Laparoscopic Excision of a Retroperitoneal Cystic Lymphangioma: Report of a Case

A 36-year-old woman without any relevant medical history was admitted to our hospital with an abdominal tumor that had caused recurrent right hypochondral and back pain for 3 months. Retroperitoneal cystic lymphangioma was diagnosed by abdominal ultrasonography and computed tomography. We suc-cessfully excised the tumor laparoscopically. Retroperitoneal cystic lymphangiomas are rare lesions that usually present in infancy, rather than in adulthood. Most patients experience chronic symptoms, necessitating therapeutic intervention. Excision is the treatment of choice, and can be performed laparoscopically in selected patients. Received: December 5, 2001 / Accepted: July 2, 2002 Reprint requests to: T. Tsukamoto     

A Ten-year, Single Institution Experience With Laparoscopic Splenectomy

Background and Objectives:

Laparoscopic splenectomy (LS) is now widely performed and is considered the standard of care for the treatment of certain diseases of the spleen. Although multiple studies have documented the safety and feasibility of laparoscopic splenectomy, little long-term data are available. We present a 10-year, single institution experience with laparoscopic splenectomy to determine trends in procedural outcome data.

Methods:

Laparoscopic splenectomy was performed in 109 consecutive, unselected patients with benign or malignant hematological diseases from March 1992 to November 2001. A prospective, longitudinal database, medical record review, and patient interviews were used for data acquisition. During the last 10-years, the annual number of laparoscopic splenectomy was relatively constant. Therefore, patients were divided into 2 cohorts, comparing the first 55 consecutive patients (Group I) with the subsequent 54 patients (Group II) who underwent LS. Data were analyzed using the unpaired Student t test, with values of P<0.05 considered significant.

Results:

Mean patient age was 39 years (range, 6 to 79) in Group I and 45 years (range, 13 to 77) in Group II. Total operative time was 151 minutes in Group I and 159 minutes in Group II (NS), estimated blood loss averaged 544 mm in Group I and 308mm in Group II (P=0.015). The mean specimen weight of the spleen was 288 g in Group I and 512 g in Group II (P=0.03). Morbidity occurred in 7 of the first 55 patients (13%) and 5 of the next 54 patients (9%). Additionally, 7 conversions to an open operation were necessary in Group I (13%) versus only 1 conversion in Group II (2%).

Conclusion:

A decade of experience with LS shows that it can be performed safely for a wide variety of indications. Over the last 10 years, the average spleen size has increased, yet a significant reduction in blood loss and conversion rate has been achieved.     

Laparoscopic Splenectomy Coupled with Laparoscopic Cholecystectomy

Background and Objectives:

The aim of this study was to evaluate the results of laparoscopic surgery performed for coexisting spleen and gallbladder surgical diseases.

Methods:

Between May 2004 and October 2012, 12 patients underwent concomitant laparoscopic splenectomy and cholecystectomy. Indications for surgery included idiopathic thrombocytopenic purpura in 5 patients, hereditary spherocytosis in 4 patients, and thalassemia intermedia in 3 patients.

Results:

The mean operative time was 100 minutes (range, 80–160 minutes), and the blood loss ranged from 0 to 150 mL (mean, 50 mL). The mean longitudinal diameter of the spleen was 14 cm. One patient required conversion to open procedure. An accessory spleen was detected and removed in one case. The mean length of hospital stay was 5 days. No deaths or other major intraoperative and/or postoperative complications occurred.

Conclusion:

Provided that the technique is performed by an experienced surgical team, concomitant laparoscopic splenectomy and cholecystectomy is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder diseases.     

Laparoscopic Splenectomy Using LigaSure

Background:

Laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases. Bleeding is the main complication and cause for conversion. We present our experience with the LigaSure and discuss its advantage as a vessel sealing system in achieving safe vascular control.

Method:

Over a 3-year period, we performed 12 consecutive LS using LigaSure at a single center. A literature review of all the patients who had undergone laparoscopic splenectomy with of the LigaSure to achieve vascular control at the hilum was carried out, assessing its advantages and outcome.

Results:

Twelve LS were performed. Eleven of these patients had ITP, and one patient had sickle cell disease. The mean blood loss was 70mL (range, 50 to 460), and operating time was 126 minutes (range, 110 to 240). Two postoperative complications occurred: portal vein thrombosis in one case and subphrenic collection in the other. The literature review revealed 8 studies with 231 cases in which the LigaSure was used to perform laparoscopic splenectomy. A significant reduction in operating time (average 102 minutes) and intraabdominal blood loss (66mL) was observed with the LigaSure compared with endostaplers.

