Laparoscopic splenectomy using ligasure

BACKGROUND: Intraoperative bleeding is the main complication and main cause of conversion during laparoscopic splenectomy (LS). We present the advantages of the use of the Ligasure Vessel Sealing System added to lateral approach for achieving a safe vascular control. METHODS: Ligasure is an energy-based device which works applying a precise amount of bipolar energy and pressure to the tissue, achieving a permanent seal. We have performed a total of 35 LS in a 5-year period using different approaches and methods of dissection, including the anterior approach, monopolar coagulation, clips, endostaplers, and ultrasonic shears. In the last 10 patients (4 males and 6 females, mean age 24 yr) we employed a technique with 4 trocars, right semilateral position associated with the entire dissection of the spleen and vessels sealing (lower pole vessels, main vascular pedicles, short gastric vessels) performed with Ligasure. Six had thrombocytopenic idiopatic purpura (ITP), 2 hereditary spherocytosis and one each b-thalassemia and hemolytic anemia. RESULTS: Nine LS were completed with one (10%) conversion because of hilar bleeding due to accidental injury with Ligasure. The average splenic weight was 485 g (range 265-1800), with an average diameter of 16 cm (range 12-25). In all but one patients (the converted one) the intraoperative blood loss was less than 100 mL (range 50-100 mL, average 80 mL). No blood transfusion were needed. The average operative time was 120 min (range 90-165), including 2 patients undergoing combined laparoscopic cholecystectomy. There was no mortality, with one (10%) postoperative complication (thrombosis of the spleno-portal axis), treated with a conservative approach. The average postoperative hospital stay was 3.5 days (range 3-6). CONCLUSIONS: The use of Ligasure, associated with the lateral position, results in a gain of time and safety. Furthermore, the average intraoperative bleeding of this series is very low.     

The pubic midline exposure for symphyseal open reduction and plate fixation

Background

Open reduction and plate fixation of the disrupted symphysis pubis is commonly performed through a horizontal Pfannenstiel incision. Certain clinical situations that complicate the soft tissue conditions of the lower abdomen may make the Pfannenstiel incision a less appealing option. We report on the use of a vertical pubic area midline skin incision in a series of patients undergoing open reduction and plate fixation of their traumatically disrupted symphysis pubis.

Materials and methods

Institutional Review Board approval was obtained for a retrospective chart review of the charts of 25 patients treated between September 2011 and October 2012. Their charts were reviewed for patient age, gender, body mass index (BMI), pelvic injury type (as classified by Young and Burgess), mechanism of injury and associated traumatic injuries. The depth of the approach was estimated using the pelvic computed tomography (CT) scan. Details from the operative procedure were recorded, as was the length of follow-up and any perioperative complications.

Results

Twenty-five patients were eligible for inclusion during the defined study time period between September 2011 and October 2012. The patients’ average age was 55.8 years (range 25–91). All patients were males. The average BMI was 29.3 (range 18.8–43.8). The depth measured on the axial pelvic CT scan from skin to symphysis was 57.6 mm (range 35.2–90.2 mm). Five of 25 patients had an isolated pelvic ring injury without other associated injuries. The injury pattern was APC2 in 18, APC3 in 3, LC2 in 2, LC3 in 1 and VS in 1 patient(s) [anterior posterior compression (APC), lateral compression (LC), vertical shear (VS)]. Urologic procedures were performed in the same surgical setting in four patients. The average blood loss was 244 ml (range 150–400 ml). The average follow-up was 2.5 months (range 1–12 months). Perioperative issues were noted in two patients. One patient died within a month of surgery as a result of his associated traumatic injuries. One patient developed a deep infection.

Conclusion

The pubic midline skin exposure is a feasible alternative to the Pfannenstiel incision for open reduction and plate fixation of the pubic symphysis.

Level of evidence

IV, Retrospective case series     

Laparoscopic splenectomy: experience of a single center in a series of 300 cases

Background

Laparoscopic splenectomy (LS) has gradually become the technique of choice for surgical removal of the spleen. The aim of this study was to evaluate the efficacy of LS in a large cohort of patients from a single center.

