Laparoscopic Spleen-preserving Research Articles

A splenic pseudocyst following laparoscopic sleeve gastrectomy: a case report

This is the first report of a patient presenting with a splenic pseudocyst following laparoscopic sleeve gastrectomy (LSG). A 26-year-old male with no chronic medical illnesses who underwent LSG presented with vague abdominal pain. An abdominal contrast-enhanced computed tomography revealed a 15 cm well-circumscribed cyst originating from the spleen. Intraoperatively, the findings were significant for a superficial cyst located at the lower pole of the spleen. A laparoscopic spleen-preserving procedure was conducted, specifically marsupialization and packing with omentum. The postoperative period was uneventful, and the patient was discharged on Day 2 postoperatively. The patient was free from complaints at outpatient follow-up clinics. Follow-up visits at the outpatient clinic were free from complaints. Pathology confirmed a splenic pseudocyst, and cytology was unremarkable. Since dissection during LSG is close to the spleen, infarction could occur, predisposing to pseudocyst formation. Marsupialization is an excellent surgical option when applied to appropriate splenic cyst types.

Comparison of Outcomes Between Laparoscopic and Open Spleen-Preserving Gastrectomy in D2 Radical Gastrectomy of Upper and/or the Middle of the Stomach: a Systematic Review and Meta-analysis

Comparison of Outcomes Between Laparoscopic and Open Spleen-Preserving Gastrectomy in D2 Radical Gastrectomy of Upper and/or the Middle of the Stomach: a Systematic Review and Meta-analysis

Short-term efficacy evaluation of laparoscopic spleen-preserving splenic hilus lymphadenectomy and left epigastrium mesogastric excision for advanced proximal gastric cancer based on mesangial anatomy

Objective: To investigate short-term efficacy of laparoscopic spleen-preserving splenic hilus lymphadenectomy and left epigastrium mesogastric excision for advanced proximal gastric cancer based on mesangial anatomy. Methods: A case series study was carried out. Case inclusion criteria: (1) patient was confirmed as gastric adenocarcinoma by gastroscopic biopsy before operation; (2) locally advanced gastric cancer was confirmed by abdominal CT before operation; (3) no distant metastases such as liver, lung, and posterior peritoneal lymph nodes, and no tumor directly invading the pancreas, spleen, liver, and colon were verified by superficial lymph node ultrasound, chest and abdominal CT before operation;(4) total gastrectomy or proximal gastrectomy plus D2 lymphadenectomy were performed, and R0 resection was confirmed by postoperative pathology. Exclusion criteria: (1) intraperitoneal dissemination or distant metastasis was found during laparoscopic exploration; (2) No.10 lymph nodes were significantly enlarged or fused into clusters; (3) pathological diagnostic data were incomplete. According to above criteria, the clinicopathological data of 36 patients who underwent laparoscopic spleen-preserving No.10 lymphadenectomy and left epigastrium mesogastric excision based on interspace anatomy for advanced proximal gastric cancer in The First Affiliated Hospital of Zhengzhou University from June 2017 to March 2018 were retrospectively collected and analyzed. The intraoperative conditions, postoperative recovery and complications of patients were analyzed. Results: In 36 patients, the mean age was (59.8±8.0) years, the mean BMI was (23.9±3.5) kg/m(2), and 8 cases (22.2%) received preoperative chemotherapy. All the patients underwent successfully the laparoscopic spleen-preserving splenic hilus lymphadenectomy and left epigastrium mesogastric excision. In the examination of postoperative resected specimens, it was found that the mesangial boundary of the upper and posterior part of the stomach was smooth, indicating the efficiency of complete mesangial resection. No case was converted to open operation. The mean time of lymph node dissection and mesangial resection was (34.2±11.4) minutes. The mean blood loss during operation was (44.8±21.3) ml. The mean number of lymph node dissection per patient was 45.6±17.6. The mean number of No. 11p+11d lymph node dissection was 3.1± 2.8 per patient, and 7 patients were pathologically positive with metastasis rate of 19.4% (7/36). The mean number of No.10 lymph node dissection was 2.9±2.5 per patient, and 2 patients were pathologically positive with metastasis rate of 5.6% (2/36). The time to postoperative flatus was (3.8±0.6) days, time to removal of nasogastric was (1.9±0.7) days, time to the first intake of fluid was (3.0±0.4) days, time to removal of drainage tube was (6.0±1.2) days. Postoperative mean hospital stay was (12.8±4.0) days. One case (2.7%) developed pulmonary embolism and 1 case (2.7%) developed gastroplegia after operation. The morbidity of postoperative complication was 5.6% (2/36). No operative site infection, postoperative bleeding and death within postoperative 30-day were observed. All the 36 patients were followed up and the median follow-up was 18 months (12-28 months). Seven patients died of tumor relapse and metastasis (3 cases died within postoperative 1 year) and another 1 case developed colonic cancer 17 months after operation. Conclusion: Laparoscopic spleen-preserving splenic hilus lymphadenectomy and left epigastrium mesogastric excision for advanced proximal gastric cancer based on mesangial anatomy is safe and feasible.

