Hand-assisted laparoscopic splenectomy for giant spleens

BACKGROUND: Laparoscopic splenectomy for massive splenomegaly is technically difficult, and the morcellated splenic tissue may be inadequate for histologic study. A hand-assisted technique may provide a technical advantage and allow removal of larger pieces of spleen. METHODS: Patients who underwent hand-assisted laparoscopic splenectomy for massive splenomegaly were reviewed. Demographic information, operative data, and outcomes data were tabulated. RESULTS: Sixteen patients met these criteria. Mean age was 56 years (range, 35-78 years). Operating time averaged 240 min (range, 165-360 min), and median blood loss was 425 cc (range, 100-1800 cc). There were no conversions to an open procedure. Mean weight of extracted spleens was 2008 g (range, 543-4090 g). Postoperative length of stay averaged 3.3 days (range, 2-7 days). There was one postoperative complication (6.25%) and no mortality. CONCLUSIONS: Hand-assisted laparoscopic splenectomy for massive splenomegaly is feasible and safe while preserving the recovery benefits of minimal access surgery. It provides an adequate specimen for histologic study.     

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.     

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.     

经腹腔镜脾切除治疗重度以上脾肿大的疗效观察

目的 探讨重度以上脾肿大经腹腔镜脾切除的安全性和有效性.方法 对1995年1月至2011年9月间行脾切除术的患者进行回顾性调查.定义脾上下极长度≥17cm或重量≥600 g为重度脾肿大,脾上下极长度≥22 cm或重量≥1600 g为巨脾.结果 行腹腔镜脾切除术22例,开腹脾切除术21例,其中巨脾患者行腹腔镜脾切除术与开腹脾切除术分别为12例和14例.与开腹脾切除术相比,巨脾患者腹腔镜脾切除术具有术中出血少( 308 ml vs 400 ml,P=0.24),术后住院时间短(3 dvs4.5d,P=0.054)和相似的并发症发生率(17 ％vs 14％),但手术时间较长(195 minvs 105 min,P=0.008),中转开腹率25％.所有行开腹脾切除术患者中再手术2例,1例死亡.结论 重度以上脾肿大经腹腔镜脾切除手术预后优于开腹手术.经腹腔镜脾切除术与手助腹腔镜脾切除预后相当.     

Laparoscopic splenectomy: outcome and efficacy for massive and supramassive spleens

BackgroundMassive and supramassive splenomegaly are relative contraindications to pure laparoscopic splenectomy (LS).MethodsA retrospective review of adult patients was conducted for splenectomy occurring from 1999 to 2009. Massive and supramassive spleens were defined as craniocaudad length ≥ 17 cm or weight ≥ 600 g and craniocaudad length ≥ 22 cm or weight ≥ 1,600 g, respectively.ResultsLS was done for 22 and open splenectomy for 21 patients, of which 12 and 14 were supramassive. Spleen weight and craniocaudad length were comparable. LS was associated with lower blood loss (308 vs 400 mL, P = .24), shorter length of stay (3 vs 4.5 days, P = .054), and similar morbidity (17% vs 14%). Two reoperations and 1 death occurred with open splenectomy. Operative times were longer for LS (195 vs 105 min, P = .008), while the conversion rate was 25%.ConclusionsIn cases of massive and supramassive splenomegaly, better outcomes are accomplished with LS than open splenectomy, and are comparable to hand-assisted LS.     

Refining the selection criteria for laparoscopic versus open splenectomy for splenomegaly

