Laparoscopic Splenectomy Group Research Articles

Robotic-Assisted and Laparoscopic Splenectomy in Children: A Single Center Comparative Study.

Background: To explore the safety, efficacy, advantages, and disadvantages of robotic-assisted splenectomy (RS) in children by analyzing and comparing the clinical data of RS and laparoscopic splenectomy (LS). Methods: The clinical data of 35 children who underwent laparoscopic or RS or partial splenectomy from February 2010 to October 2022 were included. A retrospective analysis based on general information, clinical data, and prognosis were performed. Results: Among 35 cases, 14 cases, and 21 cases underwent RS and LS, respectively. The average operation time was 167 (120-224) minutes in the RS group and 176 (166-188) minutes in the LS group. The intraoperative blood loss was significantly larger in LS group than RS group (P = .0009). The length of hospital stay was significantly longer in LS group than RS group (P = .0015), and the hospitalization cost was significantly higher in RS group than LS group (P < .0001). There were no cases of conversion to laparotomy in the RS group, but two cases in the LS group. In terms of postoperative complications, there were one and three cases in the RS and LS groups, respectively. Conclusion: The Robotic Surgical System was safe and feasible in pediatric splenectomy or partial splenectomy which was an alternative to laparoscopic surgery.

Robotic versus laparoscopic splenectomy: a systematic review of perioperative outcomes

Summary Background Elective splenectomy has various indications and can be performed open or minimally invasively. Laparoscopic splenectomy (LS) is popular but has limitations. Some studies suggest potential superiority of robotic splenectomy (RS) over LS. As such, we conducted a systematic review to determine whether RS has greater positive perioperative outcomes in comparison to LS in the adult population. Methods We searched for studies that reported perioperative outcomes and compared RS to LS in the adult population. Outcome measures were operative time, conversion to open surgery, postoperative complications, mortality, length of stay, blood loss and cost analysis. A simple, unpaired two-tailed student’s t‑test was used to compare outcomes between the RS and LS patient groups. Results After full-text analysis of 47 papers, three studies met the inclusion criteria. The studies involved 72 patients (28 in the RS group, 44 in the LS group). RS demonstrated no significantly reduced blood loss in comparison to LS (p = 0.13). RS had no cases converting to open surgery and no postoperative complications in comparison to LS. No significant difference was found between RS and LS with regards to LOS (p = 0.89) and cost benefit (p = 0.74). RS had a higher operative time in comparison to LS which was not statistically significant (p = 0.45). Conclusion The RS approach may be associated with lower blood loss and a lower risk of conversions. There was no statistical difference between RS and LS with regards to length of stay (LOS) and cost. RS takes longer to perform in comparison to LS.

Laparoscopic splenectomy in children: experience from a tertiary care referral institute in North India

The aim of this study was to compare the results of laparoscopic splenectomy (LS) with open splenectomy (OS) in children at a tertiary care referral institute in North India. The electronic medical records of all children who had undergone non-emergent splenectomies between July 2014 and December 2019 at our centre were reviewed retrospectively. Patients undergoing splenectomies for trauma or portal hypertension were excluded. During the period from July 2014 to June 2016, splenectomy was performed by an open technique. From July 2016 onwards, all splenectomy procedures were performed laparoscopically. Demographic features, indications for splenectomy, operative time, estimated blood loss, spleen weight, need for conversion, length of stay, time to oral feeds and requirement for analgesia were recorded. Data for children undergoing LS were compared with those undergoing OS. Between July 2014 and June 2016, 20 children underwent OS. Between July 2016 and November 2019, 16 children underwent LS. The groups were similar in age and sex; hereditary spherocytosis was the commonest indication in both the groups. Operating time was longer in the LS group (186 ± 20.4 min vs 136 ± 12.2 min; P < 0.05), but blood loss and complication rates were similar. Two (12.5%) conversions were necessary, primarily due to spleen size. Children undergoing LS had a shorter length of stay (3.4 ± 0.6 vs 6.8 ± 1.2 days; P < 0.05), shorter time to oral feeds (0.5 vs 2.5 days; P < 0.05), and lesser requirement for analgesia. LS is feasible and safe in children. It is superior to OS with regard to cosmesis, duration of postoperative analgesia, duration of hospital stay, and recovery of bowel function. However, operating time for LS is longer than OS at our centre currently.