Safety and Feasibility of Laparoscopic Spleen-Preserving Splenic Hilar Lymphadenectomy During Total Gastrectomy for Advanced Proximal Gastric Cancer: A Randomized Clinical Trial

Background: The splenic hilar lymph node (No. 10 LN) dissection is still controversial for patients with advanced proximal gastric cancer (APGC) not invading the greater curvature. The present study aimed to evaluate the short-term outcomes of laparoscopic spleen-preserving No. 10 lymphadenectomy (LSPL) for APGC not invading the greater curvature and the characteristic of No. 10 LN metastasis. Methods: This single-center, open-label, randomized, phase III clinical trial was done in the Department of Gastric Surgery, Fujian Medical University Union Hospital (FMUUH). Individuals aged 18 to 75 years who had histologically proven gastric adenocarcinoma in proximal stomach with clinical stage cT2-4a/N0-3/M0 not invading the greater curvature were enrolled and randomized (1:1) to receive laparoscopy-assisted total gastrectomy with either D2 lymphadenectomy (D2 group) or D2 lymphadenectomy without No. 10 LN dissection (D2- group). The main outcomes were morbidity and mortality within 30 days after surgery, number of retrieved LNs, and the metastasis rate of No. 10 LN. Analysis was based on modified intention-to-treat. Findings: From Jan 5, 2015, to Dec 10, 2018, 268 participants were randomly assigned to the D2 and D2- groups respectively. The full analysis set consisted of 263 participants in the D2 and D2- groups respectively. There were no significant differences in the intraoperative and postoperative morbidity between the D2 and D2- groups (all P>0.05). And there was no mortality in either group. There were more retrieved LNs in the D2 group than in the D2- group (45.1 vs 40.6, P=0.001). The metastasis rate of the No. 10 LN was 13.3% (35/263): 4.9% (2/41) in the early stage, and 14.9% (18/223) in the advanced stage. Pathological T (pT) stage and pN stage were related to No. 10 LN metastasis. The metastasis rates of No. 10 LN in T3-4a tumors located in the lesser curvature, posterior wall or multiple parts were all higher than 10%. Interpretation: Experienced surgeons can safely perform LSPL for APGC with more retrieved LNs. For APGC located in the lesser curvature, posterior wall or multiple parts with a clinical stage cT3-4a, dissection of the No.10 LN is necessary. Trial Registration: The study is registered with ClinicalTrials.gov, number NCT02333721; the trial has ended and this report represents the final analysis. Funding Statement: This study was supported by Scientific and Technological Innovation Joint Capital Projects of Fujian Province (2016Y9031; 2017Y9011). Construction Project of Fujian Province Minimally Invasive Medical Center (No. [2017]171). Fujian Science and Technology Innovation Joint Fund Project (2017Y9004). Joint Funds for the Innovation of Science and Technology of Fujian Province (2018Y9041). Special Fund for Clinical Research of Wu Jieping Medical Foundation (No: 320.6750.17511). Declaration of Interests: There are no conflicts of interest or financial ties to disclose from any authors. Ethics Approval Statement: The trial protocol was approved by the FMUUH Ethics Committee, and all participants provided written informed consent.

