Subtotal Splenectomy Research Articles

A case report of a large Splenic epidermoid cyst treated with partial splenectomy

Introduction and importance: Splenic epidermoid cysts are rare primary congenital cysts composed of an epithelial lining that represent a small proportion of nonparasitic splenic cysts. Despite their infrequency, there is a lack of uniform diagnostic and treatment guidelines for these cysts, emphasizing the need for further research and standardized reporting. Case presentation: A 45-year-old female presented with left upper quadrant abdominal pain, characterized by a pressing sensation. Physical examination revealed a palpable mass in the upper left quadrant. Laboratory test results were normal. Abdominal ultrasonography and CT tomography confirmed a large splenic unilocular cyst consistent with an epidermoid cyst. Surgical intervention involved aspiration of the cystic fluid, partial splenectomy, and pathological examination. The patient’s postoperative recovery was uneventful. Clinical discussion: The origin of splenic epidermoid cysts remains unclear, with theories suggesting entrapment of mesothelial cells during embryonic development. The clinical presentation varies with cyst size, often causing abdominal pain and a palpable mass. Diagnostic modalities include ultrasonography and CT scans. Surgical intervention is recommended for symptomatic or suspicious cysts to prevent complications. The chosen approach depends on cyst characteristics and patient factors. This case highlights the challenges and considerations in managing splenic epidermoid the cysts and emphasizes the need for individualized treatment approaches. Conclusion: This case contributes to the understanding of splenic epidermoid cysts and demonstrates a successful subtotal splenectomy as a treatment approach. Further research and standardized guidelines are essential to improve the management of these rare lesions and to provide better insights into their etiology and optimal treatment strategies.

Portal thrombosis after surgical treatment of schistosomatic portal hypertension.

Several studies have investigated the correlation between the effects of different surgical treatments and laboratory exams for schistosomal portal hypertension, especially concerning portal system thrombosis. The etiopathogenic factors of this thrombosis are not fully understood. In this study, the correlation between surgical treatment for schistosomal portal hypertension and the occurrence of postoperative portal system thrombosis was investigated. A total of 61 patients who underwent surgical treatment for schistosomal portal hypertension were distributed into four groups: Patients in Group 1 (n=12) underwent portal variceal disconnection associated with splenic artery ligation and spleen preservation. Patients in Group 2 (n=20) underwent portal variceal disconnection and total splenectomy. Patients in Group 3 (n=20) underwent portal variceal disconnection with subtotal splenectomy, preserving the upper splenic pole supplied by the splenogastric vessels. Patients in Group 4 (n=9) underwent portal variceal disconnection with total splenectomy and autogenous splenic implants on the greater omentum. Late postoperative portal vein thrombosis was diagnosed using Doppler ultrasound. Over the 10-year follow-up, portal vein thrombosis occurred in 26 operated patients (42.6%), with no significant difference observed among the four surgical groups (p=0.217). Most of the thrombi only partially occluded the portal system veins. All the patients presented with a thrombus inside the portal vein. There was no difference in hematological and biochemical tests between groups with or without portal vein thrombosis. Portal vein thrombosis is often observed in the late postoperative period, irrespective of the surgical treatment employed, and is not associated with patient characteristics or any hematological and biochemical tests.

Diagnosis and treatment of solid pseudopapillary tumor of the pancreas: A single center's experience.

The present study reviews the records of patients with solid pseudopapillary pancreas neoplasm (SPT). A total of 13 patients diagnosed with SPT were included in the study. The criteria for SPT in the pathology specimens were the presence of cells with an oval round orthochromatic nucleus, with a thin chromatin structure and no nucleolus distinction, lined around a fibrovascular papilla in cystic areas. The study included 11 female and two male patients, with a mean age of 33.07 (range: 16-73) years. All operated patients underwent open surgery, with five undergoing a subtotal pancreatectomy and splenectomy; one a distal pancreatectomy and splenectomy; four a spleen-preserving distal pancreatectomy; and one a pancreaticoduodenectomy. None of the operated patients developed recurrence during the long-term follow-up. The mean follow-up time of operable patients was 69.18 (range: 22-97) months, and none had metastasis at follow-up. The mean follow-up time for the malignant SPT patients was 2.75 (1.5-4) months. SPTs are rare pancreatic tumors encountered more frequently today due to advances in imaging methods and have a low potential of recurrence and a good prognosis.