İntraoperatif splenik hilus kanaması ve splenomegali robotik ve laparoskopik splenektomiden açık cerrahiye geçişe etki eden risk faktörleridir

Minimal invasive surgery is one of the most popular treatment approaches which is safe and effective in experienced hands in different clinical practices. In the present study, we aimed to evaluate the risks factors for conversion to open splenectomy and the performance of indirect hilum dissection technique. A total of 56 patients who underwent laparoscopic or robotic splenectomy for isolated spleen diseases were included into the study. Patients were divided into two groups as robotic or laparoscopic splenectomy (Group 1; n= 48) and conversion to open surgery (Group 2; n= 8). Patients were retrospectively evaluated according to clinical, biochemical, hematological and microbiological parameters and morbidity. No statistically significant difference was found between the groups in terms of age, gender, body mass index (BMI), ASA score, co-morbid disease, operation time, hospital stay, follow-up period, accessory spleen, diagnosis, international normalized ratio (INR), red cell distribution width (RDW), platelet distribution width (PDW), platelet to lymphocyte ratio (PLR), neutrophil to lymphocyte ratio (NLR), reapplication, splenosis, surgical site infection, vascular thrombus and incisional hernia (p> 0.05). On the other hand, intraoperative splenic hilum hemorrhage and increased spleen size (p <0.05) were higher in the conversion to open surgery group. In logistic regression analysis, intraoperative splenic hilum hemorrhage (B= 4.127) (OR= 61.974) (95% CI= 3.913-981.454) (p= 0.003) and increased spleen volume (B= 3.114) (OR= 22.509) (95% CI= 1.818-278.714) (p= 0.015) were found as risk factors for conversion to open surgery. Intraoperative hemorrhage from the splenic hilum and increased spleen volume (> 400 cm3) are risk factors for conversion to open splenectomy in patients undergoing elective robotic or laparoscopic splenectomy. Indirect splenic hilum dissection can decrease intraoperative hemorrhage and conversion to open surgery.

Splenectomy for people with thalassaemia major or intermedia.