Methods

From March 1992 to June 2010, 300 patients underwent LS at our hospital for predominantly hematologic disorders. The first 92 cases were performed using an anterior approach, whereas in the remaining 208 cases a lateral approach with a four-trocar technique was used. Patient demographics, diagnosis, and outcomes were reviewed.

Results

Spleen volume was similar between the anterior (350?ml) and the lateral (370?ml) approaches. The lateral approach was associated with shorter operative time (60 vs. 80?min), less blood loss (30 vs. 110?ml), and no conversion (0 vs. 2.2?%) compared to the anterior approach. Reoperations were required in three patients (1.0?%) because of bleeding, subphrenic abscess, and intestinal ischemia. Postoperative complications were significantly fewer for the lateral (4.8?%) than for the anterior (31.5?%) approach and the hospital stay was shorter (3.1 vs. 5.2?days) and there was less postoperative pain. Splenectomy for hematologic malignancies resulted in a higher morbidity rate, more postoperative pain, and longer hospital stay. Overall mortality rate was 0.3?%. No late complications were observed during the 1–5-year follow-up.

Conclusions

LS using the lateral approach with the placement of four trocars can be considered the procedure of choice for both benign and malignant diseases affecting the spleen. Extensive experience and technical standardization help to avoid surgical pitfalls, providing an adequate control of hemostasis, the excision of accessory spleens (AS), and the avoidance of parenchymal rupture.     

Optimizing laparoscopic splenectomy

Background: Laparoscopic splenectomy (LS), like other advanced laparoscopic procedures, is still an evolving procedure. The indications for surgery, criteria for patient selection, and operative technique are not yet well defined. We have therefore modified the standard technique for performing LS in an attempt to optimize the procedure. Methods: Over the past 2 years, we have performed LS in 59 patients. The last 43 patients were operated using a standardized technique that we believe to be optimal. It includes the routine use of the right lateral position, operating through three trocars, the mass transection of the splenic vasculature with a vascular endoscopic stapler, and the use of a self-retaining retrieval bag. Results: The average operating time was 79 min. Average blood loss was 95 cc, and average postoperative hospitalization was 2.3 days. There was one intraoperative complication and one postoperative complication. These results are superior to those we achieved earlier in our own experience, as well as to similar series that have been published recently. Conclusions: In our experience, the use of this new technique resulted in relatively short procedures with low morbidity. We believe that these results justify the use of LS as the procedure of choice for elective splenectomy in patients with normal or moderately enlarged spleens.     

Sutureless and stapleless laparoscopic splenectomy using radiofrequency

Background Bleeding is the main complication and cause of conversion during laparoscopic splenectomy (LS). We present the advantages of the LigaSure vessel sealing system added to the lateral approach for achieving safe vascular control. Methods We performed 63 consecutive LS in a 3-year period using LigaSure in two affiliated university hospitals. We employed a right semilateral position technique with dissection of the spleen and vessel sealing using LigaSure. Forty-two patients had benign hematological disease, 19 had malignant disease, and two had splenic cysts. Results A total of 58 LS were completed with five conversions due to hilar bleeding (three cases), difficult dissection (one), and massive splenomegaly (one). In all but five patients, blood loss was less than 100 ml. No transfusions were needed. There were five postoperative complications: portal thrombosis (one case), hemoperitoneum (two), surgical wound infection (one), and pleural effusion (one). Conclusions The use of LigaSure, and the semilateral position, results in a gain of time and safety. Furthermore, average intraoperative bleeding is very low. Paper presented in part at the 13th European Association for Endoscopic Surgery (EAES) Congress, Venice, Italy, June 2005     