Safety and feasibility of laparoscopic spleen-preserving No. 10 lymph node dissection for locally advanced upper third gastric cancer: a prospective, multicenter clinical trial

Previous retrospective studies have shown that laparoscopic spleen-preserving D2 total gastrectomy (LSTG) for advanced upper third gastric cancer (AUTGC) is safe. However, all previous studies were underpowered. We therefore conducted a prospective, multicenter study to evaluate the technical safety and feasibility of LSTG for patients with AUTGC. Patients diagnosed with AUTGC (cT2-4a, N-/+, M0) underwent LSTG at 19 institutions between September 2016 and October 2017 were included. The number of No. 10 lymph node (LN) dissections, metastasis rates, intraoperative and postoperative complications were investigated. A total of 251 patients were enrolled in the study, and 242 patients were eligible for the per protocol analysis. The average numbers of No. 10 LN dissections and metastases were 2.4 and 0.1, respectively. Eighteen patients (7.4%) had No. 10 LN metastases, and among patients with advanced gastric cancer, the rate of No. 10 LN metastasis was 8.1% (18/223). pN3 status was an independent risk factor for No. 10 LN metastasis. Intraoperative complications occurred in 7 patients, but no patients required conversion to open surgery or splenectomy. The overall postoperative complication rate was 13.6% (33/242). The major complication and mortality rates were 3.3% (8/242) and 0.4% (1/242), respectively. The number of retrieved No. 10 LNs, No. 10 LN metastasis and TNM stage had no significant influence on postoperative complication rates. LSTG for AUTGC was safe and effective when performed by very experienced surgeons, this technique could be used in patients who needed splenic hilar lymph node dissection.

Laparoscopic splenic vessels and spleen-preserving extended distal pancreatectomy for single metastatic renal cell carcinoma.

Laparoscopic splenic vessels and spleen-preserving (SVSP) distal pancreatectomy has been recommended to reduce long-term risk of developing infectious complications. Due to its technical challenge, most cases relate to <50% of the pancreatic gland being excised. We present our first case of a patient incidentally found to have a solitary pancreatic metastatic renal cell carcinoma (RCC), following left nephrectomy for kidney cancer 15 years ago. He underwent laparoscopic SVSP-extended distal pancreatectomy (EDP). Final histopathology confirmed the diagnosis and margins were clear. He made a good recovery and despite loosing >70% of his pancreas, hasn’t developed new-onset diabetes. No adjuvant chemotherapy was necessary, but he will require long-term follow-up. This case suggests that even when the pancreatic lesion is located more proximally, near or at the pancreatic neck, laparoscopic SVSP-EDP may still be considered a safe and preferable option despite its greater complexity, increased intraoperative bleeding risk and longer operative time.

Safety and Feasibility of Laparoscopic Spleen-Preserving No. 10 Lymph Node Dissection for Locally Advanced Upper Third Gastric Cancer: A Phase II Prospective, Multi-Institution Clinical Trial (CLASS-04)

Background: Previous retrospective studies have shown that laparoscopic spleen-preserving D2 total gastrectomy (LSTG) for advanced upper third gastric cancer (AUTGC) is safe. However, all previous studies were underpowered. We therefore conducted a prospective, multicenter, single-arm, phase II study to evaluate the feasibility of LSTG in patients with AUTGC. Methods: Between September 2016 and October 2017, 251 patients with newly diagnosed AUTGC (cT2-4a, N-/ , M0) underwent LSTG at 19 institutions. The primary endpoint was complication within 30 days of surgery. Postoperative outcomes were also investigated, including the number of No. 10 lymph node (LN) dissections, metastasis rates of No.10 LNs, and intraoperative complications. Findings: A total of 251 patients were enrolled in the study, and 242 patients were eligible for the per protocol (PP) analysis. The average numbers of No. 10 LN dissections and metastases were 2.38 and 0.12, respectively; 18 patients (7.4%) had No. 10 LN metastases, and among patients with advanced gastric cancer, the rate of No. 10 LN metastasis was 8.1% (18/223). A pN3 status was an independent risk factor for No. 10 LN metastasis. Intraoperative complications occurred in 7 patients, but no cases were converted to open surgery or underwent splenectomy. The overall postoperative complication rate was 13.6% (33/242). The major complication and mortality rates were 3.3% (8/242) and 0.4% (1/242), respectively. The number of retrieved No. 10 LNs, No. 10 LN metastasis and p-stage showed no significant influence on postoperative complication rates. Interpretation: LSTG for AUTGC was safe and effective when conducted by experienced surgeons. Further phase III randomized controlled trials are warranted to validate its long-term significance. Trial Registration Number: The study was registered at ClinicalTrials.gov as NCT02845986. Funding: The study was sponsored by the Scientific and technological innovation joint capital projects of Fujian Province (2016Y9031); Construction Project of Fujian Province Minimally Invasive Medical Center (No.[2017]171); The second batch of special support funds for Fujian Province innovation and entrepreneurship talents (2016B013); Chinese physicians association young physician respiratory research fund of Fujian province medical innovation project (2015-CXB-16). Declaration of Interest: We declare no competing interests. Ethical Approval: the study was approved by the institutional review boards of all participating hospitals. All investigators conducted this study in accordance with the Declaration of Helsinki. Written informed consent was obtained before patients were recruited.