Robotic-Assisted Resection of Pancreatic Rosai-Dorfman Disease

Introduction: Rosai-Dorfman disease (RDD) is a benign, proliferative disease of non-Langerhans cell histiocytes typically involving lymphoid tissue. Pancreatic involvement is extremely rare. Case Description: Our case is of a 53-year-old female who originally presented with vague epigastric abdominal pain. Magnetic resonance imaging (MRI) revealed a mass in the pancreatic body suspicious for malignancy. The patient successfully underwent a robotic-assisted subtotal pancreatectomy and splenectomy. The final pathology revealed sheets of foamy histiocytes with enlarged vesicular nuclei and nucleoli. Immunohistochemical testing was positive for S-100 protein and CD163 and negative for CD1a and ALK-1, establishing a diagnosis of pancreatic Rosai-Dorfman disease. Next generation sequencing was positive for an F53L variant mutation of the MAP2K1 gene. Discussion: Overall, there is no uniform approach for RDD treatment, treatment is usually tailored to the individual’s clinical picture. Here we describe a novel technique of robotic-assisted resection of pancreatic Rosai-Dorfman disease.

Long-term haematological response and maintained immunological function after laparoscopic subtotal splenectomy in patients with hereditary spherocytosis.

Subtotal or total splenectomy are recommended in severe and should be considered in intermediate forms of hereditary spherocytosis (HS). Data on laparoscopic subtotal splenectomy (LSTS) in HS patients are sparse. Thirty three patients with HS (median age 10.7 years (yrs), range 1.8-15.5) underwent LSTS. Baseline and follow-up investigation included haematological parameters, microscopic analysis of pitted erythrocytes (pitE), and B-cell subpopulations assessed by flow cytometry. Results were compared to those of non-splenectomised HS patients, HS patients after total splenectomy (TS), and healthy individuals. After LSTS, haemoglobin levels were normalised in all patients. During median long-term follow-up of 3.9 yrs (range 1.1-14.9), only four patients presented mild anaemia. Despite re-growing of the remnant spleen none of the patients required a second surgical intervention. As compared to TS, PitE in LSTS patients were significantly lower and indicated normal to only moderately decreased spleen function. Relative but not absolute IgM memory B-cell counts were reduced in both LSTS and TS patients. LSTS is effective for the treatment of patients with HS. A small remnant spleen is sufficient to provide adequate phagocytic function and to induce a pool of IgM memory B-cells.

Gastrointestinal: Pancreatic NETs with GCGR heterozygous mutation: Mahvash disease.

