Elective Splenectomies Research Articles

Robotic-Assisted Splenectomy by a Modified Lateral Approach: Technique and Outcomes.

Introduction The utilization of robot-assisted technique for splenectomy has recently gained popularity especially in patients undergoing splenectomy for hematological indications owing to its magnification of and easy manipulation of internal abdominal organs. Moreover, robotic splenectomy emerged as an essential teaching module before approaching more complex robotic procedures. Methods A total of 43 elective splenectomies were performed for hematological indications in Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) between January 2018 to July 2023 of which 14 patients underwent robotic splenectomy. All patients underwent lateral approach of robotic splenectomy with a modification of avoiding the lesser sac dissection. Prospectively maintained data were retrospectively analyzed and results were recorded in terms of intra-operative time taken, blood loss, need for blood and blood product transfusion and postoperative morbidity and mortality. Results The indications for patients who underwent robotic splenectomy include idiopathic thrombocytopenic purpura in eight patients, autoimmune hemolytic anemia in three patients, Evans syndrome in one patient and hereditary spherocytosis in two patients. The median splenic diameter was 14.8cm and the median platelet count before the operation was 10,800 cells/cubic millimeter (7000-3,20,000). The mean operative time was 92 minutes and blood loss was 40ml. The median duration of hospital stay was 2.4 days. All 14 patients had therapeutic success and there was no procedure-related mortality or morbidity. Conclusion Robotic splenectomy using the modified lateral approach can safely be performed with comparable operative time, blood loss and overall morbidity. However further studies are mandatory to confirm the advantage of this modified technique of lateral approach of robotic splenectomy.

Elective Splenectomy for Haemolytic Anaemia: A Case Series

The spleen plays an important role in immune surveillance and haematopoiesis. Elective splenectomy is sometimes indicated for excessive cellular destruction (hypersplenism) or sequestration, lymphomatous or myeloid disease, or tumours. Hereditary haemolytic anaemias are disorders with a variety of causes, including red cell membrane defects, red blood cell enzyme disorders, congenital dyserythropoietic anaemias, thalassaemia syndromes, and haemoglobinopathies. Splenectomy is one of the therapeutic approaches in the management of haematological conditions. This is case series of 12 cases who underwent elective splenectomies for haemolytic anaemias in a tertiary care centre, over a period of one year. Out of the 12 patients, 10 patients were diagnosed to have Hereditary Spherocytosis (HS) and 2 patients were diagnosed with sickle cell anaemia. For all patients, preoperative blood transfusion was done to bring the Haemoglobin (Hb) above 9 g/dL for elective splenectomy. Among the 10 patients with HS, 6 patients had concomitant cholelithiasis for which cholecystectomy was done in the same sitting and three patients developed postoperative complication which was managed appropriately with no mortality and minimum morbidity. However, more detailed studies on this subset of patients are needed for the establishment of guidelines and optimal outcomes.

103. Evaluating The Appropriateness of Vaccine Administration in Patients with Splenectomy

Abstract Background The spleen removes microorganisms from the bloodstream and produces antibodies for enhanced immune response. Patients with asplenia are at increased risk for infections caused by encapsulated organisms and have a 6-fold increased risk of sepsis compared to the general population. Those that acquire an infection have a mortality rate of 80%. The CDC recommends administering the meningococcal, influenza, pneumococcal, and Haemophilus influenzae type B (Hib) vaccine at least 2 weeks before or after splenectomy. Methods This retrospective chart review evaluated the appropriateness of vaccine administration for patients undergoing splenectomy at Long Island Jewish Medical Center (LIJMC) from January 2016 to June 2020. Patients were included if they were admitted to LIJMC, 18 years or older, and had splenectomy at LIJMC within previous 7 years. Patients were excluded if they were pregnant, admitted to an outside hospital for splenectomy, or had an unknown time of splenectomy. The primary objective was appropriateness of vaccine administration. Inappropriateness was defined as having at least 1 error with administration, including vaccine omissions, timing of vaccine, sequencing (Pneumovax®23 given before Prevnar13®), vaccine interaction (Menactra® given with Prevnar13®), or duplicated vaccines. Results Of the 174 patients screened, 29 patients were included in analysis, with a mean age of 58.2 ± 20.6 years. The splenectomy was elective in 69% of patients and emergent in 31% of patients. The vaccine regimen was given inappropriately in 96.6% of patients. The reasons for inappropriateness were vaccine selection (100%), timing (39.3%), vaccine sequence (39.3%), vaccine interaction (14.3%), and duplicate vaccines (7.1%). Excluding emergent splenectomies, 100% of patients received an inappropriate vaccine regimen. The vaccines were given at least 2 weeks before elective splenectomies in 40% of patients, peri-operatively in 30% of patients, and not given in 25% of patients. Conclusion Patients undergoing splenectomy received inappropriate vaccine regimens mainly due to omissions, timing, and sequencing. Prevnar13® should be given before Pneumovax®23 when both are indicated and vaccines should be administered at least 2 weeks before splenectomy. An orderset was created to mitigate errors with vaccine selection for patients undergoing splenectomy. Disclosures All Authors: No reported disclosures.