后外侧入路腹腔镜脾切除术:附37例报告

目的探讨后外侧入路腹腔镜脾切除术（LS）的临床应用价值。方法1994年12月至2005年12月我院在开展16例前入路LS的基础上，采用后外侧入路完成37例LS，回顾分析后外侧入路LS的临床资料。结果除1例因套圈套扎脾蒂失败，遂扩大切口将脾脏提至腹壁按常规手术处理脾蒂外，其余手术均在完全腹腔镜下完成。切除脾脏长径7～18cm，7例病人发现副脾（18．9％）。术后切口感染1例，平均手术时间为130min，平均术中失血量80ml，平均术后住院5．5d。结论后外侧入路有利于LS操作，是一种值得推广的手术入路。     

Comparison of blood vessel sealing among new electrosurgical and ultrasonic devices

Background

Bipolar electrosurgical devices and ultrasonic devices are routinely used in open and advanced laparoscopic surgery for hemostasis. New electrosurgical and ultrasonic instruments demonstrate improved quality and efficiency in blood vessel sealing.

Methods

The 5-mm laparoscopic Gyrus PKS? Cutting Forceps (PK), Gyrus Plasma Trissector? (GP), Harmonic Scalpel^® (HS), EnSeal? Tissue Sealing and Hemostasis System (RX), LigaSure? V with LigaSure? Vessel Sealing Generator (LS), LigaSure? V with Force Triad? Generator (FT), and Ligamax? 5 Endoscopic Multiple Clip Applier (LM) were tested to compare burst pressure, sealing time, and failure rate. Each device was used to seal 13 small (2–3 mm diameter), 13 medium (4–5 mm diameter), and 13 large (6–7 mm diameter) arteries from euthanized pigs. A p value <0.05 was considered statistically significant.

Results

Mean burst pressures were not statistically different for 2–3 mm or 6–7 mm vessels. For 4–5 mm vessels, LS had the highest mean burst pressure recorded. Mean seal times were shorter for every vessel size when FT was compared with LS (p < 0.05). The shortest sealing times for 2–3 mm vessels were recorded for GP. The shortest sealing times for medium and large vessels were observed with FT. The highest percentage failure rate for each vessel size occurred with GP. For 4–5 mm diameter vessels, the failure rate was 48% for GP, 41% for PK, and 22% for HS. For 6–7 mm diameter vessels, the failure rate was 92% for GP, 41% for PK, and 8% for HS. LM and FT had no recorded failures.

Conclusion

Among the new 5-mm laparoscopic electrosurgical and ultrasonic instruments available for testing, RX, LS, and FT produced the highest mean burst pressures. FT had the shortest mean seal times for medium and large vessels. Minimal or no seal failures occurred with HS, RX, LS, LM, and FT.     

Incidence of major and minor vascular injuries during lateral access lumbar interbody fusion procedures: a retrospective comparative study and systematic literature review

During lateral lumbar fusion, the trajectory of implant insertion approaches the great vessels anteriorly and the segmental arteries posteriorly, which carries the risk of vascular complications. We aimed to analyze vascular injuries for potential differences between oblique lateral interbody fusion (OLIF) and lateral lumbar interbody fusion (LLIF) procedures at our institution. This was coupled with a systematic literature review of vascular complications associated with lateral lumbar fusions. A retrospective chart review was completed to identify consecutive patients who underwent lateral access fusions. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used for the systematic review with the search terms “vascular injury” and “lateral lumbar surgery.” Of 260 procedures performed at our institution, 211 (81.2%) patients underwent an LLIF and 49 (18.8%) underwent an OLIF. There were no major vascular complications in either group in this comparative study, but there were four (1.5%) minor vascular injuries (2 LLIF, 0.95%; 2 OLIF, 4.1%). Patients who experienced vascular injury experienced a greater amount of blood loss than those who did not (227.5?±?147.28 vs. 59.32?±?68.30 ml) (p?=?0.11). In our systematic review of 63 articles, major vascular injury occurred in 0–15.4% and minor vascular injury occurred in 0–6% of lateral lumbar fusions. The systematic review and comparative study demonstrate an increased rate of vascular injury in OLIF when compared to LLIF. However, vascular injuries in either procedure are rare, and this study aids previous literature to support the safety of both approaches.

