. Preoperative and postoperative evaluation at 3, 6, and 12 months included assessment of the severity of anal incontinence, constipation, changes in constipation-related symptoms, and colonic transit time. Results: Median operation time was 255 min (range, 180–360) in the resection rectopexy group and 150 min (range, 90–295) in the rectopexy alone group. Median postoperative hospital stay was 5 days (range, 3–15) and median time off work was 14 days (range, 12–21) in both groups. There were no deaths. Postoperative morbidity was 24%. Incontinence improved significantly regardless of which method was used. The main determinant of constipation was excessive straining at defecation. Constipation was cured in 70% of the patients in the rectopexy group and 64% in the resection rectopexy group. Symptoms of difficult evacuation improved, but the changes were significant only after resection rectopexy. Two patients (7%) developed recurrent total prolapse during a median follow-up of 2 years (range 12–60 months). Conclusions: Laparoscopic-sutured rectopexy and laparoscopic-assisted resection rectopexy are feasible and carry an acceptable morbidity rate. They eliminate prolapse and cure incontinence in the great majority of patients. Constipation and symptoms of difficult evacuation are alleviated. Received: 30 April 1999/Accepted: 8 July 1999/Online publication: 22 May 2000     

Laparoscopic versus open splenectomy for massive splenomegaly: a comparative study

BACKGROUND: Despite the benefits of the laparoscopic approach to splenectomy, its application in patients with massive splenomegaly (splenic weight >or= 1000 g) remains controversial. In this study we evaluated the safety and feasibility of laparoscopic splenectomy for massive splenomegaly compared with open splenectomy. MATERIALS AND METHODS: One surgeon applied the laparoscopic approach to splenectomy to all comers with massive splenomegaly, while other surgeons carried out the surgery through a laparotomy. The outcomes of the two approaches were compared on an intention-to-treat basis. Results of continuous variables are shown as medians. RESULTS: Fifteen patients underwent laparoscopic splenectomy between 2000 and 2005, and 13 underwent open splenectomy between 1996 and 2003. The two groups were comparable for age, sex, American Society of Anesthesiologists score, and splenic weight (1.3 vs. 1.1 kg). There was one conversion (6.6%) to open surgery. Although laparoscopic splenectomy was associated with significantly longer operating time (175 vs. 90 minutes, P < 0.001), it carried lower postoperative morbidity and mortality (13.3 vs. 30.8% and 0 vs. 7.7%, respectively). Laparoscopic splenectomy was associated with significantly lower total dose (29 vs. 264 mg morphine-equivalent, P < 0.0001) and duration of opiate usage (1 vs. 4 days, P < 0.0001); duration of parenteral hydration (24 vs. 96 hours, P = 0.006) and more rapid resumption of oral diet (24 vs. 72 hours, P = 0.017); and a shorter postoperative hospital stay (3 vs. 10 days, P < 0.0001). CONCLUSIONS: The laparoscopic approach to splenectomy for massive splenomegaly is feasible and safe. Despite a longer operating time, the postoperative recovery following laparoscopic splenectomy is smoother, with lower morbidity and shorter postoperative hospital stay compared with open splenectomy.     

Laparoscopic splenectomy for ITP

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

Laparoscopic surgery for splenic disorders

Laparoscopic splenectomy (LS) has recently been gaining acceptance as an alternative to open splenectomy. However, several aspects, such as learning curve, residual splenic function, and management of large spleens, remain controversial. In this paper we present the analysis of technical details and immediate and late outcome of a consecutive series of 64 cases of splenic disorders approached by laparoscopy. Between Feb-1993 and April-1997, 64 patients with a wide range of splenic disorders were treated by laparoscopy, and prospectively recorded. Age, body mass index, operative time, number of trocars, perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia, stay and morbidity were analyzed. Late failures after LS were reevaluated with ^99mTc-heat-damaged red blood cells scintigraphy and CT. LS was performed in 61 patients, and two cases with splenic cyst and one splenic artery aneurysm received a laparoscopic partial cystectomy and aneurysmectomy. LS was performed through an anterior approach in 12 patients and laterally in 49. Conversion rate was 6.5%. Accessory spleens were found in 7 patients (7/61, 11.5%). Morbidity was 16%. There was no correlation between the weight of the spleen, platelet count or obesity with operative time. A lateral approach was associated with a decrease in operative time (p < 0.002), postoperative stay (p < 0.001), transfusion (p < 0.04) and number of trocars (p < 0.001). Operative time was significantly longer in large spleens (>1000 gr) (p < 0.001). However, there were no differences in transfusion rate, stay, morbidity or conversion rate. After a follow up of 12 m, 10 patients revealed a low platelet count. Scintigraphy showed residual splenic tissue in 3 (ITP). A wide range of splenic disorders can be treated by laparoscopy, including enlarged spleens. This technique should be continually audited, but initial results reflect the approach's safety and advantages provided that great technical care is taken and an exhaustive search for accessory spleens is conducted. Received: 29 January 1997/Accepted: 22 May 1997     

A simple laparoscopic method to provide access to the gastroesophageal junction in obese patients

By now, the feasibility of laparoscopic surgery in obese patients is well established; a conversion rate of 1.4–4.3% has been reported [1, 2]. The main reason for conversion in these cases is the difficulty encountered in exposing the gastroesophageal junction due to a huge fatty liver that covers the entire upper abdomen (``the invisible stomach' [1]). We report here a simple method that allows easy access to the upper stomach in such cases. This technique involves the exposure of the gastroesophageal junction using a laparoscopic suprahepatic route. Received: 30 April 1999/Accepted: 5 October 1999/Online publication: 24 March 2000     

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP)

Background: Laparoscopic splenectomy (LS) has rapidly become the preferred surgical treatment for idiopathic thrombocytopenic purpura (ITP), but its long-term efficacy for this disorder is unproved. This report documents the author's 5-year experience with, and long-term follow-up of, LS for ITP. Methods: Between September 1992 and September 1997, 30 patients with clinical ITP and intractable thrombocytopenia were referred as surgical candidates. Two of them (7%) were converted to open, and the other 28 underwent successful LS. The operative approach evolved from a supine lithotomy to right lateral decubitus position, and the harmonic scalpel became the primary dissection tool in the later part of the study. Results: The 28 successful LS patients constituted the study group. Accessory spleens were identified and resected in six patients (21%). Surgical times and blood loss averaged 2.4 h and 170 cc, respectively. The typical hospital stay was 2 days. Initial reversal of thrombocytopenia and ultimate cessation of oral steroids was achieved in 25 of 28 patients (89%). There were no deaths, but two patients had major complications (bleeding and pneumonia). All but two patients experienced a return to full activity and/or employment by 3 weeks post-LS. In the three cases that failed LS, none had residual splenic tissue on subsequent radionuclide scan. Long-term follow-up (2–60 months) was obtained in 22 of 28 patients (79%). The only death (at 13 months) resulted from oncologic disease. Twenty-one patients had lasting clinical remission of ITP. A positive preoperative response to oral steroids was the best predictor of success. Conclusions: This 5-year experience with LS supports its use for the surgical treatment of ITP. The procedure is safe and efficacious, resulting in brief hospitalization, minimal recovery time, and excellent long-term results. Received: 11 October 1998/Accepted: 19 February 1999