BACKGROUND: Although laparoscopic splenectomy is considered the procedure of choice for patients with normal-sized spleens, the benefits are less clear in the presence of splenomegaly, which represents a heterogeneous patient population with a variety of underlying diseases. The aim of this study was to compare the outcomes of laparoscopic (LS) and open splenectomy (OS) for spleens between 15 and 25 cm in length in order to identify strategies for patient selection for the laparoscopic approach. STUDY DESIGN: The medical records of concurrent patients undergoing splenectomy for splenomegaly (>15 cm in the long axis) from 2000 to 2005 were reviewed at two hospitals. At one hospital, LS was performed unless the spleen was >25 cm in length, while the other hospital used OS exclusively. Demographic, intraoperative, and postoperative variables were compared for patients potentially eligible for LS. Data are expressed as median (interquartile range) and were analyzed by using nonparametric tests. A value P < 0.05 was considered statistically significant. RESULTS: Sixty-five laparoscopic and 25 open splenectomies were performed at the two hospitals, of which 34 were for splenomegaly. Five open cases involved spleens >25 cm and were excluded, leaving 18 LS (13 hand assisted) and 11 OS for further analysis. The groups were similar in comorbidity score, spleen length, hematologic diagnosis, and intraoperative blood loss. The open group was younger, included more females, and had a shorter operative time. Time to oral intake (1 vs. 2 days; P = 0.04) and length of hospital stay (3 vs. 6 days; P = 0.01) were shorter in the LS group. Postoperative complications occurred in 7 (39%) LS and 6 (55%) OS patients (P = 0.47); these were major in 3 LS patients and 1 OS patient (P = 1.0). All 3 major complications after LS occurred in the 3 patients with myelofibrosis and involved a conversion or reoperation by laparotomy for bleeding. CONCLUSIONS: Laparoscopic splenectomy confers benefit for most patients with splenomegaly between 15 and 25 cm, as it is associated with faster time to oral intake and a shorter hospital stay. Major morbidity after laparoscopic splenectomy was mostly related to surgery for myelofibrosis. These patients did not derive any benefit from the laparoscopic approach due to bleeding complications, requiring a conversion or relaparotomy.     

Is the laparoscopic approach reasonable in cases of splenomegaly?

Laparoscopic splenectomy in cases of splenomegaly has been shown to be feasible in experienced hands, even though the size of the spleen increases the operative time and difficulty. Laparoscopic splenectomy for splenomegaly offers the same advantages as for patients with smaller spleens: a shorter hospital stay and a faster recovery. Recent experience has shown that hand-assisted laparoscopic surgery makes the surgical maneuvers during laparoscopic splenectomy in cases of splenomegaly considerably easier while preserving the advantages of a purely laparoscopic approach. This technique may facilitate and broaden the application of laparoscopy for splenectomy in patients with enlarged spleens.     

Hand-assisted laparoscopic splenectomy in the setting of splenomegaly

Background Hand-assisted laparoscopic surgery (HALS) devices may be well suited to splenectomy in cases of splenomegaly.Methods All cases of HALS for splenectomy between 1997 and 2001 were reviewed. Patient characteristics, operative details, and morbidity and mortality were analyzed.Results HALS for splenectomy was performed in 54 patients. A total of 39 patients with massive splenomegaly (MS) (>600 g) were identified. The average weight of the MS group was 1285 ± 505 g. There was one (3%) conversion. Operative time was 159 ± 65 min, estimated blood loss was 257 ± 240 ml, and length of hospital stay was 5.4 ± 2.9 days. Morbidity was limited to 13 patients (24%), and there were two postoperative mortalities (5.1%).Conclusions HALS for splenectomy in the setting of splenomegaly is feasible and safe. For the surgeon considering a laparoscopic approach in the setting of splenomegaly, a hand-assisted technique is ideally suited for removal of the enlarged spleen.Paper presented at the annual meeting of the European Association for Endoscopic Surgery (EAES), 1st European Endoscopic Surgery Week, Glasgow, Scotland, June 2003     

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 patients with normal-sized spleens versus splenomegaly: does size matter?

Laparoscopic resection has become the standard means for removal of normal-sized spleens in many medical centers. The application of minimally invasive techniques in the setting of splenomegaly is less well defined and was previously considered a contraindication to the laparoscopic approach. The purpose of this prospective study of consecutive patients was to compare the outcomes of patients undergoing laparoscopic splenectomy for normal-sized spleens (150 g or less) versus those with clear evidence of splenomegaly (500 g or greater). One hundred forty-two patients met the inclusion criteria. The most common diagnosis in the normal-sized spleen group was idiopathic thrombocytopenia purpura (67 of 82, 82%). Malignant hematologic diseases (lymphoma and leukemia) were the most common diagnoses in the splenomegaly group (35 of 60, 58%). Mean operative times (127 vs 172 minutes) and estimated blood loss (123 vs 173 cm3) were lower for those patients with normal-sized spleens (P < 0.05). There were no statistical differences in conversion rates, lengths of stay, or complications between the two groups. We conclude that laparoscopic splenectomy is safe and effective in the setting of splenomegaly despite modest but statistically longer operative times and increased operative blood loss when compared with laparoscopic splenectomy for normal-sized spleens.     