     

腹腔镜脾切除术治疗特发性血小板减少性紫癜

目的：探讨腹腔镜脾切除术治疗特发性血小板减少性紫癜的手术安全性、可行性和临床疗效。方法：回顾性分析35例内科治疗无效的特发性血小板减少性紫癜患者行腹腔镜脾切除术的临床资料。33例成功地完成腹腔镜脾切除术。另2例在腹腔镜脾切除后脾床渗血，施行小切口脾床止血。结果：手术时间70～180min，平均4120min。术中出血量20-600mL，平均120mL。平均住院时间6．4d，无并发症发生。术后随访3～20个月，平均lO个月，19例完全有效，12例部分有效，总有效率88．6％。结论：腹腔镜脾切除术治疗特发性血小板减少性紫癜安全可行、痛苦少、恢复快。     

Laparoscopy Splenectomy for Massive Splenomegaly

ABSTRACT

Objective: This study is aimed to evaluate the feasibility of laparoscopic splenectomy (LS) for massive splenomegaly in patients with hypersplenism secondary to portal hypertension and liver cirrhosis. Method: A retrospective study of adult patients was conducted for splenectomy occurring from January 2006 to December 2010. We have performed the surgical procedures of splenectomy in 80 patients who were suffering from splenomegaly or hypersplenism secondary to portal hypertension and liver cirrhosis, among whom 40 patients underwent LS and another 40 patients received open surgery (OS). Results: Among the patients who had undergone LS, 2 patients were converted to OS and the other 38 patients underwent complete LS. The operation time, intraoperative blood loss, and the length of stay in LS group and OS group were 100–200 min (mean: 150 ± 30 min) vs. 120–210 min (mean: 100 ± 30 min), 50–1,000 ml (mean: 150 ± 110 ml) vs. 60–900 ml (mean: 140 ± 50 ml) and 4–9 days (mean: 6.1 ± 2.2 days) vs. 8–14 days (mean: 11.3 ± 2.3 days), respectively. No deaths occurred in the two groups, and there are no significant differences between the two groups in terms of estimated blood loss, complications, length of stay, and operating time. Conclusion: LS for treatment of massive splenomegaly is a feasible, effective, and safe surgical technique. Hypersplenism secondary to portal hypertension and liver cirrhosis are not supposed to be considered absolute contraindications to LS.     

Lichen sclerosus in men is associated with elevated body mass index, diabetes mellitus, coronary artery disease and smoking

Purpose

To elucidate disease associations and possible etiology of lichen sclerosus (LS), we identified comorbidities present in men with LS. LS is a chronic inflammatory disease of unknown etiology affecting genitals and urethra of men commonly resulting in strictures.

Methods

Men with LS of the urethra, penis, prepuce and scrotum were identified. A control population was generated from men seen in the Department of Urology matched by age and race in a 5:1 ratio. A case–control study was performed and comorbidities identified by ICD9, CPT codes and medication use via systematic electronic medical record review. Subgroup analysis of men with urethral strictures was performed based on their LS status.

Results

Men with LS had a significantly higher mean body mass index [31.0 (range 18.9–52.6)] compared to controls [28.1 (16.8–64.1), p = 0.001], significantly increased rate of coronary artery disease (CAD) (15.3 vs. 8.9 %, p = 0.05) as well as a twofold higher rate of diabetes mellitus (15.5 vs. 8.3 %, p = 0.02). Of men with LS and stricture disease, 11/19 (58 %) were current or former smokers, compared to 28 % of men with strictures without LS (p = 0.006). No association of LS with other morbidities like hyperlipidemia, hypertension, cerebrovascular disease, peripheral vascular disease or dermatologic disorders was found.

Conclusions

Men suffering from LS have an increased BMI and a higher prevalence of concomitant CAD, diabetes mellitus and tobacco use. Development and chronicity of LS may not be a purely dermatologic condition, but be associated or confounded by systemic or vascular compromise from disorders of CAD, DM and smoking.     