Conclusion:

The use of LigaSure and the semilateral position results in a gain of time and safety in addition to low intraoperative bleeding, need for transfusion, minimal complications and a low conversion rate.     

Vacuum Stabilization of the Spleen in Laparoscopic Splenectomy

Background and Objectives:

Recovery from laparoscopic splenectomy is greatly enhanced when compared with recovery from the laparotomy approach, yet a minority of spleens are removed laparoscopically. The spleen is smooth, rounded, and vascular, making it difficult to directly grasp, stabilize, or retract laparoscopically. The LiVac Retractor is a laparoscopic liver retractor comprising a soft silicone open ring that apposes 2 substantially planar surfaces when a vacuum is applied. It was evaluated for its efficacy in stabilization of the spleen during 2 laparoscopic splenectomies.

Methods:

The 2 patients gave consent for laparoscopic splenectomy with splenic retraction using the LiVac Retractor. The entire 3-port laparoscopic procedure was video recorded, with the resected spleens weighed as wet specimens. The patients'' postoperative courses are described.

Results:

The spleen was retracted securely for the duration of the hilar dissection in both patients. Exposure of the splenic hilum was excellent. There were no visible signs of injury to either spleen and recovery of both patients was unremarkable.

Conclusions:

The LiVac Retractor provided stable retraction and excellent exposure of the splenic hilum during both laparoscopic splenectomies, without organ injury. Early hilar dissection with vascular control was facilitated, reducing the risk of bleeding from other components of the dissection.     

减少腹腔镜脾切除术术中出血的初步体会

目的探讨预防和减少腹腔镜脾切除术(laparoscopic splenectomy,LS)术中出血的手术技巧和措施。方法2008年1月～2010年3月行LS 40例。脾动脉位于胰尾上缘者,先分离并结扎脾动脉主干,离断脾周韧带;脾动脉位于胰尾后方或胰尾内者,先离断脾周围韧带和剥离胰尾,显露和离断脾蒂血管,完成LS。结果完成LS 31例,LS联合LC 7例,LS联合胆囊切除,贲门周围血管离断术2例。术中切除副脾3例。手术时间90～210 min,平均130 min;出血量50～800 ml,平均160 ml。术后12～24 h胃肠蠕动恢复,术后24 h拔胃管后进食。术后住院5～9 d,平均7.5 d。1例特发性血小板减少性紫瘢(idiopathic thrombocytopenic purpura,ITP)术后效果不佳,血小板一直<50×109/L,口服泼尼松20 mg/d维持治疗;23例ITP随访4个月～2年,平均1年,无复发;2例门脉高压症随访1年,未发生消化道出血。结论围手术期改善凝血,提高血小板计数,术前行脾动脉CT血管造影,手术时在胰腺上缘结扎脾动脉,分离脾周围韧带时避免撕裂脾包膜,妥善处理脾蒂血管,谨慎对待门脉高压症患者,可减少LS术中出血。     

Cystic Lymphangioma of the Gallbladder: Report of a Case

Abdominal lymphangioma is usually diagnosed within the first 2 years of life and is extremely rare in adults. The most common location of abdominal lymphangioma is the mesentery, but there are sporadic reports of its development in the gallbladder. A 66-year-old woman was found to have a cystic lesion near the gallbladder. Preoperative studies, including endoscopic ultrasonography, computed tomography, and magnetic resonance imaging, showed a tumor with multilocular cystic structure, originating in the gallbladder fossa. The patient underwent exploratory laparotomy, and the mass was resected en bloc with the gallbladder, as there was no evidence of malignancy on intraoperative ultrasonography. Macroscopically, the tumor was a multilocular cystic mass, 6 × 3 × 2 cm in size, with a rough, sponge-like appearance. Histologically, the cystic tumor was diagnosed as a lymphangioma, originating in the gallbladder. To our knowledge, only three other cases of a cystic lymphangioma originating in the gallbladder have been reported in the medical literature of the world.     