Thalassaemia is a genetic disorder of the haemoglobin protein in red blood cells. It has been historically classified into thalassaemia minor, intermedia and major, depending on the genetic defect and severity of the disease. The clinical presentation of β-thalassaemia varies widely from a mild asymptomatic form in thalassaemia minor, to a severe disease in thalassaemia major where individuals are dependant on life-long blood transfusions. The hallmark of thalassaemia syndromes is the production of defective red blood cells that are removed by the spleen resulting in an enlarged hyperfunctioning spleen (splenomegaly). Removal of the spleen may thus prolong red blood cell survival by reducing the amount of red blood cells removed from circulation and may ultimately result in the reduced need for blood transfusions. To assess the efficacy and safety of splenectomy in people with β-thalassaemia major or intermedia. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Review Group's Haemoglobinopathies Trials Register, compiled from searches of electronic databases and the handsearching of journals and conference abstract books. We also searched online trial registries and the reference lists of relevant articles and reviews (27 July 2018).Date of the most recent search of the Group's trials register: 02 August 2019. We included randomised controlled and quasi-randomised controlled studies of people of any age with thalassaemia major or intermedia, evaluating splenectomy in comparison to conservative treatment (transfusion therapy and iron chelation) or other forms of splenectomy compared to each other (laparoscopic, open, radio-frequency). Two authors independently selected and extracted data from the single included study using a customised data extraction form and assessed the risk of bias. The quality of the evidence was assessed using GRADE. One study, including 28 participants was included in the review; the results were described, primarily, in a narrative manner. This study assessed the feasibility of splenectomy using a laparoscopic approach versus open surgery. Given the lack of detail regarding the study methods beyond randomisation, the overall risk of bias for this study was unclear. The study was carried out over a period of 3.5 years, with each participant followed up only until discharge (less than one week after the intervention); it did not assess the majority of the outcomes outlined in this review (including two of the three primary outcomes, frequency of transfusion and quality of life). A total of three serious post-operative adverse events (the review's third primary outcome) were reported in the laparoscopic splenectomy group (one case of atelectasis and two cases of bleeding), compared to two events of atelectasis in the open surgery group; however, there were no significant differences between the groups for either atelectasis, risk ratio (RR) 0.50 (95% confidence interval (CI) 0.05 to 4.90) or for bleeding, RR 5.00 (95% CI 0.26 to 95.61) (very low-quality evidence). In addition, the study also reported three serious cases of intra-operative bleeding in the laparoscopic group which mandated conversion to open surgery, although the difference between groups was not statistically significant, RR 7.00 (95% CI 0.39 to 124.14) (very low-quality evidence). These effect estimates are based on very small numbers and hence are unreliable and imprecise. From this small study, there appeared to be an advantage for the laparoscopic approach, in terms of post-operative hospital stay, although the group difference was not large (median difference of 1.5 days, P = 0.03). The review was unable to find good quality evidence, in the form of randomised controlled studies, regarding the efficacy of splenectomy for treating thalassaemia major or intermedia. The single included study provided little information about the efficacy of splenectomy, and compared open surgery and laparoscopic methods. Further studies need to evaluate the long-term effectiveness of splenectomy and the comparative advantages of surgical methods. Due to a lack of high quality evidence from randomised controlled studies, well-conducted observational studies may be used to answer this question.

Analysis of the surgical treatment of the patients operated on by using laparoscopic and classic splenectomy due to benign disorders of the spleen.

Laparoscopic splenectomy became the standard surgical procedure in the 1990s. The goal of this study was to analyze the outcome of the patients who underwent laparoscopic splenectomy for the benign hematologic diseases of the spleen and compare its results with open splenectomy. The study was conducted as a retrospective cohort study analyzing and comparing the data obtained from 196 patients' case records in the Clinic for Digestive Surgery, Clinical Center of Serbia, for the benign disorders of the spleen, divided into two groups: patients operated with laparoscopic technique and patients in whom classic splenectomy was performed. The analyzed parameters were divided into three groups as preoperative, intraoperative and postoperative. In the laparoscopic splenectomy group, less intraoperative blood loss, lower incidental intraoperative complications and a shorter duration of surgery were recorded. The incidence of postoperative complications and reoperations was higher in the group of classically operated patients. Postoperative recovery, expressed by the duration of postoperative abdominal drainage, recovery of intestinal peristalsis and length of postoperative hospitalization, was significantly shorter in the laparoscopic group. Laparoscopic splenectomy is an effective and safe surgical procedure in the treatment of many benign diseases of the spleen. Improvement of the laparoscopic technique of surgical teams and technical improvement of the laparoscopic equipment can lead to even wider application of laparoscopic splenectomy as standard operative procedure, and thus to safer and better quality treatment of patients with wider spectrum diseases of the spleen.

Hand-assisted Laparoscopic Splenectomy Advantages Over Complete Laparoscopic Splenectomy For Splenomegaly.