HPB P64 An audit on the appropriate prescribing of antimicrobial prophylaxis and vaccinations in patients who underwent a splenectomy by the hepatobiliary department at University Hospital Southampton between January 2020 and April 2022

Abstract Background Patients who have an absent or dysfunctional spleen are at risk of overwhelming post splenectomy infection (OPSI), a condition associated with high mortality rates. The incidence of OPSI ranges from 0.1% to 8.5% (1). This is most commonly from Streptococcus pneumoniae but also from Haemophilus influenzae type b (Hib) and Neisseria meningitidis (2). These infections can have a sudden onset and run a fulminant course. The highest risk of infection is in childhood, age over 50 years old and in the first two years post splenectomy (3). Indications for splenectomy include trauma and malignancy. It is strongly advised that these patients have antibiotic prophylaxis and appropriate vaccinations administered to reduce the risk of OPSI. In University Hospital Southampton (UHS), the hepatobiliary department carry out elective splenectomies usually together with distal pancreatectomies and also do emergency splenectomies due to trauma (4). An audit was carried out at UHS to assess prescribing of antimicrobial prophylaxis and vaccinations in patients undergoing elective and emergency splenectomies by the hepatobiliary department at University Hospital Southampton between January 2020 and April 2022. Methods Patients who underwent a splenectomy at UHS between January 2020 and April 2022 were selected. The hospital inpatient record (CHARTs), e-prescribing record (JAC) and GP record (CHIE) were used to evaluate if patients received appropriate antimicrobial prophylaxis and appropriate vaccinations as per national and local guidelines detailed below. For patients undergoing an elective splenectomy, the pneumococcal vaccine (Pneumovax) should be given at least two weeks prior to surgery (2, 5). If this is not possible, and in emergency scenarios, patients should be given Pneumovax, the meningococcal ACWY vaccine (Menveo) and the meningococcal group B vaccine (Bexsero) two weeks post-surgery. A second dose of Bexsero should be given one month after this. Patients should have a booster dose of Pneumovax every five years and the Influenza vaccine yearly. Patients should receive intravenous benzylpenicillin or clarithromycin twice a day until the patient can take oral medication. This can be switched to phenoxymethylpenicillin twice a day or erythromycin twice a day. This should continue for two years or lifelong if they are in the ‘at risk’ group which includes; over 50 years old or under 16 years old, history of previous invasive pneumococcal disease and patients previously treated for haematological malignancy. Results 88 patients underwent a splenectomy between January 2020 and April 2022. 3% of patients had emergency surgery; the rest were elective cases. Indications for splenectomy included pancreatic cancer, intraductal papillary mucinous neoplasm (IPMN), splenic B cell lymphoma, pancreatitis, gastric varices, metastatic ovarian cancer and metastatic renal carcinoma. 21% of patients did not receive Pneumovax and 22% of patients did not receive Bexsero two weeks post-surgery. 23% of patients did not receive ACWY and 34% of patients did not receive the second dose of Bexsero 4 weeks post discharge. 30% of patients did not receive their yearly Influenza vaccination. Overall, 21% of patients received no vaccinations. 1% of patients did not receive prophylactic antibiotics on discharge. 39% of patients’ discharge paperwork did not have appropriate documentation about when vaccinations needed to be administered. Conclusions Compliance rates of vaccinations and antimicrobial prophylaxis should be 100% to prevent overwhelming post splenectomy infection. Data collection on patients who do not have a CHIE record proved difficult. While collecting data, it was noted that there has been guideline change between 2020 and 2021; In 2020, the ACWY vaccination was recommended to be administered 4 weeks post splenectomy. In 2021, this changed to 2 weeks later. In 2021, the requirement for the Hib vaccination was removed. A recurring issue during the audit process was a lack of documentation in patient discharge summaries. Whilst there are a proportion of patients who have not received their post-splenectomy vaccinations, it is reassuring to note that none of these patients had subsequent admissions to hospital with overwhelming infections based on their CHARTs records. We have created a proforma that can be brought up on CHARTs during follow up appointments for documentation of compliance with vaccinations. GPs can be easily contacted about missing vaccinations. We also recommended that all discharge paperwork have clear documentation of when vaccinations should be administered and that a re-audit should be done in 2023.