Laparoscopic splenectomy for blunt trauma: a safe operation following embolization

Background  Embolization of the injured spleen from blunt trauma reduces the risk of continued or delayed hemorrhage in patients being treated with nonoperative management (NOM). Splenectomy is required in some patients following embolization due to continued bleeding or infarction with abscess formation. Laparoscopic splenectomy for blunt trauma can be done safely in patients following embolization. Methods  A retrospective chart review was conducted on patients undergoing splenectomy following embolization due to blunt trauma at two level I trauma centers. Minimally invasive techniques were compared to laparotomy for operative time, operative blood loss, and postoperative length of stay. Results  Eleven of 46 patients required splenectomy following embolization, eight for continued bleeding and three for abscess formation. Four of these patients had their spleens removed laparoscopically, three for continued bleeding and one for abscess formation. Patients undergoing laparoscopic splenectomy for continued bleeding had slightly longer operative times, more blood loss but shorter postoperative stay than those undergoing laparotomy. (96 versus 76 min, 500 versus 300 cc, and 4.0 versus 7.0 days, respectively). Laparoscopic removal of the abscessed spleen took 270 min compared to 55 and 90 min for the open procedures but the postoperative hospital stay was only 6 days compared to 10 and 13 days. There were no serious complications in any patients. Conclusion  Laparoscopic removal of the spleen following embolization for blunt trauma is safe and should be considered in patients that have persistent bleeding or are at risk for delayed bleeding, as well as patients in whom complications of infarction and abscess formation develop.     

应用血管闭合系统行腹腔镜脾切除11例报告

目的 探讨＂结扎速＂血管闭合系统（LigaSure vessel sealing system,LVSS）在腹腔镜脾切除术（laparoscopic splenectomy, LS）中的临床应用价值. 方法 2005年8月～2006年9月,使用LVSS行LS 11例.LVSS离断脾结肠韧带及脾胃韧带,在胰尾上缘分出脾动脉,可吸收夹夹闭,在近脾门处LVSS离断脾蒂. 结果 10例LS获成功,其中9例完全应用LVSS完成手术;1例因脾蒂分离困难,应用Endo-GIA离断脾蒂.1例因脾脏与周围组织粘连紧密中转开腹.手术时间60～150 min, 平均110 min;出血量80～400 ml. 无术后大出血、胰漏、胃漏等并发症发生. 结论 LS应用LVSS有安全、止血可靠、体内无异物存留等特点.     

急诊腹腔镜脾切除术在外伤性脾破裂中的应用

目的探讨急诊腹腔镜脾切除术（1aparoscopic splenectomy,LS）治疗外伤性脾破裂的可行性。方法回顾分析我院2010年11月-2012年3月因外伤性脾破裂行急诊Ls20例的临床资料,根据脾蒂的不同类型,18例用Endo．GIA施行一级脾蒂离断,2例用Hem-o-lok施行二级脾蒂离断。结果20例手术均成功,无中转开腹,手术时间80-180min,平均110min,术中腹腔内有出血约700-1,2500ml,平均1300ml。术后无明显并发症发生。20例术后随访6个月,所有患者10天基本恢复正常生活,15—45天恢复正常工作,无严重术后并发症。结论急诊Ls治疗外伤性脾破裂可行。     

腹腔镜二级脾蒂离断法脾切除

目的总结腹腔镜二级脾蒂离断法脾切除的应用价值。方法2006年9月～2007年5月,行腹腔镜二级脾蒂离断法脾切除13例,其中外伤性脾破裂出血5例、特发性血小板减少性紫癜2例、肝硬化脾功能亢进6例。结果全部镜下完成,未使用手辅助。手术时间150～300min,平均210min,术中出血50～800ml,平均350ml,术后住院5～9d,平均7.5d,无手术并发症。随访1～6个月,血小板均在正常范围。结论腹腔镜二级脾蒂离断法脾切除术安全、可行、微创。     

Laparoscopic Spleen-Preserving Pancreatic Tail Resection for an Intrapancreatic Accessory Spleen Mimicking a Nonfunctioning Endocrine Tumor: Report of a Case

Laparoscopic surgery is now performed for several pancreatic disorders, such as benign tumors of the pancreatic body or tail, which are a good indication for laparoscopic resection. However, the risk of pancreatic fistula after distal pancreatectomy, performed laparoscopically or by open surgery, is a topic of debate. We report the case of a 61-year-old man in whom a routine follow-up computed tomography (CT) scan showed a solid, well-defined mass, 1.5cm in diameter, in the pancreatic tail. The mass was homogeneously enhanced from the early phase to the super-delayed phase on enhanced CT. We suspected a nonfunctioning endocrine tumor of the pancreas, and surgery was performed laparoscopically. After dissecting the pancreatic tail away from the splenic hilum and the splenic vessels, it was resected using only a linear stapler. The histological diagnosis was an intrapancreatic accessory spleen. The patient was discharged on postoperative day 14, but was readmitted 6 days later because of a pancreatic fistula, which was treated by CT-guided percutaneous drainage.     