Laparoscopic splenectomy (LS) is generally applied for splenectomy, However, it also brings some technical challenges, especially for splenomegaly. Hand-assisted laparoscopic splenectomy (HALS) can help to overcome these drawbacks while maintaining the superiority of LS. This study was aimed to evaluate the efficacy and advantage of HALS for splenomegaly. Between January 2014 and November 2017, 91 patients with splenomegaly in 2 surgical centers were randomly assigned to either HALS (n=45) or LS (n=46). The patients' characteristics, intraoperative details, and the postoperative outcomes in both groups were compared. Baseline features (sex, age, main diameter, Child-Pugh grade) of both groups had no significant difference (P<0.05). Compared with LS group, the HALS group operation time (141±46 vs. 172±43 min; P=0.001) was shorter, intraoperative blood loss [215 (122.332) vs. 230 (130.740) mL; P=0.026], hospital expenses (5.5±1.5 vs. 6.4±2.4 WanRMB; P=0.022), and conversion rate (1/45 vs. 9/46; P=0.015) were lower. However, there was no significant difference for hospital stay (6.4±2.8 vs. 6.7±3.0 d; P=0.662) and complications (15/45 vs. 12/46; P=0.893) between the 2 groups. In addition, there were no significant differences in postoperative white blood cell (10.6±2.9 vs. 10.9±3.5; P=0.747), AST [61 (47.94) vs. 57 (37.86) U/L; P=0.513], and ALT [68 (54.120) vs. 55 (36.99) U/L; P=0.302] levels. HALS can maximize the benefits for patients, while maintaining the advantages of LS and open splenectomy. It is the ideal surgical treatment for splenomegaly.

Hand-assisted laparoscopic splenectomy is a useful surgical treatment method for patients with excessive splenomegaly: A meta-analysis.

BACKGROUNDHand-assisted laparoscopic splenectomy (HALS) can help overcome the drawbacks of laparoscopic splenectomy (LS) while maintaining its advantages.AIMTo evaluate the efficacy and advantages of HALS for splenomegaly.METHODSThe relevant literature was reviewed using the PubMed, EMBASE, Cochrane, Ovid Medline, and Wanfang databases to compare the clinical outcomes of HALS and LS. Odds ratios or mean differences were calculated with 95% confidence intervals for fixed-effects and random-effects models. Overall, 754 patients from 16 trials who met the inclusion criteria were selected.RESULTSIn pure splenectomy, blood loss volume (P < 0.001) and conversion rate (P = 0.008) were significantly lower in the HALS group than in the LS group. Conversely, for splenomegaly, the operative time (P = 0.04) was shorter and blood loss volume (P < 0.001) and conversion rate (P = 0.001) were significantly lower in the HALS group than in the LS group. However, no significant difference was observed in hospital stay length, blood transfusion, time to food intake, complications, or mortality rate between the two groups. Moreover, in splenectomy and devascularization of the upper stomach (DUS), the operative time (P = 0.04) was significantly shorter and blood loss volume (P < 0.001) and conversion rate (P = 0.05) were significantly lower in the HALS + DUS group than in the LS + DUS group. However, no significant difference was observed in hospital stay length, timing of diet, and complications between the two groups.CONCLUSIONHALS is an ideal surgical treatment method for splenomegaly because it can maximize the benefits for patients while maintaining the advantages of LS.

Prediction of Technical Difficulties in Laparoscopic Splenectomy and Analysis of Risk Factors for Postoperative Complications in 468 Cases.

Prediction of intraoperative difficulties may be helpful in planning surgery; however, few studies explored this issue in laparoscopic splenectomy (LS). We performed retrospective analysis of consecutive 468 patients undergoing LS from 1998 to 2017 (295 women; median age 47 years). The patients were divided into difficult LS and control groups. The inclusion criteria for difficult LS were operative time ≥mean + 2SD; intraoperative blood loss ≥500 mL, intraoperative adverse events (IAE), conversion. Primary outcomes were risk factors for difficult splenectomy and secondary outcomes for perioperative morbidity. Fifty-six patients were included in the difficult LS group (12%). Spleens ≥19 cm and higher participation of younger surgeons in consecutive years were predictive for difficult splenectomy. Age ≥53 years and diagnosis other than idiopathic thrombocytopenic purpura (ITP) were independent risk factors of spleen ≥19 cm. The perioperative morbidity was 8.33%; its OR was increased only by blood loss and IAEs. Only blood loss significantly increased serious morbidity. Male sex, spleens ≥19 cm, and IAEs were independent risk factors for intraoperative hemorrhage. Spleen length ≥19 cm was a risk factor for difficult LS and intraoperative hemorrhage. Diagnoses other than ITP in patients aged ≥53 years with ≥19 cm spleens are predictive for intraoperative difficulties and perioperative complications.