A 61 year old female was found to have a pancreatic tumor in 2013. Preoperative laboratory tests showed fasting and 2-h postprandial glucagon levels were more than 400 pg/mL (upper limit, 150 pg/mL) with normal gastrin, blood glucose, and insulin. Preoperative contrast-enhanced CT (CECT) showed diffusely enlarged and inhomogeneously enhanced pancreas with a 2-cm high-density tumor in the pancreatic body. The tumor was obviously enhanced (Fig. 1a–c). Octreotide imaging showed high somatostatin receptor expression in the tumor. The patient underwent subtotal distal pancreatectomy and splenectomy. On postoperative pathological examination, two gray and white solid tumors were found, measuring 1.2 and 2 cm, respectively. On histology, diffuse hyperplastic islets, dysplasia, and microadenomas were detected in residual pancreatic tissue and the pancreatic resected stump. The two lesions were immune-positive for Ki-67 (index 1%), chromogranin A, synaptophysin, E-cadherin, glucagon, gastrin, and insulin (partial) (Fig. 2). The patient was treated with octreotide acetate 20 mg per injection after surgery. But postoperative fasting glucagon level was still high, fluctuating from 513.16 to 3197.49 during 7-year follow-up. Meanwhile, postoperative CECT showed enlargement of the residual pancreatic head (Fig. 1d). Whole-genome sequencing of peripheral blood demonstrated heterozygous mutation of c.1345C>T, which lead to premature termination of translation, and c.922C>T, which lead to arginine replaced by tryptophan. The case was finally diagnosed as Mahvash disease. Mahvash disease is a rare autosomal recessive hereditary pancreatic neuroendocrine neoplasms caused by defective glucagon receptor gene (GCGR) in the liver and associated reactive pancreatic α-cell hyperplasia. Although whole-genome sequencing demonstrated two heterozygous mutations of GCGR, the clinical and pathological features highly suggested Mahvash diagnosis. Diffusely enlarged and unevenly enhanced pancreas indicated coexistence of hyperplastic α cell, hyperplastic islets, and microadenomas. Significant hyperglucagonemia without glucagonoma syndrome further strengthen diagnostic confidence. Most Mahvash diseases were homozygous mutation, and heterozygous mutation are extremely rare. However, reports of patients with heterozygous mutation often showed sub-centimeter lesions (5.5 mm reported by Miller et al. and 5 mm reported by Henopp et al.). To our knowledge, this is the first time large lesions (>1 cm) has been reported in patient with heterozygous mutation of GCGR. There is possibility that heterozygous mutation of GCGR can also be Mahvash disease.

Laparoscopic Subtotal Splenectomy in Children and Adolescents With Spherocytosis.

Laparoscopic Subtotal Splenectomy in Children and Adolescents With Spherocytosis.

Serous Cystadenocarcinoma of Pancreas: A Rare Find

Abstract Introduction/Objective Pancreatic cystic neoplasms comprise 1-2% of pancreatic lesions and most of these lesions are cystadenomas. Serous cystadenocarcinoma is an extremely rare but known malignant condition described in the literature and the diagnosis is restricted to cases with distant metastasis of tumor beyond the pancreas. Per WHO, cytologic atypia, vascular, perineural, and adjacent organ and lymph node involvement by direct spread are insufficient for the diagnosis of serous cystadenocarcinoma. Methods/Case Report We report an interesting case of serous cystadenocarcinoma of pancreas in a 55-year-old male with medical history of prostate cancer was found to have a 15 cm mass pancreatic tail suspicious for neuroendocrine tumor and 5 small hepatic lesions suspicious for metastasis. The patient underwent subtotal pancreatectomy and splenectomy, and wedge resection of liver lesions. On gross examination, a yellow cystic mass was present in the pancreatic tail measuring 13.2 cm in the maximum dimension. H&E slides from the pancreas and liver demonstrated a neoplasm composed of cystic and solid areas, within a background of fibrosis and focal hemorrhage. Cystic areas showed microcysts composed of cells with clear cytoplasm and round to oval bland nuclei. Solid areas demonstrated almost no microcysts but sheets and clusters of cells with clear to scant cytoplasm, oval to round nuclei, few areas of atypical hyperchromatic cells, and occasional mitosis. Very focal clusters and cords of neuroendocrine cells, constituting less than 5% of the tumor volume were also identified. Immunohistochemical stains demonstrated the neoplastic cells both in cystic and solid areas were positive for CK7, CK19, MUC6, and inhibin. Ki67 demonstrated an overall proliferation index of 3%. Chromogranin and synaptophysin were negative within the solid and cystic components of the tumor, however, showed positive staining within neuroendocrine foci. Neoplastic cells were negative for all other tested markers including beta-catenin, ER, Hep-par 1, HMB45, IMP3, MART-1, PAX-8, and trypsin. RB1 expression was retained within neoplastic cells. Results (if a Case Study enter NA) N/A. Conclusion The differentiation between benign and malignant serous cystadenoma both histologically and clinically may be very difficult as some cases of serous cystadenocarcinoma may not show overt cytologic atypia. The presence of metastasis, which most often occurs in the liver is required for the diagnosis of serous cystadenocarcinoma.