Robot-Assisted Versus Laparoscopic Approach for Splenectomy in Children: Systematic Review and Meta-Analysis.

Aim: To compare the outcomes of pediatric splenectomies for hematologic diseases performed by robot-assisted laparoscopic surgery (RALS) and laparoscopic approach. Materials and Methods: Web of Science, Scopus, and PubMed databases were systematically searched for publications in English language from January 2000 to March 2020. All the studies dealing with pediatric elective splenectomies performed by RALS were included. The primary outcomes were the rate of postoperative complications and conversion. The secondary outcomes were the length of hospital stay and the operative time. Results: The search yielded 969 articles. Ten articles were included in the systematic review. Eighty patients underwent RALS splenectomy. Thirteen postoperative complications (16%) were reported and RALS was converted to open surgery in five cases (6.3%). Five of the included articles, three retrospective studies and two case series, were considered relevant for the meta-analysis and dealt with 130 patients. Of them, 71 children (55%) underwent RALS. No difference in the rate of complications was found between the two approaches (P = .235). RALS presented a similar rate of conversion to open surgery (P = .301). The mean operative times and length of hospital stays for RALS, reported in three different studies, were 107.5, 159.6, 140.5 minutes and 4.2, 3.93, 2.1 days, respectively. Conclusion: Even if few studies were included in the review, this meta-analysis reported similar rates of complication and conversion for RALS when compared with laparoscopy. Further studies are required to prove that this innovative technique was as safe and feasible as the current gold standard technique.

Elective Splenectomy in Immune Thrombocytopenic Purpura: An Analysis of National Inpatient Sample (NIS) Database between Years 2006 and 2014