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.     

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 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: 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.     

Hand-assisted laparoscopic splenectomy vs conventional laparoscopic splenectomy in cases of splenomegaly

HYPOTHESIS: Laparoscopic splenectomy (LS) is the procedure of choice for elective splenectomy. Splenomegaly may preclude safe mobilization and hilar control using conventional laparoscopic techniques. Hand-assisted LS (HALS) may offer the same benefits of minimally invasive surgery for splenomegaly while allowing safe manipulation and splenic dissection. DESIGN: A retrospective review of patients with splenomegaly undergoing conventional LS or HALS was performed. SETTING: Tertiary care referral center. PATIENTS: Hand-assisted LS was performed at the start of the operation for patients with splenomegaly; splenomegaly was determined by palpation of the splenic tip extending to the midline or the iliac crest, or by a craniocaudal splenic length of greater than 22 cm. Splenomegaly was defined as a splenic weight of greater than 700 g after morcellation. MAIN OUTCOME MEASURES: Patient demographic characteristics, operative indications, splenic weight after morcellation, morbidity, mortality, and clinical outcomes were evaluated. RESULTS: Forty-five patients with splenomegaly were identified: 31 underwent standard LS and 14 underwent HALS. The HALS group had significantly larger spleens than the conventional LS group (mean weight, 1516 vs 1031 g; P =.02). Mean operative time (177 vs 186 minutes; P =.89), estimated blood loss (602 vs 376 mL; P =.17), and length of hospital stay (5.4 vs 4.2 days; P =.24) and complication rates (5 [36%] of 14 vs 5 [16%] of 31; P =.70) were similar between the HALS and the standard LS groups. No perioperative mortality occurred. CONCLUSIONS: Hand-assisted LS is a safe and efficacious procedure for these extremely difficult cases. Hand-assisted LS provides the benefits of a minimally invasive approach in cases of splenomegaly.     

Minimal-access splenectomy: a viable alternative to laparoscopic splenectomy in massive splenomegaly.

BACKGROUND: Laparoscopic splenectomy of normal-sized spleens or in moderate splenomegaly is performed with increasing frequency. By using a modification of the open laparotomy, minimal-access splenectomy is an attractive alternative in severe splenomegaly. METHODS: Between September 2002 and October 2003, 9 patients (mean age, 58.8 years; range, 41 to 72) with severe splenomegaly (mean length, 27.9 cm; range, 23 to 32) underwent minimal-access splenectomy. Indications for splenectomy were non-Hodgkin's lymphoma in 5 cases and idiopathic myelofibrosis in 4. RESULTS: Minimal-access splenectomy was successfully completed in all patients. Mean operative time was 124 minutes (range, 75 to 165). Postoperative complications occurred in 2 cases; one perioperative death occurred in a patient with idiopathic myelofibrosis as a consequence of a secondary blast crisis. Median postoperative hospital stay was 9.1 days (range, 6 to 15). CONCLUSIONS: Minimal-access splenectomy seems to be a viable alternative to laparoscopic splenectomy in cases of severe splenomegaly. It combines the advantages of hand assistance like shorter operative times and increased safety of the procedure to the classical benefits of minimally invasive surgery.     

Hand-assisted laparoscopic splenectomy in patients with splenomegaly or prior upper abdominal operation

BACKGROUND: Laparoscopic splenectomy (LS) in patients with significant splenomegaly or prior upper abdominal operation is technically challenging with a high conversion rate to open operation. We hypothesized that hand-assisted laparoscopic splenectomy (HLS) in this setting would improve operative (OR) outcomes without impacting post-OR ileus, length of stay, morbidity, or mortality, compared with LS. METHODS: All patients with splenomegaly (spleen weight > or = 500 g) or prior upper abdominal operation undergoing LS or HLS between March 1996 and June 2001 were reviewed. Nonparametric continuous variables were expressed as median and intraquartile range with statistical significance determined by Wilcoxon rank sum test. RESULTS: Of 41 patients reviewed, 22 underwent HLS, whereas 19 underwent LS. Median OR time for HLS was significantly less than for LS (161 minutes vs 212 minutes, P =.004). HLS was associated with a lower conversion rate (13.6% vs 36.8%, P =.08) and blood loss (325 mL vs 550 mL, P =.18) than LS, which approached statistical significance. HLS did not increase post-OR ileus, length of stay, morbidity, or mortality. CONCLUSIONS: HLS in patients with significant splenomegaly or prior upper abdominal operation significantly shortens OR time compared with LS without adversely impacting post-OR ileus, length of stay, morbidity, or mortality. In addition, HLS may be associated with a lower conversion rate and decreased blood loss.     