Laparoscopic splenectomy for solitary splenic tumors

Background  Solitary splenic masses are a rare entity. There is a paucity of data in the literature on the evaluation and laparoscopic treatment for splenic masses. To further elucidate the evaluation and laparoscopic management of splenic masses we evaluated our own data. Materials and methods  Data was collected retrospectively for all patients who underwent laparoscopic splenectomy (LS) in our institution for the diagnosis of a solid mass. Patients’ charts were reviewed. Complementary data was completed when needed by telephone interviews. Results  28 patients underwent LS for solid splenic masses between 1997 and 2006. Mean age was 54.3 years and 68% were women. Patients’ symptoms included abdominal pain (46.5%), anemia (32%), weight loss (21%), and palpable abdominal mass (21%). Fifty-three percent were asymptomatic at diagnosis. Preoperative patients’ imaging included computed tomography (92.8%), abdominal ultrasound (71.4%), and positron emission tomography (PET, 32%). Seven patients (25%) had a history of lymphoproliferative disease. The mass size as measured by computed tomography (CT) scan ranged from 4 to 11 cm. Three patients (10.7%) had multiple splenic lesions. Mean operative time was 125 min. Mean estimated blood loss was 200 ml. Five patients (17.9%) had massive splenomegaly. Conversion rate was 14.3%. In three patients (10.7%) the spleen was removed with additional organs’ tissue (stomach and pancreas). Two patients (7.1%) were reoperated. There was no postoperative mortality. Mean hospital stay was 4.7 days. Four patients (14.3%) were readmitted due to complications. Pathology revealed eight patients (28%) with benign tumors and the rest (71.4%) with malignant lymphoma. Conclusions  Splenic solid tumor is a rare entity. Most of the cases were eventually diagnosed as malignant tumors. In our series, all malignant tumors were non-Hodgkin lymphoma. The most common benign lesion was inflammatory pseudotumor. This study has demonstrated the feasibility and safety of LS for diagnosis and treatment of both benign and malignant tumors of the spleen.     

腹腔镜脾切除与开腹脾切除治疗肝硬变门静脉高压致脾功能亢进疗效比较的系统评价

目的系统评价腹腔镜脾切除（LS）与开腹脾切除（OS）治疗肝硬变门静脉高压致脾功能亢进的疗效。方法计算机检索了Cochrane Central Register of Controlled Trials、Cochrane Database of Systematic Reviews、Medline、Embase、CINAHL、CBM、CNKI、VIP和万方数据库中,所有关于LS术（LS组）与OS术（OS组）治疗肝硬变门静脉高压致脾功能亢进的随机对照试验和临床同期对照试验。根据纳入和排除标准筛选文献、提取资料和进行质量评价后,采用RevMan 5.1.0软件进行Meta分析。结果共纳入17篇临床同期对照试验和1篇随机对照试验。Meta分析结果显示：LS组患者的术中出血量、术后住院时间、术后并发症发生率及术后1 d的白细胞水平均低（短）于OS组（P〈0.05）;其手术时间、术后7 d的白细胞水平、术后血小板计数（1 d和7 d）、术后丙氨酸氨基转移酶水平（1 d和7 d）和术后总胆红素水平（1 d和7 d）与OS组比较差异均无统计学意义（P〉0.05）。结论 LS术有助于减少肝硬变门静脉高压致脾功能亢进患者的术中出血量,缩短术后住院时间,减少术后并发症的发生;但目前的证据尚不能证明LS术能改善此类患者的肝功能。     

Single Access Laparoscopic Splenectomy

Background:

Laparoscopic splenectomy has been performed in a standard fashion with 4 to 5 trocars since the early 1990s. Single access laparoscopy has recently gained interest, but single access laparoscopic splenectomy has not been reported to date. It has the possible benefits of less pain, faster recovery, better cosmesis, with theoretically similar costs to that of traditional trocars.

Methods:

A case is presented and the surgical technique of single access laparoscopic splenectomy is detailed.

