Laparoscopic splenectomy: a single center experience. Unusual cases and expanded inclusion criteria for laparoscopic approach

Abstract

Laparoscopic splenectomy (LS) is nowadays considered as the gold standard for most hematological diseases where splenectomy is necessary, but many questions still remain. The aim of this study was to analyze our 5-years experiences consisting of 48 consecutive LS cases in order to assess the optimal approach and the feasibility of the procedure also in malignant diseases and unusual cases such as a primary spleen lymphoma, a big splenic artery aneurism, or a spleen infarct due to a huge pancreatic pseudo-cyst. Forty-eight consecutive patients underwent LS from January 2006 to January 2011 with at least 1-year follow-up. Clinical data and immediate outcome were retrospectively recorded; age, diagnosis, operation time, perioperative transfusion requirement, conversion rate, accessory incision, hospital stay, and complications were analyzed. We had 14 cases of malignant splenic disease, the most frequent malignant diagnosis was non-Hodgkin's lymphoma (12/14, 85.7 %). Splenomegaly (interpole diameter (ID) >20 cm) was observed in 12 cases (25 %) and massive splenomegaly (ID >25 cm) in 3 cases (6.25 %). Conversion to laparotomy occurred in two patients (4.16 %), both associated to uncontrollable bleeding in patients with splenomegaly. Mean operative time was 138 ± 22 min. Mean hospital stay was 4.5 days. Postoperative morbidity rate was 8.8 % for the benign group and 35.7 % in the malignant group. Mortality occurred in 1/48 patients (2.08 %), as a result of overwhelming post-splenectomy infection (OPSI). LS can be performed safely for malignant splenic disease and splenomegaly without any statistically significant increase of morbidity and mortality rate. Conversion rate is increased for massive splenomegaly. LS should be considered as the preferential approach even in patients with malignant disease, splenomegaly, or unusual cases. Massive splenomegaly should be considered as relative contraindication to LS even at experienced centers.

Laparoscopic Splenectomy for Benign Hematological Disorders in Adults: A Systematic Review

“…Most authors prefer the lateral approach for spleen mobilization (7,9,10,14,20). Almost all of them agree that the division of the gastrosplenic ligament and the short gastric vessels can be safely performed using an ultrasonic scalpel, while Al-Mulhim advocates the use of Ligaclips for the ligation of short gastric vessels greater than 4 mm in diameter (7).…”

“…A drain tube was routinely placed in all patients. Marte et al suggested that in cases of known or suspected malignancy, the spleen should be retrieved through a Pfannenstiel incision (14). A drain tube was left in all patients for 2 days.…”

“…Depending on each study's methodology, the mean operative time was reported as being between 75 and 162 min, (6,7,9,10,13,14,25,44), the mean operative time between 150 and 165 min (17,19) and the median operative time between 109 and 144 min (18,20). However, splenomegaly (7), low platelet count (9), anterior approach (10), indications other than immune thrombocytopenic purpura (ITP) (18,20) and concomitant laparoscopic cholecystectomy (18,20), significantly prolonged the operative time.…”

“…LS can be performed with minimal blood loss (mean 36-60 ml) (6,13,17,19,25) and significantly less blood loss compared to OS (14). In the study of Vecchio et al, platelet transfusion was occasionally required (1 out of 12 patients) (6); in other studies, the need for packed erythrocyte transfusion was rare (9, 10), while intraoperative blood loss of more than 600 ml (9), as well as the anterior approach (10), almost always lead to packed erythrocyte transfusion.…”

“…Encountering the hand-assisted technique as a modification of LS, literature reports a very low conversion rate to OS, varying between 0 and 4% (6,7,9,10,14,17,19). In order of frequency, intraoperative bleeding (9,10,14), splenomegaly (11,17), anterior approach (10) and surgeon's inexperience (10) constitute the main predisposing factors for conversion.…”