S1767 Metastatic Solid Pseudopapillary Neoplasm of the Pancreas, Rare Presentation of an Uncommon Tumor

Introduction: Solid pseudopapillary neoplasms (SPN) make up less than 3% of all diagnosed pancreatic neoplasms. Abdominal CT or MRI are the imaging modalities most utilized, and biopsy is necessary to confirm the diagnosis. Resection of the mass is standard of care and the prognosis is quite good, with 5-year survival rates of over 95%. Both recurrence and metastasis of the tumor are exceedingly rare, occurring in only 1-4% of patients. Case Description/Methods: A 26-year-old female presented with several years of abdominal pain. CT scan revealed a 10cm mass in the neck and body of the pancreas and patient underwent a hybrid resection including subtotal pancreatectomy, splenectomy, and cholecystectomy. Pathology showed a neoplasm extending to the inked margins with positive beta-catenin and CD10 nuclear staining with no evidence of metastasis. At the age of 32, the patient presented again with abdominal pain. A CT and PET scan showed numerous LUQ, perirenal, pancreatic, and periadrenal soft tissue densities. Laparoscopic resection of a 3.5x3 cm soft tissue mass near the remnant pancreas was performed, showing fibrous stroma with angulated islands of epithelioid cells with cystic degeneration and positive staining for vimentin, CD56, and beta-catenin. Resection of multiple abdominal soft tissue tumors, in bulk measuring more than 10 cm, as well as complete omentectomy, left adrenalectomy, bilateral salpingo-oophorectomy, appendectomy, and hyperthermic intraperitoneal chemotherapy with cisplatin was performed. Pathology showed multiple metastatic tumors all consistent with SPN. The appendix, left adrenal gland, bilateral ovaries, and all lymph nodes were negative for any tumor. Two years later, MRI revealed 3.0 x 2.1 cm hyperintense lesion in the caudate lobe of the liver. EUS with biopsy was performed, revealing clusters of uniform, bland cells with ovoid nuclei and associated fibrillary stroma circumscribing vessels with a background of hemorrhagic debris (Figure). Immunohistochemistry showed cells positive for vimentin, LEF1, and beta-catenin, again consistent with SPN. Discussion: This is one of the few cases of multiple instances of both recurrence and metastasis of SPN documented in the literature. This case report shows that serial imaging studies and close follow-up are needed even years after resection and that, although rare, recurrence and metastasis can occur more than one time after the initial diagnosis.Figure 1.: Biopsy of the caudate liver lesion showing clusters of uniform, bland cells with ovoid nuclei and associated fibrillary stroma and hemorrhagic debris, consistent with SPN.

Enterocutaneous fistula in incisional hernia: unsual complication

Enterocutaneous fistula is defined as an abnormal communication between the intestinal lumen and the skin usually associated with abdominal surgeries, trauma, Crohn's disease, hernia mesh erosions and diverticulitis. We report a case of 46-year-old male, obese, referred to general surgery for enterocutaneous fistula in hernia sac. He had undergone exploratory laparotomy for gunshot wound to the abdomen 6 years ago where he underwent subtotal colectomy, splenectomy and terminal ileostomy with amputation of the rectal stump. In the current case report, obesity and surgical technique at laparotomy closure (a history of major exploratory laparotomy for gunshot wound) were the risk factors associated with the appearance of the fistula. Moreover, there was presence of midline incisional hernia with small bowel loops inside the hernia sac, which according to the European Commission Hernia Society should be avoided because it facilitates the formation of fistulas.