Results:

The patient is an otherwise healthy 24-year-old male with medically refractory idiopathic thrombocytopenic purpura and a platelet count of 15 000. A splenectomy was performed using a single incision laparoscopic technique. The patient was placed in a right lateral decubitus position, and a 2.5-cm left upper quadrant incision was made. A multi-instrument flexible single incision port was used that held 3 trocars. A standard splenectomy was performed through this port. A linear stapler was used to transect the splenic hilum. The procedure time was just over 2 hours. The patient did well, was happy with his incision, and was discharged with a platelet count of 108 000.

Conclusions:

Single access laparoscopic splenectomy is feasible in select patients and may provide a less painful, better cosmetic result.     

Carcinoid Tumor of the Spleen: Report of a Case

Carcinoid tumors are uncommon tumors of the neuroendocrine system. They grow slowly and may remain silent for years before presenting with carcinoid syndrome. A diagnosis of asymptomatic carcinoid tumor is difficult. Wide resection of the primary tumor and metastatic lesions is the first choice of treatment. Primary carcinoid is sometimes distributed through-out the entire body, but it is rare in the spleen. We herein present a rare case of a symptomless carcinoid tumor that predominantly invaded the spleen with liver metastasis. Received: February 8, 2001 / Accepted: July 17, 2001     

Identification of Accessory Spleens During Laparoscopic Splenectomy Is Superior to Preoperative Computed Tomography for Detection of Accessory Spleens

Background:

Missed accessory spleen (AcS) can cause recurrence of hematologic disease after splenectomy. The objective of the study was to determine whether detection of AcS is more accurate with preoperative computed tomography (CT) scan or with exploration during laparoscopic splenectomy.

Methods:

A retrospective chart review was performed for 75 adult patients who underwent laparoscopic splenectomy for various hematologic disorders from 1999 to 2009. Preoperative CT scans were performed in all patients. Patients were followed for recurrence of disease, and a scintigraphy scan was performed in those with suspected missed AcS.

Results:

The most common diagnosis was idiopathic thrombocytopenic purpura in 29 patients (39%), followed by non-Hodgkin''s lymphoma in 22 patients (29%). Sixteen AcSs were found during surgery in 15 patients (20%), and preoperative CT scan identified 2 of these. Twelve AcSs were located at the splenic hilum (75%). Nine patients experienced recurrence of their disease, and none had a missed AcS on subsequent scintigraphy. Sensitivity of exploratory laparoscopy for detection of AcS was 100%, and for preoperative CT scan was 12.5% (P = .005).

Conclusion:

Exploratory laparoscopy during splenectomy is more accurate than preoperative imaging with CT scan for detection of AcS. Preoperative CT scan misses AcS frequently and should not be obtained for the purpose of its identification.     

Giant Cystic Lymphangioma of the Small Bowel Mesentery: Report of a Case

We herein describe the case of a 48-year-old man who presented to our hospital with abdominal distension and pain. Preoperative studies including abdominal ultrasonography and computed tomography failed to determine the cause of the pain. At laparotomy, a giant cystic tumor of the small bowel mesentery was found. Histologically, the tumor was diagnosed as a cystic lymphangioma. Although mesenteric lymphangiomas are rare, especially in adults, they should be considered as a possible cause of acute abdomen. Received: August 8, 2001 / Accepted: January 8, 2002     

腹腔镜脾脏手术成败因素分析

目的分析影响腹腔镜脾脏手术成败的各种因素，并总结应对这些因素的经验。方法对2001年9月至2012年11月共开展的183例腹腔镜脾脏手术进行统计，分析影响腹腔镜脾脏手术成败的各种因素，并总结应对这些因素的经验。结果所有病例由普外科不同医疗组操作完成。183例腹腔镜脾脏手术中，149例手术成功（成功率81.4％），30例中转开腹（中转率16．4％），4例出现术后并发症（并发症发生率2．2％）。结论多种因素共同决定了腹腔镜脾脏手术是否能够成功开展。充分术前准备，加强对这些因素的认识，能够确保腹腔镜脾脏手术的成功。     

Laparoscopic management of a ruptured giant epidermoid splenic cyst.

BACKGROUND: Epidermoid splenic cysts are uncommon lesions of the spleen. They are known to become symptomatic as a consequence of enlargement, infection, or rupture, the latter being an exceedingly rare complication traditionally treated with open splenectomy. We herein report a unique case of a giant epidermoid splenic cyst that ruptured spontaneously and was successfully treated with the laparoscopic approach. CONCLUSION: Laparoscopic surgery may be considered an initial treatment option in cases of very large epidermoid cysts even when rupture occurs.