Operative outcome of laparoscopic colorectal cancer surgery in a regional hospital in a developing country: A propensity score-matched comparative analysis

ObjectiveLaparoscopic surgery is an alternative procedure for colorectal cancers. However, high-level supporting evidence has been derived from high-volume centers in developed countries. During the early phase of applying the laparoscopic approach, we evaluated the procedure’s short-term outcomes in our regional middle-volume hospital in a developing country.MethodsWe retrospectively analyzed data for a cohort of 223 colorectal cancer patients who underwent elective surgery from October 2017 to September 2019. We compared 165 patients undergoing open surgery (OS group) with 58 undergoing laparoscopic surgery (LS group) using a propensity score-matched analysis.ResultsAfter matching, each group contained 58 patients for evaluating outcomes. The LS group had more harvested mesenteric lymph nodes (5.0 nodes, 95% confidence interval (CI): 1.8–8.1; p-value: <0.01) with comparable blood loss (p-value: 0.54) and margin status (p-value: 0.66). However, LS was more time-consuming (68.8 min longer; 95% CI: 53.0–84.7; p-value: <0.01). Morbidity and mortality rates were equivalent (odds ratio (OR): 1.3, 95% CI: 0.25–2.73, p-value: 0.74, and OR: 2, 95% CI: 0.18–22.1, p-value: 0.57, respectively). The LS group experienced fewer days to begin normal eating (?0.5 days, 95% CI: ?0.9 to ?0.1, p-value: 0.04) and shorter hospital stay (?1.5 days, 95% CI: ?2.7 to ?0.4, p-value: <0.01). The conversion rate was 3.5%.ConclusionThe laparoscopic approach was applicable even in a regional middle-volume hospital in a developing country. However, longer surgical time was a drawback.     

Incisional Complications and Cosmetic Evaluation After Hand-assisted Retroperitoneoscopic Donor Nephrectomy

PurposeHand-assisted retroperitoneoscopic (HARP) donor nephrectomy prevents major complications, but incision site complications may be more frequent in hand-assisted approach. We evaluated long-term incisional complication rates and cosmetic outcomes after HARP donor nephrectomy in our series.Materials and MethodsA total of 609 donors who underwent nephrectomy between February 2009 and June 2016 were invited for physical examination and face-to-face interview. A total of 209 donors (35.3%) participated to the study. Sex, age, body mass index (BMI), mean follow-up period, incision-related outcomes of cosmesis, and postoperative complications were evaluated. Body image scale (BIS) and cosmetic scale (CS) (scar test) questionnaires were applied. Higher cosmesis and body image scores indicated greater satisfaction.ResultsA total of 191 donors had paramedian (91.4%), and 18 donors had Pfannenstiel incision (8.6%); 121 donors were female (57.9%). The donor mean age and BMI were 49.1 (SD, 1.8) years and 29.7 (SD, 5.1), respectively. Body mass index was significantly lower in the Pfannenstiel group (P < .001). The mean BIS score was 18.9 (SD, 1.8), and the CS questionnaire score was 19.3 (SD, 4,7). The BIS score was significantly better in donors with Pfannenstiel incisions (P < .001), but there was no statistical significance in CS score. The total rate of wound infection was 4.8%, and rate of incisional hernia was 4.8%. The rate of incisional hernia was more frequent in donors with paramedian incision (5.2%), but there was no statistical significance. Six donors (2.9%) required rehospitalization because of incision site complications.ConclusionHand-assisted retroperitoneoscopic donor nephrectomy avoids intra-abdominal complications, but rate of incision site complications can be higher in hand-assisted procedure. The donors were convinced from the cosmetic outcome after HARP donor nephrectomy. The ones who had Pfannenstiel incision had better satisfaction according to BIS score.     