Background: Over the years, splenectomy has dropped out of favor as a treatment option for Immune Thrombocytopenic Purpura (ITP) and is now considered only for patients who have failed multiple lines of therapy. One of the major concerns is surgical morbidity. We aim to study in-hospital outcomes following elective splenectomy in this population Methods: This is a retrospective cohort analysis of NIS database (years 2006 to 2014). Patients ≥18 years of age, who had an elective admission associated with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) procedure code for splenectomy were included in the study. Our cohort of interest was patients with ITP who underwent elective splenectomy (ITP ES). ICD-9-CM diagnosis codes were used to identify patients with ITP. All other patients who underwent elective splenectomy were labeled as non-ITP ES. Utilization of intensive care services was identified by procedure codes associated with vasopressor use, cardiopulmonary resuscitation, mechanical ventilation and initiation of dialysis in the absence of pre-existing end stage renal disease. Primary outcome was inpatient mortality and secondary outcome was length of stay (LOS). Associated factors were analyzed using multivariate logistic regression analysis. A p-value <0.05 was considered significant. We used STATA for statistical analysis. Results: A total of 102,698 admissions for elective splenectomies (ES) in adults were identified between the years 2006 and 2014,of which 11.36% (n= 11,668) were ITP ES. Inpatient mortality and mean LOS for all patients undergoing ES was 2.53% and 8.51 days respectively. Inpatient mortality and mean LOS in the ITP ES cohort was 0.86% and 4.37 days respectively. In the entire cohort of ES, inpatient mortality was lower in those with ITP versus non-ITP (OR 0.36, p<0.001). Also females had lower mortality when compared to men (OR 0.50, p<0.001). Inpatient mortality was higher with increasing age (OR 1.03, p<0.001) and Charlson Comorbidity Index (CCI) ≥3 vs 0 (OR 1.54, p <0.001). Mean length of stay was lower in those with ITP vs non ITP by 3.3 days (p<0.001). Within the ITP-ES cohort, mortality was higher with increasing age (OR 1.12, p <0.001), CCI ≥3 vs 0 (OR 18.39, p< 0.0001) and CCI 2 vs 0 (OR 8.61, p 0.008). Inpatient mortality was lower in teaching hospitals compared to non-teaching hospitals with a trend towards significance (OR 0.35, p 0.05). Gender, insurance status, income quartile, geographic region and hospital size did not affect odds of inpatient mortality in this cohort. Length of stay (LOS) in ITP ES cohort had positive correlation with age (coefficient 0.038, p<0.001), income quartile 51-75th vs 0-25th percentile (coefficient 0.81, p 0.03), CCI ≥3 vs 0 (coefficient 3.29, p<0.001), CCI 2 vs 0 (coefficient 2.11, p<0.001), CCI 1 vs 0 (coefficient 0.86, p<0.001). There was no association of gender, insurance status and geographic region with LOS within this cohort. Conclusion: Inpatient mortality and length of stay in admissions for elective splenectomy was significantly lower in ITP patients compared to non ITP patients. Also, in ITP patients undergoing elective splenectomy, older age and a charlson comorbidity index of 2 or above were associated with higher odds of dying in the same admission.These findings from real world data have practical implications for clinicians and patients, as they weigh the pros and cons of splenectomy as a treatment option for ITP. Table Disclosures Donthireddy: Viracta: Other: PI for Clinical Trial.

Laparoscopic Splenectomy: Has It Become the Standard Surgical Approach in Pediatric Patients?

BackgroundSplenectomy is often required in the pediatric population as part of the treatment of hematologic disorders and can be performed laparoscopically or open. We evaluated the comparative effectiveness of laparoscopic (LS) and open (OS) splenectomies using the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) data set. MethodsThe NSQIP-P data set was used to identify children who underwent elective splenectomy between January 2012 and December 2016. Thirty-day outcomes between OS and LS, and LS alone and concurrent LS and cholecystectomy were compared using univariate and multivariate analysis. ResultsMost of the splenectomies (91%) were performed laparoscopically. There was no difference in overall complications between OS (n = 60) and LS (n = 613), although OS had a higher risk of perioperative transfusion (OR 3.19, 95% CI 1.52-6.69). LS was associated with a shorter median hospital length of stay (2 versus 4 d, P < 0.001) and similar mean operative times compared to OS (120 versus 133 min, P = 0.559). There was no difference in outcomes of children undergoing LS versus LS and concurrent cholecystectomy (n = 129). ConclusionsLS has become the standard approach for elective splenectomies in the pediatric population and has minimal morbidity, and when indicated, concurrent cholecystectomies do not increase the risk of complications. Levels of evidenceIII.

Laparoscopic versus open splenectomy for splenomegaly: the verdict is unclear.