Laparoscopic spleen-preserving complete splenic hilum lymphadenectomy for advanced proximal gastric cancer

For advanced proximal gastric cancer, total gastrectomy with D2 lymphadenectomy is the standard surgical therapy containing splenic hilum lymph nodes (LNs) dissection. However, laparoscopic spleen-preserving complete splenic hilum LNs dissection for advanced proximal gastric cancer is technically challenging. Herein, we introduced an omnibearing method for laparoscopic spleen-preserving complete splenic hilar lymphadenectomy in racial total gastrectomy. The order of lymphadenectomy was No. 4d and 6 LNs-No. 12a, 8a, 9 and 7 LNs-No. 1, 3 and 5 LNs-No. 4sb, 4sa and 2 LNs-No. 10 and 11 (anterosuperior) LNs-No. 10 and 11 (posterior) LNs. During dissecting No. 10 and 11 LNs, we divided them into two parts, namely LNs anterosuperior and posterior to the splenic vessel. Laparoscopic total gastrectomy with spleen-preserving splenic hilum LNs dissection using an omnibearing method for advanced proximal gastric cancer was safe and technically feasible in experienced hands. Further studies in terms of its clinical significance are needed.

Learning Curve of the Application of Huang Three-Step Maneuver in a Laparoscopic Spleen-Preserving Splenic Hilar Lymphadenectomy for Advanced Gastric Cancer.

To investigate the learning curve of the application of Huang 3-step maneuver, which was summarized and proposed by our center for the treatment of advanced upper gastric cancer.From April 2012 to March 2013, 130 consecutive patients who underwent a laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) by a single surgeon who performed Huang 3-step maneuver were retrospectively analyzed. The learning curve was analyzed based on the moving average (MA) method and the cumulative sum method (CUSUM). Surgical outcomes, short-term outcomes, and follow-up results before and after learning curve were contrastively analyzed. A stepwise multivariate logistic regression was used for a multivariable analysis to determine the factors that affect the operative time using Huang 3-step maneuver.Based on the CUSUM, the learning curve for Huang 3-step maneuver was divided into phase 1 (cases 1–40) and phase 2 (cases 41–130). The dissection time (DT) (P < 0.001), blood loss (BL) (P < 0.001), and number of vessels injured in phase 2 were significantly less than those in phase 1. There were no significant differences in the clinicopathological characteristics, short-term outcomes, or major postoperative complications between the learning curve phases. Univariate and multivariate analyses revealed that body mass index (BMI), short gastric vessels (SGVs), splenic hilar artery (SpA) type, and learning curve phase were significantly associated with DT. In the entire group, 124 patients were followed for a median time of 23.0 months (range, 3–30 months). There was no significant difference in the survival curve between phases.AUGC patients with a BMI less than 25 kg/m2, a small number of SGVs, and a concentrated type of SpA are ideal candidates for surgeons who are in phase 1 of the learning curve.

Laparoscopic spleen-preserving complete splenic hilum lymphadenectomy for advanced proximal gastric cancer

For advanced proximal gastric cancer, total gastrectomy with D2 lymphadenectomy is the standard surgical therapy containing splenic hilum lymph nodes (LNs) dissection. However, laparoscopic spleen-preserving complete splenic hilum LNs dissection for advanced proximal gastric cancer is technically challenging. Herein, we introduced an omnibearing method for laparoscopic spleen-preserving complete splenic hilar lymphadenectomy in racial total gastrectomy. The order of lymphadenectomy was No. 4d and 6 LNs-No. 12a, 8a, 9 and 7 LNs-No. 1, 3 and 5 LNs-No. 4sb, 4sa and 2 LNs-No. 10 and 11 (anterosuperior) LNs-No. 10 and 11 (posterior) LNs. During dissecting No. 10 and 11 LNs, we divided them into two parts, namely LNs anterosuperior and posterior to the splenic vessel. Laparoscopic total gastrectomy with spleen-preserving splenic hilum LNs dissection using an omnibearing method for advanced proximal gastric cancer was safe and technically feasible in experienced hands. Further studies in terms of its clinical significance are needed.