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.

Comparation of laparoscopic splenectomy for regional portal hypertension using the anterior versus the posterolateral approach

Objective To study the anterior versus the posterolateral approach for laparoscopic splenectomy for patients with chronic pancreatitis-induced regional portal hypertension (PRPH). Methods The retrospective cohort study was carried out on 62 patients who underwent laparoscopic splenectomy for PRPH at the People's Hospital of Zhengzhou University from Jan 2010 to Jun 2016. The patients were divided into 2 groups: the anterior approach group and the posterolateral approach group, and to compare the differences. Results The operation time, amounts of intraoperative non-splenic blood loss, duration of recovery of intestinal peristalsis, duration of drainage, and duration of postoperative hospital stay were (135.0±12.8) min vs (126.0±13.1) min, (323.7±50.9) ml vs (245.1±35.0) ml, (25.5±2.5) h vs (23.5±3.3) h, (5.7±1.0) d vs (3.2±1.3) d and (9.3±1.5) d vs (7.3±1.2) d in the anterior approach laparoscopic splenectomy group versus the posterolateral approach laparoscopic splenectomy group. These differences were significantly different (all P<0.05). On follow-up of the 62 patients, improvements in the varicose veins of the lower esophagus and fundus of stomach at 3 month postoperatively were observed. All these patients recovered well from surgery. Conclusion The posterolateral approach laparoscopic splenectomy approach significantly improved the treatment results in patients with chronic pancreatitis-induced regional portal hypertension. Key words: Portal hypertension, regional; Laparoscopic splenectomy; Posterolateral approach; Chronic pancreatitis

Splenectomy for haematological diseases: comparison between laparoscopic and open procedures

Background: In some hematological diseases, the spleen may become enlarged, inflamed and causes destruction of normal blood elements. Laparoscopic splenectomy (LS) was first prescribed in 1991 by Delaitre et al and since that date, it gained a steadily increasing worldwide agreement as an option for splenectomy in patients with hematological diseases. It was reported that this can be performed safely and effectively, with lower incidence of morbidity and mortality. The objective of the study was to compare laparoscopic with open splenectomy as regard its benefits and hazards in haematological diseases.Methods: This prospective study had been conducted in General Surgery Department, Sohag Faculty of Medicine. The study included patients with haematological diseases indicated for elective splenectomy, during the period from January 2015 to June 2017. Twenty patients were included for open surgery (OS) and 20 cases were included for laparoscopic splenectomy (LS).Results: Surgical time was significantly longer in LS than OS group. There was significant correlation between surgical time and splenic size in both groups. Most of the LS patients had been operated upon using the anterior approach (65%). Hospital stay after operation in the LS group was much less than the OS group. Return of off-bed activities, bowel movements, oral intake and drain removal were longer but not significantly different compared to LS figures.Conclusions: Laparoscopic splenectomy for haematological indications can be done safely for the properly selected patients with less blood loss and hospital stay but it requires more operative time as compared to conventional splenectomy.

Laparoscopic versus open splenectomy in children with benign hematological diseases in children

Introduction: Splenectomy whether open or laparoscopic addresses the role of the spleen in the hematology disorders, particularly that of the cellular sequestration and destruction and antibody production. Laparoscopic splenectomy (LS) has been increasingly used for the removal of spleen in children. However, there are still certain questions as regards the feasibility, economic reflections, appropriate splenic size suitable for LS, vascular control of that organ, and final outcomes related to either procedure. Patients and methods: In the period between May 2007 and March 2017, 70 children with benign hematological diseases underwent splenectomy, either laparoscopic or open. They were divided into group A and group B. Group A included cases who had LS, and group B included cases who had open splenectomy (OS). We performed LS while the child was in the right lateral position. In cases of normal splenic size, we used three ports and four ports in cases of splenomegaly. OS was performed in supine position. Results: A total of 70 children were subjected to splenectomy, of whom 20 were boys and 50 were girls. Thalassemia was present in 36 cases, idiopathic thrombocytopenic purpura in 24 cases, and spherocytosis in 10 cases. Five cases were converted to the traditional approach, and three of them were because of huge splenomegaly and two cases were because of accidental bleeding. In the LS group, small-sized spleens were extracted using retrieval bags, whereas large spleens were extracted through Pfannenstiel incision. OS procedure was performed through midline incision. Cholecystectomy was performed in five cases during the original procedure because of gall bladder stones: three cases in group A and two cases in group B. Conclusion: Although both LS and OS achieved the same goal for the children with benign hematological disease, the advantages of minimal invasive surgery made LS the standard approach for treatment of children with benign hematological diseases. However, the main concern is the high economic burden of LS when compared with OS. Keywords: children, laparoscopic, open, splenectomy