The benefits of laparoscopic splenectomy (LS) over open splenectomy (OS) for normal-sized spleens have been well documented. However, the role of laparoscopy for moderate and massive splenomegaly is debated. A retrospective review of patients undergoing elective splenectomy at one institution from 1997 to 2017 was conducted. Moderate and massive splenomegaly was defined as splenic weight of 500-1000g and greater than 1000g, respectively. We performed a 1:2 matching of laparoscopic to open splenectomy to control for differences in splenic weight. Differences in perioperative morbidity (infection, thromboembolism, reoperation, readmission), intraoperative factors (blood loss, operative time), length of stay, and mortality were examined. A total of 491 elective splenectomies were identified. 268 cases were for splenic weights greater than 500g. After a 1:2 matching of LS:OS, we identified 22 LS and 44 matched OS for moderate splenomegaly. The LS group had longer mean operative times (178 vs. 107min, p < 0.01), with similar length of stay and blood loss. For massive splenomegaly, 26 LS were identified and matched to 52 OS. LS had longer mean operative times (171 vs. 112min, p < 0.01) and higher readmission rates (27% vs. 6%, p < 0.05). Other factors and outcomes did not differ between LS and OS for moderate or massive splenomegaly. The conversion rate for LS was higher for massive versus moderate splenomegaly, but was not statistically significant (35% vs. 14%, p = 0.09). LS for moderate and massive splenomegaly is associated with longer operative times. Other perioperative outcomes were comparable to OS, with no demonstrated benefits for LS. Although LS may be a feasible approach to moderate and massive splenomegaly, its benefits require further clarification in this patient population.

Laparoscopic splenectomy is emerging 'gold standard' treatment even for massive spleens.

Since its first description by Delaitre and Maignien in 1991, laparoscopic splenectomy (LS) has evolved as treatment of choice for mild-to-moderately-enlarged spleens and for benign haematological disorders. LS is a challenge if massive spleens or malignant conditions necessitate treatment, but we report our method and its feasibility in this study. We undertook a retrospective study of prospectively collected data of all elective splenectomies carried out in our firm of upper gastrointestinal surgeons from June 2003 to June 2012. Only patients opting for elective LS were included in this study. From June 2003 to June 2012, elective splenectomy was carried out in 80 patients. Sixty-seven patients underwent LS and 13 underwent open splenectomy (OS). In the LS group, there were 38 males and 29 females. Age ranged from 6 years to 82 years. Spleen size in the LS group ranged from ≤11 cm to 27.6 cm. Twelve patients had a spleen size of >20 cm. Weight ranged from 35 g to 2,400 g. Eighteen patients had a spleen weight of 600-1,600 g and eight had a spleen weight >1,600 g. Operating times were available for 56 patients. Mean operating time for massive spleens was 129.73 min. There was no conversion to OS. There were no major complications. With improved laparoscopic expertise and advancing technology, LS is safe and feasible even for massive spleens and splenic malignancies. It is the emerging 'gold standard' for all elective splenectomies and has very few contraindications.

Robotic splenectomy: what is the real benefit?

The laparoscopic approach to a difficult splenectomy requires a longer total operative time and is frequently associated with an increased risk of bleeding and a high conversion rate. A total of 418 elective splenectomies were registered in the Department of General Surgery and Liver Transplantation of Fundeni Clinical Institute between January 1995 and June 2012, of which 299 splenectomies (212 laparoscopic and 77 robotic) were performed by a single surgical team and retrospectively documented. The effect of the learning curve and the relative complexity of each type of procedure were analyzed using the Minimally Invasive Splenectomy Score, which further allowed categorizing the splenectomies as simple or difficult. Statistical analyses using the CUSUM algorithm of the intra- and postoperative parameters of the laparoscopic and robotic approaches, for both the simple and the difficult splenectomies, were performed. The results of the statistical analyses clearly indicated that there was a learning curve effect for laparoscopic splenectomy but not for robotic splenectomy. When compared with the laparoscopic approach in difficult splenectomies, the robotic approach had a shorter total operative time (84.13 vs. 97.2 min), less blood loss (30.88 vs. 156.9 ml), and decreased risk of hemorrhagic complications during surgery. Laparoscopic splenectomy remains the approach of choice for simple splenectomies in the surgical treatment for common indications. The robotic system is particularly beneficial in difficult splenectomies (i.e., partial splenectomy, splenectomy in liver cirrhosis, splenic tumors, or malignant hemopathies).