Application of Huang's three-step maneuver for laparoscopic spleen-preserving splenic hilus lymphadenectomy for advanced proximal gastric cancer

Objective To investigate the clinical efficacy of Huang's three-step maneuver in laparoscopic spleen-preserving splenic hilar (No. 10 lymph node) lymphadenectomy for advanced proximal gastric cancer. Methods The clinical data of 122 patients who underwent laparoscopic spleen-preserving No. 10 lymphadenectomy for advanced proximal gastric cancer by Huang's three-step maneuver at the Affiliated Union Hospital of Fujian Medical University from March 2013 to December 2013 were retrospectively analyzed. All the patients received laparoscopy-assisted radical total gastrectomy combined with spleen-preserving D2 lymph node dissection. The intraoperative and postoperative recoveries and complications of patients were analyzed. All patients were followed up by outpatient examination, visit, correspondence and telephone interview up to March 1, 2014. Results One patient received splenectomy due to intraoperative splenic artery injury and the other 121 patients received successfully laparoscopic spleen-preserving No. 10 lymphadenectomy. The operation time, volume of intraoperative blood loss, time and volume of blood loss in No. 10 lymphadenectomy were (175 ±27) minutes, (60 ±43) mL, (21 ± 8) minutes and (15 ±13 ) mL, respectively. The total and mean numbers of lymph node dissection in 122 patients were 4 797 and 44 ±18, respectively. The total and mean numbers of No. 10 lymph node dissection were 354 and 2.9 ± 2.4, respectively. Thirty-seven No. 10 lymph node metastases were detected in 15 patients, with a metastasis rate of 12.30% (15/ 122). The time to anal exsufflation, time for fluid diet intake, duration of hospital stay and incidence of complications were (4.0 ± 0.8) days, (4.9 ± 1.8) days, (12 ± 7) days and 11.48% (14/ 122) , respectively. All the 122 patients were followed up for a median time of 8 months (range, 2-12 months). No tumor recurrence, tumor metastasis and death were observed during follow-up. Conclusions Huang's three-step maneuver simplifies the complicated surgical procedures of laparoscopic spleen-preserving No. 10 lymphadenectomy for advanced proximal gastric cancer, its clinical efficacy is satisfactory with an advantage of clinical application. Key words: Gastric neoplasms; Laparoscopy; Splenic hilar; Lymph node dissection

Comments to young surgeons concerning laparoscopic spleen-preserving D2 lymph node dissection for advanced gastric cancer on the upper body.

Qualified radical gastrectomy with lymph node dissection is very important to the prognosis of patients with gastric cancer. Now D2 lymph node dissection is standard procedure for gastric cancer surgery, and spleen hilar lymph node dissection is mandatory for gastric cancer in upper body. Because the anatomy of vessels in this area is very complicated, D2 lymph node dissection is technical challenging not only for open gastrectomy but also for laparoscopic one. Adapting a new technique is important to all surgeons, but we surgeons should always consider a patient's safety as the most important factor during surgery and that efforts should be based on scientific rationale with oncologic principles. I hope that the recent report by Huang et al. about laparoscopic spleen preserving hilar lymph node dissection would be helpful to young surgeons who will perform laparoscpic total gastrectomy for gastric cancer.

Huang's three-step maneuver for laparoscopic spleen-preserving No. 10 lymph node dissection for advanced proximal gastric cancer.

Due to the complexity of the splenic hilar vessels, their anatomical variation and the narrow and deep space, as well as the bleeding-prone splenic parenchyma and the difficulty to manage splenic or vascular bleeding at the splenic hilum,the procedure remains challenging and technically demanding procedure for the performance of laparoscopic pancreas- and spleen-preserving splenic hilar lymph nodes dissection. Based on our experiences, we gradually explored a set of procedural operation steps called "Huang's three-step maneuver". In this paper, we not only provide the concrete operation steps for the surgeon, but we also provide our recommended technique of pulling and exposure for assistants. This new maneuver simplifies the complicated procedure and improves the efficiency of laparoscopic spleen-preserving splenic hilar lymphadenectomy, making it easier to master and allowing for its widespread adoption.