Laparoscopic Splenectomy for Massive Splenomegaly: Does Size Matter?

Laparoscopic splenectomy (LS) has become the most common approach for elective splenectomy, but use of LS for patients with massive splenomegaly (MS) remains controversial. By the 2008 European guidelines, LS for MS (spleen size >20 cm) is generally not recommended. We performed a retrospective analysis of 229 consecutive patients undergoing LS, hand-assist (HALS), and open splenectomy (OS) at our institution from January 1, 1995 to December 2016. Eighty-six (38%) had MS. Patient demographics, comorbidities, operative details, and outcomes were analyzed. Of 86 patients with MS, 27 (31%) underwent LS, 12 (14%) HALS, and 47 (55%) OS. No significant difference was revealed in patient demographics, comorbidities, American Society of Anesthesiologists class, and spleen size (24.2 cm vs. 23.7 cm vs. 26.6 cm, P = .06). Benign spleen diseases (23), malignancy (57%), and miscellaneous (20%) were indications for surgery. The mean operative time and estimated blood loss in LS, HALS, and OS were 153, 168, and 131 minutes (P = .17) and 100, 162, and 278 mL (P = .24), respectively. Three patients (11.1%) with LS and 1 (8.3%) with HALS required conversion to OS for different reasons (spleen size, technical difficulties, bleeding). Morbidity was similar in all three groups (P = .99). One mortality (1.1%) was noted after OS. Six (7%) patients in the LS group and three (3.5%) in the OS group developed postsplenectomy thrombosis of splenic, mesenteric, and portal veins. Length of stay was shorter in patients with LS and almost reached clinical significance (3.2 vs. 4.9 vs. 5.2 days; P = .06). LS is safe, feasible, and associated with shorter hospital stay than HALS and OS for MS.

Modified splenic arterial embolization plus laparoscopic splenectomy in the management of patients with splenomegaly and hypersplenism secondary to portal hypertension

Objective To investigate the safety and effectiveness of modified splenic arterial embolization (SAE) plus laparoscopic splenectomy (LS) in patients with splenomegaly and hypersplenism se-condary to portal hypertension. Methods The clinical data of 54 patients with splenomegaly and hypersplenism secondary to portal hypertension admitted to the Xinqiao Hospital of the Third Military Medical University from April 2012 to December 2015 were collected and retrospectively analyzed. 24 patients underwent modified splenic arterial embolization plus LS (the SAE+ LS group), and 30 patients underwent LS alone (the LS group). The postoperative surgical outcomes between the two groups were compared. Continuous data were analyzed using the t test, and categorical data were analyzed using the Chi-square test. Results The modified splenic arterial embolization plus LS was performed successfully in all the patients in the SAE+ LS group, and no patient required open surgery. Six patients in the LS group were converted to laparotomy. A shorter operative time [(150±29) min vs. (210±40) min, t=-6.098, P<0.05], less intrao-perative blood loss [(168 ± 58) ml vs. (314 ± 87) ml, t=-6.981, P<0.05], and shorter postoperative hospitalization stay [(5.5 ± 0.6) d vs. (7.6 ± 1.3) d, t=-6.797, P<0.05] in the SAE+ LS group were observed when compared with the LS group. There were no significant differences in postoperative complication rates, postoperative gastrointestinal function recovery, oral intake and off-bed activity times between the two groups. Conclusion The modified splenic arterial embolization plus LS was safer and more effective in treating splenomegaly and hypersplenism secondary to portal hypertension than LS alone. Key words: Splenic artery embolization; Laparoscopic splenectomy; Splenomegaly; Hypersplenism; Portal hypertension

Splenectomy for people with thalassaemia major or intermedia.