Outcomes of laparoscopic versus open splenectomy

PurposeLaparoscopic techniques have gained wide clinical acceptance in surgical practice today. The laparoscopic approach has been established as the technique of choice for elective splenectomies performed on normal sized spleens. The purpose of this study was to evaluate the outcome of patients undergoing laparoscopic splenectomy (LS) at the TOBB University of Economics and Technology (ETU) Hospital and Kecioren Training and Research Hospital.MethodsOne hundred and thirty-five patients underwent splenectomy between January 2000 and July 2010. For comparison, the records of 130 patients undergoing splenectomy were evaluated for age, gender, hospital stay, time to start of diet, conversion rate, operation time and wound infection.ResultsMean operation time means the time interval between surgeon commencing operation to end of operation. Mean operation time in patients treated by LS was 132 minutes and 121 minutes in open splenectomy (OS). Mean hospital stay was 5.65 days in patients undergoing LS and starting of diet was 1.21 days. In patients treated by OS, mean hospital stay was 9.17 days, starting of diet was 2.37 days. Four patients were converted to open surgery. Conversion rate was 6.4 percent. In the early post operative period (within 10 days of surgery) 9.2%, LS group had lower incidences of wound infection rate after surgery than OS group (4.8%, 7.4%, respectively; P = 0.06).ConclusionLS is a safe and effective alternative to OS for treatment of splenic diseases in patients of all ages.

Laparoscopic Splenectomy in a Minimal Resource Setting

This study examines the perioperative outcome of laparoscopic splenectomy in a minimal resources setting in the Caribbean. Seventeen consecutive patients who underwent elective laparoscopic splenectomies by a single surgeon from August 2003 to December 2008 were studied. Data collected included patients' demographics, indications for surgery, operative time, complications, and outcome. 88% were females, the median age being 33.3 years. Idiopathic thrombocytopenic purpura was the most common indication (82%) in majority of the cases. Other indications included hereditary spherocytosis, hypersplenism, and metastatic disease. The mean operative time was 88.8 minutes and the mean hospital length of stay was 3.3 days. One case was converted to open splenectomy. Five patients experienced postoperative complications. There was no mortality. Despite limited blood banking facilities and hematology support, laparoscopic splenectomy may be safe in minimal resources setting, if cases are selected carefully and performed by an experienced surgeon with short operative times.

Elective laparoscopic splenectomy for giant hemangioma: a case report

Although unusual, hemangioma is the most common primary splenic neoplasm. Splenectomy is indicated when the tumor is large, with increased risk of hemorrhage. The laparoscopic approach is preferred for most elective splenectomies. Although technically feasible, laparoscopic splenectomy can be a challenge in the patient with splenomegaly. We present herein a case of an 18-year-old male asymptomatic patient who underwent laparoscopic splenectomy for the incidental finding of splenomegaly caused by a large splenic hemangioma. Laparoscopic splenectomy appears to be a safe and effective procedure, in appropriately experienced hands, for patients with splenomegaly, given the spleen's fragile anatomy and its relationship to other abdominal viscera.

Does open surgery continue to have a role in elective splenectomy?

Since it was first reported in 1991, laparoscopic splenectomy has become the procedure of choice for elective splenectomy. However, doubts have been raised regarding the suitability of patients with splenomegaly (>1 kg) for laparoscopic resection because there have been reports of greater morbidity and higher conversion rates in this group of patients. Since 2000, patients referred to the authors' center for splenectomy with an estimated spleen weight exceeding 1 kg have undergone splenectomy by the open approach. Between September 1995 and April 2005, 95 elective splenectomies were performed by a single surgeon. Operative data were collected prospectively. A comparison between the operations that took place before 2001 (n = 47) and those performed after 2000 (n = 48) for all sizes of spleen showed significant reductions in conversion rate, operative time, and hospital stay in the later group. As compared with laparoscopic splenectomy (n = 11), open splenectomy (n = 18) for cases of splenomegaly resulted in a significantly shorter operative time, less operative blood loss, and no significant difference in hospital stay. Although laparoscopic splenectomy is the treatment of choice for the majority of patients requiring elective splenectomy, the procedure for patients with significant splenomegaly requires caution and common sense. This study shows that an open splenectomy for these patients significantly reduces operative time and blood loss without increasing morbidity or hospital stay.