Mucinous cystic neoplasm of the pancreas in a male – A case report

Mucinous cystic neoplasms (MCNs) are rare tumours of the pancreas that occur almost exclusively in females and predominantly present in the body and tail. They are typically large, unilocular megacysts that do not communicate with the ductal system and are histologically lined by intestinal, pseudopyloric or gastric foveolar type epithelium that often form papillae, surrounded by characteristic dense ovarian type stroma. The WHO Classification of Tumours (5th edition) published in 2019 emphasised that the distinctive ovarian-type stroma is required for the diagnosis of MCN. MCNs in males are extremely rare and are often misdiagnosed preoperatively. Review of the literature confirmed only 14 reported cases in males up to 2017. We present a 51-year-old male that presented with a pancreatic mass who underwent a subtotal pancreatectomy and splenectomy. The lesion was completely excised and findings showed a 46 mm unilocular cystic lesion lined by low cuboidal to columnar epithelium with gastric foveolar type mucin. The wall of the cyst demonstrated the presence of ovarian type stroma confirming MCN. Immunohistochemistry showed positivity to ER and PR. The case demonstrates the importance of recognising that this rare entity can present in the male population as well.

Laparoscopic Subtotal Pancreatectomy and Splenectomy for Pancreatic Body Solid Pseudopapillary Tumor: A Case Presentation with Video

Background: Most Pancreatic solid pseudopapillary tumors are asymptomatic and incidentally found by imaging. In some cases, patients may present with nonspecific symptoms, including abdominal discomfort, nausea, vomiting, or pain. Many of these lesions, located frequently in the body or tail of the pancreas, require resection. Aim: My aim is to present a case of young female patient underwent laparoscopic subtotal pancreatectomy and splenectomy for pancreatic solid pseudopapillary tumor located in the pancreatic body, describing the technique along with the post-operative course. Methods and Results: A case of young female patient underwent a laparoscopic subtotal pancreatectomy and splenectomy using a five ports technique and surgical staplers for pancreatic transaction and vascular control. Specimen was retrieved through small Fanestiel incision. The patient had a smooth postoperative course. Specimen came as pancreatic solid pseudotumor tumor. Conclusion: Laparoscopic approach is feasible and safe for subtotal pancreatectomy and splenectomy for pancreatic body tumor resection.

Study of the upper pole after subtotal splenectomy in rats.

To evaluate macro/microscopic viability of the upper pole (UP) in rats after 80 days of subtotal splenectomy preserving the upper pole (SSPUP). Twenty-five male Wistar rats were submitted to SSPUP. After 80 days, the rats were euthanized, and the remaining UP was evaluated macroscopically regarding appearance, color, consistency, length, width, thickness, and presence of fibrosis/necrosis; and microscopically regarding presence of red and white pulp, fibrosis/necrosis. Two rats died during surgery and were removed from the statistical analysis. There was statistically significant increase in length and width between the pre and postoperative in the experimental group, with no significant difference in thickness. In the manipulation group, the macroscopic appearance of the spleen was normal in pre and postoperative, with viability preserved. In the experimental group, two UP of the spleen were not found during the second surgery. Macroscopically, it was observed absence of fibrosis and necrosis in all cases. Microscopically, the white and red pulp were intact in both groups. Two spleens of rats in the manipulation group presented areas with fibrosis and necrosis focus, which were not enough to be considered inviable. The UP of the spleen remained viable in 91.3% of the cases.

Laparoscopic subtotal pancreatectomy and splenectomy for pancreatic body tumor; case presentation with video

Background: The development of cross-section imaging increased the number of diagnosed pancreatic cystic tumors (PCNs). Many of these lesions, located frequently in the body or tail of the pancreas, require resection. Aim: My aim is to present a case of female patient underwent laparoscopic subtotal pancreatectomy and splenectomy for PCNs located in the pancreatic body, describing the technique along with the post-operative course. Methods and results: A case of female patient underwent a laparoscopic subtotal pancreatectomy and splenectomy using a five ports technique and surgical staplers for pancreatic transaction and vascular control. Specimen was retrieved through small Fanestiel incision. No morbidity or mortality happened. Specimen came as mucinous cystic tumor. Conclusion: Laparoscopic approach is feasible and safe for subtotal pancreatectomy and splenectomy for pancreatic body tumor resection.