Morbidity of hand-assisted laparoscopic splenectomy compared to conventional laparoscopic splenectomy: a 6-year review

Background

Laparoscopic splenectomy (LS) has several advantages over the open procedure but can be technically demanding when performed in patients with massive splenomegaly. We hypothesized that patients who undergo hand-assisted LS (HALS) may experience the benefits of LS while having their enlarged spleens removed safely.

Methods

We reviewed the charts of patients who underwent HALS or LS between January 2003 and June 2008. Evaluated parameters included intraoperative and early postoperative morbidity and mortality, conversion to open surgery, need for blood transfusion, length of postoperative hospital stay, patient demographics, diagnosis leading to splenectomy, splenic weight and number of postoperative days to resuming normal diet. Differences were analyzed while controlling for splenic weight and malignant diagnosis using multiple linear and logistic regression analysis.

Results

In all, 103 patients underwent splenectomy (23 HALS, 80 LS). Patients who had HALS were older and had larger spleens, and a greater proportion had malignant diagnoses. We observed no significant differences in morbidity, conversion to open surgery or need for blood transfusion. The mean length of postoperative stay, duration of surgery and days to resuming full diet were longer in the HALS group. No patients died. No group differences were significant after controlling for splenic weight and malignant diagnosis.

Conclusion

The morbidity associated with HALS is comparable to that with LS. The longer duration of surgery and hospital stay for HALS patients was likely related to greater splenic weight, older age and greater proportion of malignant diagnoses. Hand-assisted LS is a viable alternative to open surgery in patients with massive spleens.     

Laparoscopic splenectomy for hematologic disorders: experience with the first fifty patients

BACKGROUND: Splenectomy is increasingly being performed by various minimal access surgical modalities for select hematologic disorders. METHODS: A retrospective analysis was performed on the first 50 patients on whom laparoscopic splenectomy (LS) was attempted. The data studied included indications for surgery, patient demographics, intraoperative parameters, and patient outcomes. A total laparoscopic approach (TLS) was employed in 38 patients and a hand-assisted technique (HALS) was used in 12 patients with massive splenomegaly. Eight patients had concomitant surgical procedures: 7 patients underwent laparoscopic cholecystectomy and 1 patient received a kidney transplant. The most common indications for LS were idiopathic thrombocytopenic purpura (ITP) (50%) and hereditary spherocytosis (24%). RESULTS: LS was successfully completed in 48 patients (96%). Thirty-four patients (68%) required perioperative blood or platelet transfusions. The mean spleen diameter was 17.1 cm (range, 11.2-28.4 cm) on imaging study and mean intact splenic weight was 1019 gm. The mean operative time was 188 minutes (range, 90-340 minutes) in the TLS group and 171 minutes (range, 120-240 minutes) in the HALS group. The mean intraoperative blood loss was 306 mL (range, 40-640 mL) in the TLS group and 163 mL (range, 100-300 mL) in the HALS group. The mean postoperative hospital stay was 3.2 days (range, 2-5 days). CONCLUSION: TLS is safe and feasible in patients with nonpalpable spleens. A concomitant laparoscopic procedure for treating coexisting abdominal pathology may be performed without additional morbidity. The HALS technique may be preferable in patients with splenomegaly (palpable spleens), as it appears to offer intraoperative advantages for retraction, dissection, hemostasis, and organ retrieval.     

Laparoscopic splenectomy: A retrospective review of 75 cases

Laparoscopic splenectomy (LS) is considered a safe procedure for spleens of normal size as well as for larger spleens. Seventy-five consecutive patients underwent LS. Splenomegaly was defined by diameter >15 cm and by weight >400 g. Thirty patients had splenomegaly. The outcomes with spleens <15 cm and spleens >15 cm were compared. LS was successfully completed in 73 cases (97.4%). Spleens >15 cm required longer operating time and were associated with greater blood loss (P < 0.001), longer hospital stay, and more complications. Two patients needed blood transfusion. No overwhelming postsplenectomy infection was registered, and operative mortality was zero.