Klinische Relevanz von Nebenmilzen nach elektiven und notfallmäßigen Splenektomien

Clinical Relevance of Accessory Spleens Following Elective and Emergency Splenectomies Background: With respect to the various functions of the spleen, a careful risk-benefit analysis must be done before splenectomy. Methods: During 10 years, 211 splenectomies were carried out in our hospital. In 185 of these clinical cases the documents were complete for an analysis. Results: The most frequent indications for surgical treatment were immunothrombocytopenia (22.2%) and lymphogranulomatosis (18.9%) followed by spleen bleedings (24.3%) of traumatically, iatrogenic or spontaneous origin. Postoperative complications such as pulmonary and cardiological disorders, disorders in wound healing, and abscesses could be found in 31.3% of the elective and in 80.4% of the emergency cases. 5.2 and 21.9% of the patients died after elective treatment and emergency surgery, respectively, resulting in an overall mortality of 10.8%. In the latter group death was mostly related to the severe concomitant injuries. The main problem during the postoperative period is the high rate of infections which could be attributed to the loss of an immunologically active organ. Postoperative thrombocytosis was temporary in most cases. A sepsis developed in 4.9% of the patients with a lethal outcome in 2.7% of the cases. 13.5% of the patients showed accessory spleens. In those patients suffering from immunothrombocytopenia and lymphogranulomatosis, they were even found in 22 and 20% of the cases, respectively. 12.1% of the 58 reinspected patients showed accessory spleens; some of them even had multiple accessory spleens. Mostly, solitary accessory spleens were found. They were located in the neighborhood of the spleen or – after splenectomy – in the former spleenic area. The size of accessory spleens ranged between some millimeters and 5 cm with an average length of about 1–2 cm. Accessory spleens were either completely unobtrusive with no function at all, or they can take over some spleenic functions, regardless of their size and location. Especially in combination with immunothrombocytopenia, they may be responsible for the failure of an otherwise successful splenectomy. However, relapses after splenectomy could not generally be attributed to accessory spleens since relapses also occurred after additional exstirpation of accessory spleens. Conclusion: As some accessory spleens take over specialized functions of the spleen while others remain unobtrusive, the benefit of splenectomy for the treatment of blood-related malignancies is hardly foreseeable.

The Ascendance of Laparoscopic Splenectomy

The application of laparoscopic techniques for abdominal procedures has been achieved with varying success. The general acceptance of laparoscopic splenectomy (LS) may be hindered by its infrequent performance and difficulty in manipulating the spleen. A retrospective review of splenectomies performed for primary splenic pathology was done to assess the role and outcome of LS. One hundred fifty LSs were performed from July 1995 through September 1999. Over that time period the proportion of LS performed increased steadily from 17 to 75 per cent of all splenectomies. The primary indications for splenectomy included immune thrombocytopenic purpura in 75 (50%), lymphoma/leukemia 36 (24%), and splenomegaly 19 (13%). There were 86 females and 64 males. Immediately before operation 36 patients (4%) had a platelet count <50,000/ mL, and 24 patients (16%) a hemoglobin <10 mg per cent. The mean operative time was 161 minutes with an average blood loss of 138 cm3 (<50-800). The mean morcellated weight of the entire group was 411 g (33-3300) indicating generally large splenic size. In the 37 patients with splenomegaly the mean weight was 735 g (293-3300). There were two conversions to open splenectomy. Two patients with hematologic malignancy, splenomegaly, and cytopenias died from overwhelming post-splenectomy sepsis (1.3%). Morbidity occurred in 14 (9%) with the most common complication being pancreatitis in seven (5%). The median length of postoperative stay was 2.4 days (range 1-5). In summary LS has rapidly replaced the open approach for nearly all elective splenectomies in adults and children. When performed with the patient in the lateral position it can be accomplished with minimal morbidity, even in complex patients, including those with splenomegaly.