Thalassaemia is a genetic disease of the haemoglobin protein in red blood cells. It is classified into thalassaemia minor, intermedia and major, depending on the severity of the disease and the genetic defect. Thalassaemia major and intermedia require frequent blood transfusions to compensate for the lack of well-functioning red blood cells, although this need is significantly less in thalassaemia intermedia.Damaged or defective red blood cells are normally eliminated in the spleen. In people with thalassaemia there is a large quantity of defective red blood cells which results in an enlarged hyperfunctioning spleen (splenomegaly). Removal of the spleen may thus prolong red blood cell survival by reducing the amount of red blood cells removed from circulation and may ultimately result in the reduced need for blood transfusions. To assess the efficacy and safety of splenectomy in people with beta-thalassaemia major or intermedia. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Review Group's Haemoglobinopathies Trials Register, compiled from searches of electronic databases and the handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews.Date of the most recent search: 25 April 2016. We included randomised controlled studies and quasi-randomised controlled studies of people of any age with thalassaemia major or intermedia, evaluating splenectomy in comparison to conservative treatment (transfusion therapy and iron chelation) or other forms of splenectomy compared to each other (laparoscopic, open, radio-frequency). Two authors independently selected and extracted data from the single included study using a customised data extraction form and assessed the risk of bias. One study, including 28 participants was included in the review; the results were described, primarily, in a narrative manner. The study assessed the feasibility of splenectomy using laparoscopy in comparison to open surgery. Given the lack of detail regarding the study methods beyond randomisation, the overall risk of bias for this study was unclear. The study was carried out over a period of 3.5 years, with each participant followed up only until discharge (less than one week after the intervention); it did not assess the majority of the outcomes outlined in this review (including two of the three primary outcomes, frequency of transfusion and quality of life). A total of three serious post-operative adverse events (the review's third primary outcome) were reported in the laparoscopic splenectomy group (one case of atelectasis and two cases of bleeding), compared to two events of atelectasis in the open surgery group; however, there were no significant differences between the groups for either atelectasis, risk ratio 0.50 (95% confidence interval 0.05 to 4.90) or for bleeding, risk ratio 5.00 (95% confidence interval 0.26 to 95.61). In addition, the study also reported three serious cases of intra-operative bleeding in the laparoscopic group which mandated conversion to open surgery, although the difference between groups was not statistically significant, risk ratio 7.00 (95% confidence interval 0.39 to 124.14). These effect estimates are based on very small numbers and hence are unreliable and imprecise. From this small study, there appeared to be an advantage for the laparoscopic approach, in terms of post-operative hospital stay, although the group difference was not large (median difference of 1.5 days, P = 0.03). The review was unable to find good quality evidence, in the form of randomised controlled studies, regarding the efficacy of splenectomy for treating thalassaemia major or intermedia. The single included study provided little information about the efficacy of splenectomy, and compared open surgery and laparoscopic methods. Further studies need to evaluate the long-term effectiveness of splenectomy and the comparative advantages of surgical methods. Due to a lack of high quality evidence from randomised controlled studies, well-conducted observational studies may be used to answer this question.