Laparoscopic Spleen-Preserving Splenic Hilar Lymphadenectomy Performed by Following the Perigastric Fascias and the Intrafascial Space for Advanced Upper-Third Gastric Cancer

BackgroundLaparoscopic spleen-preserving Splenic hilar lymphadenectomy (LSPL) is required in laparoscopy-assisted total gastrectomy for advanced proximal gastric cancer. However, it is considerably difficult and risk in clinical practice. Thus, we explore the application of LSPL performed by following the perigastric fascias and the intrafascial space in D2 radical gastrectomy for advanced upper-third gastric cancer.MethodsFrom July 2010 to December 2012, 109 patients with T2–3 upper-third gastric cancer underwent LSPL. Of these patients, 55 underwent classic LSPL (classic group), and the remaining 54 patients underwent LSPL performed by following the fascias and intrafascial space (fascia group). Clinicopathologic characteristics and intraoperative and postoperative variables were compared between the two groups.ResultsThere were no significant differences in clinicopathological characteristics between the two groups (P>0.05). All of the operations were successful without conversion to laparotomy. The operation time, mean splenic hilar lymph node (LN) dissection time, mean total blood loss and mean blood loss from splenic hilar LN dissection were significantly lower in the fascia group than in the classic group (P<0.05), whereas the times to first flatus, fluid diet and soft diet and the duration of hospital stay were similar in both groups. The mean number of harvested LNs (No. 10 and No. 11d) was slightly higher in the fascia group, but the difference was not significant. No significant difference in morbidity was found between the fascia group and the classic group (9.3% vs.10.9%, P>0.05). At a median follow-up of 12 months(range 5 to 35 months), none of the patients had died or experienced recurrent or metastatic disease.ConclusionLSPL performed by following the fascias and intrafascial space is an optimal and safe technique based on anatomical logic, and it reduces the difficulties associated with LSPL, making it easier to master and allowing its widespread adoption.

Pankreatik endokrin tümörü taklit eden İntrapankreatik aksesuar dalak

Accessory spleens are present in 10% of population and are formed during embryonic development. When an accessory spleen is located in the pancreas, it may mimic a hypervascular pancreatic tumor and can make a diagnostic difficulty. Most of the cases were identified only after surgical resection. Herein, we present the case of a 52-year old man whom laparoscopic spleenpreserving distal pancreatectomy was performed with suspicion of neuroendocrine tumor. Postoperative histopathological examination revealed the intrapancreatic accessory spleen.

Laparoscopic total gastrectomy with spleen-preserving splenic hilar (No. 10) lymph nodes dissection

Laparoscopic total gastrectomy with spleen-preserving splenic hilar (No. 10) lymph nodes dissection is challenging due to the tortuous splenic vessels and possibility of parenchymal injury to the spleen or pancreas. Based on our anatomical understanding of peripancreatic structures, we combined the characteristics of laparoscopic surgery and developed a strategy using retro-pancreatic approach for laparoscopic spleen-preserving No. 10 lymph nodes dissection.

Hand-assisted Laparoscopic Spleen-preserving Total Gastrectomy for Gastric Cancer: Technical Feasibility and Early Results

To evaluate the feasibility and safety of hand-assisted laparoscopic spleen-preserving total gastrectomy for gastric cancer, we compared the operative outcomes between two methods for dissection of lymph nodes along the distal splenic artery (No. 11d) and at the splenic hilum (No. 10). Sixty-four patients with proximal or total gastric cancer operated on in our department from October 2009 to February 2012 were divided into two groups: the extracorporeal method group (EMG) and the intracorporeal method group (IMG). Operative time, estimated blood loss, number of lymph node retrieval, times of analgesic injection, time to the first flatus, and postoperative hospital stay were compared between the two groups. Estimated blood loss, times of analgesic injection, time to the first flatus, and postoperative hospital stay were equivalent between the two groups. The operative time was significantly shorter in the IMG than the EMG. There were no significant differences in tumor size, retrieved lymph nodes, American Joint Committee on Cancer/Union for International Cancer Control staging, or resection margins between the two groups. Hand-assisted laparoscopic spleen-preserving total gastrectomy is technically feasible and safe and allows for adequate lymphadenectomy.