Vascular anatomy and surgical approach in oblique lateral interbody fusion at lumbosacral transitional vertebrae

BackgroundOblique lateral interbody fusion (OLIF) at lumbosacral junction is typically performed on the central window between the bifurcations of iliac vessels. However, the central window of lumbosacral transitional vertebrae (LSTVs) is usually obstructed by the iliocaval venous structures. We aimed to describe the vascular anatomy and surgical approach in OLIF at LSTVs compared with those in OLIF at typical L5-S1 junction.MethodsSixty-eight consecutive patients who underwent OLIF at lumbosacral junction were included. Of these, 31 patients had LSTVs and 37 patients had typical L5-S1 junction. The position of the iliocaval junction and the configuration of the left common iliac vein were compared using the preoperative CT and MR images of the lumbar spine. The surgical approach and intraoperative vascular findings were analyzed.ResultsAlmost 70% of LSTVs had the iliocaval junction at low or very low position. Mobilization of left common iliac vein for central window was potentially difficult in almost 74% of OLIF at LSTVs while it was not required or was potentially easy in almost 80% of OLIF at typical L5-S1. Vascular injury was identified in 2 (6.5%) patients with OLIF at LSTVs and in 3 (8.1%) patients with OLIF at typical L5-S1 junction (P = 0.904).ConclusionsIn our series, OLIF at LSTVs was performed through lateral window in 93.5% of the cases. Preoperative evaluation of the iliocaval junction using CT/MR of lumbar spine was reliable and valid in the determination of OLIF approach at lumbosacral junction.     

Implementation of laparoscopic splenectomy in children and the incidence of portal vein thrombosis diagnosed by ultrasonography

Background

The aim of this study is to evaluate if symptomatic or asymptomatic PVT, as diagnosed with ultrasonography (US), occurs more often in children after the introduction and implementation of LS compared to open splenectomy.

Methods

A retrospective cohort of 76 splenectomized patients for benign hematological disease were analyzed, 24 after open splenectomy (OS) and 52 after LS.

Results

In six of the OS and 40 after LS a postoperative US was obtained. In two patients after LS, a PVT was seen on US. Both patients were symptomatic and also underwent a laparoscopic cholecystectomy. The length of stay in the hospital was significantly shorter for LS (median 4.5 days, range 2–12) compared to OS (median 7 days, range 5–12), (P = .00). Median operation time of OS was 65 min (range 35–130 min) and of LS 170 min (range 85–275 min) (P = .00). There was no difference in postoperative complications.

Conclusion

The risk of developing a PVT after laparoscopic splenectomy seems low, and thus LS is not contraindicated in patients with benign hematological disease. When combining LS and laparoscopic cholecystectomy, prophylactic heparin might be considered.     

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。     

The Pfannenstiel scar and its implications in DIEP flap harvest: a clinical anatomic study

Background

Despite the utility of the deep inferior epigastric artery perforator (DIEP) flap, the presence of abdominal wall scars can limit flap perfusion. Pfannnstiel scars are among the most common abdominal scars, during which undermining at either a subfascial or suprafascial level can damage perforators. There is an anecdotal belief that raising a DIEP flap in the presence of a Pfannenstiel scar may be less reliable due to vascular disruption.

Methods

A clinical prospective analysis of retrospectively recorded imaging from 150 patients (300 hemi-abdominal walls) was undertaken. Preoperative imaging, with two computer software programmes used to reconstruct three dimensional (3-D) volume-rendered images and analyse vasculature, was used to accurately identify and measure perforators.

Results

A total of 959 perforators were identified, with 319 perforators identified in the ‘Pfannenstiel scar’ group and 640 perforators in the ‘no abdominal scar’ group. All patients, except for one patient with a Pfannenstiel scar, had one or more perforators that were larger than 1.0 mm in diameter. There were no differences in the number of DIEA perforators (6.81 vs 6.22, p?=?0.2819); however, perforators of the ‘Pfannenstiel scar’ group were of larger mean diameter than the ‘no abdominal scar’ group (0.96 vs 0.85 mm (p?=?0.0027).