Natural orifice transumbilical versus conventional incision laparoscopic splenectomy: a comparative study

Objective To study the feasibility, safety, operative skills and clinical advantage of natural orifice transumbilical laparoscopic splenectomy. Methods The clinical data of patients who underwent natural orifice transumbilical laparoscopic splenectomy (group A, n=9) and conventional laparoscopic splenectomy (group B, n=15) in our department from Nov. 2011 to Nov. 2014 were reviewed. The operative time, estimated blood loss, post-operation complications, hospital stay, incision satisfaction score and total cost were compared between two groups. Patients with immune thrombocytopenia, presume hereditary splecocytosis and idiopathic hypersplenism were included. Results All the procedures were successfully carried out laparoscopically. The estimated blood loss and total cost showed no significant differences between group A and group B [(196.7±118.7) ml vs (188.7±110.8) ml; (3.7±0.5) vs (3.6±0.7)×104 yuan, P>0.05]. As to the incision satisfaction score, group A was superior to group B [(4.1±0.6) vs (3.4±0.7), P<0.05]. The operation time of group A was significantly longer than that of group B [(201.7±43.2) min vs (131.0±37.1) min, P<0.05]. Conclusion Natural orifice transumbilical laparoscopic splenectomy is a safe and feasible procedure with better satisfactory clinical outcomes than conventional laparoscopic splenectomy. Key words: Laparoscopic splenectomy, transumbilical, concealed approach, conventional approach

Does Laparoscopic Splenectomy have the Advantage on Postoperative Pain?

Purpose: The aim of this study is to elucidate the fundamental characteristics of the laparoscopic splenectomy and to compare the clinical outcomes and postoperative pain between the laparoscopic splenectomy and the conventional open splenectomy. Methods: From January 2005 to January 2013, 28 patients underwent a splenectomy at Pusan National University Hospital, South Korea (PNUH). This study was a comparison of the demographic features and clinical results between the laparoscopic splenectomy (n=15) and open splenectomy (n=13). Results: For the two groups of patients, the following were similar: estimated blood loss, transfusion, operative time, duration of patient-controlled analgesia, and the additional administration of painkillers. In the laparoscopic splenectomy group, the postoperative hospital stay (7.9±1.6 days versus 5.9±1.4 days, p=0.002) and the diet start time (2.7±0.3 days versus 1.8±0.8 days, p=0.003) were significantly shorter. No significant difference in postoperative pain was observed between the two groups. Conclusion: In this study, there was no benefit for postoperative pain in the LS group. However, the laparoscopic splenectomy has several benefits, including a shorter postoperative hospital stay and an earlier diet start time; in addition, it is feasible and safe.

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.

A meta-analysis study of laparoscopic versus open splenectomy with or without esophagogastric devascularization in the management of liver cirrhosis and portal hypertension.

The aim of this meta-analysis was to determine whether laparoscopic splenectomy (LS) and LS with esophagogastric devascularization (LSED) were the minimally invasive alternative for portal hypertension. A meta-analysis of comparative clinical trials was performed to assess our questions noted above. The databases PubMed, ScienceDirect, and Springerlink were searched. In total, 725 patients with liver cirrhosis and/or portal hypertension from eight published comparative trials were included. The operation time in the laparoscopic group was more than that in the open group [weighted mean difference (WMD) 35.24 (16.74, 53.74); P<.001]. However, there were less intraoperative blood loss [WMD -194.84 (-321.34, -68.34); P=.003] and a shorter postoperative hospital stay [WMD -4.33 (-5.30, -3.36); P<.001] in the laparoscopic group. The incidence of complications was similar in the two groups. In the subgroup studies about LS versus open splenectomy, no significant differences were found in operation time, intraoperative blood loss, and complication rates. The postoperative hospital stay in the LS group was apparently decreased [WMD -4.07 (-4.93, -3.21); P<.001]. Although the operation time of LSED was longer [WMD 43.23 (17.13, 69.32); P=.001], LSED was associated with less intraoperative blood loss [WMD -189.26 (-295.71, -82.81); P<.001] and a shorter postoperative hospital stay [WMD -5.41 (-7.84, -2.98); P<.001]. Meta-analysis did not favor either LSED or open splenectomy with esophagogastric devascularization in term of complication rates. The results of this meta-analysis were in favor of LS and LSED for being a safe, minimally invasion alternative for patients with liver cirrhosis and portal hypertension.