Laparoscopic extended (subtotal) distal pancreatectomy with resection of both splenic artery and vein

Spleen-preserving distal pancreatectomy can be performed safely and effectively by resecting both splenic vessels (Warshaw procedure). This simplified spleen-preserving technique might also be applied to minimally invasive distal pancreatectomy of benign and borderline malignant tumor. Although the conservation of both splenic vessels is paramount to preserving the spleen during laparoscopic distal pancreatectomy, preservation of the splenic vessels is not always possible, especially under the following conditions: (1) relatively large tumor, (2) associated with chronic pancreatitis, (3) tumor abutting splenic vascular structures, and (4) bleeding during the splenic vessel conserving procedure, which are potential indications of laparoscopic extended Warshaw procedure. Patient preparation and position was the same as that described in our previous study. During the study's time period, 38 consecutive patients underwent laparoscopic spleen-preserving distal pancreatectomy. Of those, five patients underwent a laparoscopic extended Warshaw procedure, which all included among 16 patients of extended distal pancreatectomy by dividing the pancreas at the pancreatic neck. All patients were women with a median age of 55 (range, 38-75) years. Median total operation time and blood loss were 215 (range, 200-386) minutes and 100 (range, 0-300) ml, respectively. The median length of hospital stay was 8 (range, 5-15) days. All of postoperative complications (two grade A and two grade B postoperative pancreatic fistula; one grade A bleeding) were able to be treated conservatively. During the median follow-up period of 11 (range, 7-42) months, one focal splenic infarction and one gastric varix were noted; however, no clinically significant complications were reported. Laparoscopic spleen-preserving extended distal pancreatectomy with resection of both the splenic vessels is feasible and safe. This surgical technique is thought to increase the chance of preservation of the spleen with minimally invasive distal pancreatectomy in well-selected benign or borderline malignant tumor of the distal pancreas.

Laparoscopic spleen-preserving No. 10 lymph node dissection for advanced proximal gastric cancer in left approach: a new operation procedure

BackgroundTo explore the feasibility of laparoscopic spleen-preserving No. 10 lymph node dissection in a left-sided approach for advanced proximal gastric cancer.MethodsThe clinical data of 32 patients with advanced proximal gastric cancer who underwent laparoscopic spleen-preserving No. 10 lymph node dissection from June 2010 to December 2011 were analyzed.ResultsLaparoscopic spleen-preserving No. 10 lymph node dissection using a left-sided approach was successfully performed for all patients without open conversion. The mean operation time was 206.4±54.3 minutes, mean intraoperative blood loss was 68.2±34.1 ml, mean number of No. 10 lymph nodes dissected was 2.8±2.1, mean number of positive No. 10 lymph nodes was 0.6±1.2, and the incidence of No. 10 lymph node metastasis was 11.6%. The mean postoperative hospital stay was 11.3±1.5 days. The postoperative morbidity rate was 9.4%, and there was no postoperative death. Splenic lobar vessels of all 32 patients were anatomically classified and divided into three types: 4 patients had a single lobar vessel, 22 had two lobar vessels and 6 had three lobar vessels.ConclusionsLaparoscopic spleen-preserving No. 10 lymph node dissection for advanced proximal gastric cancer using a left-sided approach is technically feasible. It simplifies the complicated surgical procedure of No. 10 lymph node dissection and leads to the popularization and promotion of this technique.

Open and Laparoscopic Spleen-preserving, Splenic Vessel-preserving Distal Pancreatectomy: Indications and Outcomes

BackgroundSpleen-preserving distal pancreatectomy has been described lately in order to reduce the risks associated with splenectomy. The aim of this study is to report a series of open and laparoscopic distal pancreatectomies with splenic vessel preservation. MethodsFrom June 2001 to April 2007, 11 spleen-preserving distal pancreatectomies were performed, utilizing open and laparoscopic techniques. The main variables recorded were demographics, intra- and postoperative complications, and final pathology results. ResultsAll 11 spleen-preserving distal pancreatectomies were performed successfully. Laparoscopic resection was possible in seven patients. Postoperative morbidity consisted of one pancreatic fluid collection. The overall incidence of pancreatic leak was 18%. The final pathology revealed serous cystadenoma in 36% of the cases, neuroendocrine tumor in two cases, three mucinous cystadenomas, one carcinoid tumor, and one intrapancreatic spleen. With a median follow-up of 26 months, no splenic vein thrombosis was detected. ConclusionsOpen or laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation is a feasible and safe procedure. In selected cases of cystic lesions and low grade neoplasms, distal pancreatectomy with splenic preservation is possible.