Is splenectomy more dangerous for massive spleens?

background Reports vary about whether risks are greater for removal of massive (≥1500 g) spleens than for smaller (<1500 g) spleens. We sought to determine the hazards of splenectomy. methods: We reviewed 223 consecutive adults with elective splenectomies for hematologic diseases. Morbidity and mortality rates were combined with published data to create a meta-analysis. results Patients with massive spleens are more likely to have postoperative complications (relative risk [RR] 2.1, 95% confidence interval [Cl] 1.3 to 3.4; P = 0.003) and death (RR 4.7, 95% Cl, 1.5 to 15.1; P = 0.01). However, when the investigation is restricted to comparable diagnoses, patients with massive spleens do not differ from those with smaller spleens regarding complications (RR 1.4, 95% Cl, 0.8 to 2.7; P = 0.3) or mortality (RR 2.1, 95% Cl, 0.5 to 9.7; P = 0.4). These observations are confirmed by metaanalysis. Furthermore, multivariate analysis indicts age as a critical risk of complications and death. conclusions Increased age and underlying illness are the predominant factors associated with morbidity and mortality following splenectomy for hematologic disease. Adjusting for age and diagnosis, spleen size is not a hazard.

The Superiority of the Left Subcostal Incision Compared to Mid-line Incisions in Surgery for Morbid Obesity.

We describe a 13-year experience using a left subcostal incision in performing gastroplasties and Roux-en-Y gastric bypasses (RYGBP) in morbidly obese patients. We have also used it successfully in the general population in several other types of surgical procedures, including Nissen fundoplications in adults and infants, gastrectomies, truncal vagotomies, pyloroplasties, jejunoileal bypass reversals, and elective splenectomies. Over 200 cholecystectomies have been carried out through this incision as additional procedures with relative ease, not requiring any further extension of the incision. There were no hernias in a group of 1,067 primary gastroplasty and RYGBP patients, and the wound infection rate has been quite low, apparently because of the incision's distance from the potentially contaminated umbilicus. We feel that the use of this incision further simplifies and therefore adds a safety factor not seen with the standard vertical incision in this group of surgical patients.

SPLENECTOMY FOR IMMUNE THROMBOCYTOPENIC PURPURA: AUCKLAND EXPERIENCE 1979–87

Of 148 elective splenectomies performed in Auckland during 1979-87, 48 were performed as therapy for immune thrombocytopenic purpura (ITP). In all cases medical therapy had either failed to maintain their platelet count (36 patients), or side-effects of medical treatment had made continuation unacceptable (12 patients). The mean age of the group was 31 years and there were 15 males and 33 females. Thirty-four of 48 patients (71%) had a favourable response to splenectomy: platelet count was maintained above 150 x 10(9)/l and medical therapy was no longer required. There was no operative or inhospital mortality. Seven patients experienced postoperative complications (mainly infections) of which none were life-threatening. There was no difference in response between males and females (67% and 73% response rate, respectively), and the response rates of Europeans and non-Europeans were similar (71% and 69%, respectively). By contrast, the average age of the responders [29 years) was almost 10 years younger than the non-responders (38 years). It is concluded that the use of splenectomy as therapy for patients with ITP, who have either failed to respond to medical management or for various reasons cannot tolerate the complications associated with steroid therapy, is a safe procedure which in the present series was associated with no operative mortality and an acceptably low rate of morbidity. Younger ITP patients (less than 30 years) have a better chance of responding favourably to splenectomy than do older patients (greater than 40 years).

Complications after elective splenectomy in children.

Elective splenectomies performed in children aged 0-14 during the period 1968 to 1977 have been reviewed. One hundred and twelve children were splenectomized during the period studied. The indication for splenectomy was usually a haematological disorder e.g. hereditary spherocytosis or idiopathic thrombocytopenia. As splenectomized children run the risk of developing overwhelming sepsis, inquiries have been sent to all children. Two cases of nonfatal pneumococcal septicaemia are reported. Although the incidence of septicaemia is low, spleensaving operations are to be preferred where possible. When splenectomy is performed, pneumococcal antibodies should be determined. If a low titre is found, polyvalent pneumococcal vaccine should be used.