Conclusions

The presence of a Pfannenstiel scar is associated with larger perforator size than controls and no diminution in overall perforator number. As such, a Pfannenstiel scar may in fact aid DIEP flap harvest, a finding consistent with anecdotal outcomes.Level of Evidence: Level III, risk / prognostic study.

     

True benefit or selection bias: an analysis of laparoscopic versus open splenectomy from the ACS-NSQIP

Background

By virtue of the benefits associated with minimally invasive approaches, laparoscopic splenectomy (LS) is believed to have better patient-related outcomes compared to open splenectomy (OS). However, there are limited data directly comparing the two techniques.

Methods

Patients who underwent elective LS and OS between 2005 and 2010 were identified from the public use file of the ACS-NSQIP database using the Current Procedural Terminology codes 38120 and 38100. Patients who had concomitant procedures were excluded. Because of the nonrandom assignment of surgical techniques, a selection bias could have been responsible for the differences in patient outcomes. Therefore, patient characteristics and comorbidities that were available and could have been potential confounders were compared and regression analysis was performed to determine independent risk factors associated with serious and overall morbidity as well as mortality.

Results

During the study period 1,644 and 851 patients underwent LS and OS, respectively. Compared to patients who underwent LS, patients who had OS had a longer median length of hospital stay (3 vs. 6 days, P < 0.0001) and higher incidences of serious (7 vs. 17 %, P < 0.0001) and overall morbidity (12 vs. 25 %, P < 0.0001) and mortality (1.4 vs. 3.3 %, P = 0.02). However, there were certain significant differences in the characteristics and comorbidities of the patients that could have confounded outcomes. On regression analysis, OS was not associated with higher mortality (OR = 1.43, 95 % CI 0.7–2.7, P = 0.28) but was associated with higher serious morbidity (OR = 1.8, 95 % CI 1.4–2.3, P = 0.001) and overall morbidity (OR = 2.0, 95 % CI 1.6–2.4, P = 0.0001).

Conclusion

After adjusting for available confounders, patients who underwent LS had lower morbidity and similar mortality rates. Although certain confounders such as previous surgical history, underlying pathology, and spleen size could still have potentially influenced outcomes, the data suggest that patient outcomes after LS are excellent and when technically possible a minimally invasive technique should be the preferred approach for splenectomy.     

Laparoscopic robotic liver surgery: the Henri Mondor initial experience of 20 cases

Laparoscopic liver surgery is now an established practice in many institutions. It is a safe and feasible approach in the hands of trained surgeons. The introduction of robotics into surgery represents progression in the field of minimally invasive surgery but has seen a slow uptake in the hepatopancreaticobiliary subspeciality. We report our initial experience in 20 cases of laparoscopic robotic liver resection (LRLR). From March 2011 to April 2013 patients with lesions within the liver were assessed and consented for laparoscopic robotic liver surgery. This is a retrospective analysis of a prospectively kept database on preoperative details and intraoperative and postoperative outcomes. During the time period there were 20 LRLRs. The median age was 62 years (range 39–80 years) with a male to female ratio of 14:6. Ten patients had left lateral sectionectomies, 10 patients had atypical segmental resections; 14 patients had resections for malignancies, 6 patients had resections for benign disease. One case was converted to open resection. The mean operating time was 176.4 ± 74.6 min (range 60–300 min), the mean blood loss was 107 ± 106 ml (range 50–700 ml) and the mean hospital stay was 6.5 ± 3.7 days (range 2–16 days). Two patients required blood transfusions. The incidence of postoperative complications was 10 % (n = 2). LRLR overcomes some of the disadvantages of conventional laparoscopic surgery. It is a technically feasible and safe approach for wedge resections and left lateral sectionectomy of the liver without oncological compromise. However, this surgical technique requires advanced laparoscopic skills and there is an associated steep learning curve. Further studies are needed to determine the potential advantages of this technique for the patient compared to the traditional laparoscopic approach.     

Laparoscopic splenectomy: an evolving technique

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