Successful Simultaneous Anatomic Subtotal Splenectomy During Pediatric Living-Donor Liver Transplantation: A Case Report

Some liver transplant recipients may present with persistent hypersplenism post transplant. Persistent thrombocytopenia and leukopenia may put immunosuppressed transplant recipients at a higher risk of serious, even life-threatening bleeding and infection and limit the use of some drugs (such as mycophenolate mofetil) that could reduce white blood cell and platelet counts during the postoperative period. Herein, we report the first case, to the best of our knowledge, of successful simultaneous anatomic subtotal splenectomy during living donor liver transplantation in a 6-year-old girl with biliary atresia, cirrhotic portal hypertension, severe hypersplenism, and massive splenomegaly. The normalization of platelet and leukocyte counts observed in this patient on the third and first day of the transplant were maintained within the reference ranges during the whole follow-up period, with no significant remnant splenic regrowth and occurrence of serious procedure-related complications. Currently at 48 months of follow-up, the patient has remained in good general condition with normal liver allograft function and peripheral blood cell counts. Our case demonstrates that simultaneous anatomic subtotal splenectomy during liver transplantation may be an effective and feasible treatment for the prevention of persistent hypersplenism post transplant, achieving a long-term desired hematological response, in a selective category of pediatric cirrhotic patients with severe hypersplenism and massive splenomegaly.

Long-Term Evaluation of the Outcomes of Subtotal Laparoscopic and Robotic Splenectomy in Hereditary Spherocytosis.

Hereditary spherocytosis (HS) is a common inherited disease affecting the erythrocyte membrane. Total splenectomy (TS) is effective in reducing hemolysis and decreasing the need of transfusions, but total removal of the spleen represents a potential risk factor for infectious and non-infectious complications. On the other hand, subtotal splenectomy (STS) could be an alternative therapy for HS. The aim of this study is to establish which surgical approach has the best outcome in HS. All patients (n = 63) receiving splenectomy for HS between 2002 and 2016 from one institution were retrospectively reviewed. Hemoglobin and reticulocytes levels during preoperative and postoperative follow-up periods were compared. Additionally, a meta-analysis was performed analyzing data regarding hemoglobin and reticulocytes levels from several available studies. At 1-year follow-up, our clinical data showed that mean hemoglobin levels increased after TS from (mean ± SD) 9.77 ± 1.82 to 11.88 ± 2.08g/dl, while after STS from 8.98 ± 1.66 to 11.87 ± 1.38g/dl. At 3-year and 5-year follow-up after TS, we observed an increase from 9.77 ± 1.82 to 13.59 ± 2.03 and 13.46 ± 1.64g/dl, respectively. At 3-year and 5-year follow-up after STS in our cohort, we observed an increase from 8.98 ± 1.66 to 13.21 ± 1.95 and 13.68 ± 1.65g/dl, respectively. The meta-analysis (for a follow-up period of 1year) showed that the hemoglobin levels increased with 2.61g/dl (95% CI 2.15-3.08g/dl; p < 0.001) after TS, and with 1.67g/dl (95% CI 1.25-2.10g/dl; p < 0.001) after STS. We conclude that subtotal and minimally invasive splenectomy could be considered as the first line of treatment in severe HS cases, especially in children.

Macro and microscopic comparison of the upper pole of the spleen with the lower pole in partial splenectomy.

Purpose To evaluate the viability of the upper (UP) and lower pole (LP) of the spleen from a macro and microscopic point of view, after subtotal splenectomy with preservation (SSP) of the UP and the LP.Methods Seventeen male Wistar rats, two months old, were submitted to SSPUP and SSPLP and 5 to simulated operation (SG). After 80 days, the rats were euthanized, and the remaining LP and UP and intact spleens were evaluated macroscopically and microscopically.Results Two rats died during the operation. Macroscopic analysis showed that in 15 LP, one of them was not viable and in 15 UP and in 5 spleens in the SG, all were viable. In the statistical analysis, there was no difference in relation to viability. The LP and UP analyzed showed variation. As for the length, the UP increased significantly; however, in relation to the width, there was a significant increase in the LP in relation to the UP. In addition, the weight of the UP was significantly greater than that of the LP. Microscopic analysis attested viability of the splenic remnants.Conclusion There was no significant difference regarding the viability of UP and LP, in macroscopy and microscopy.

The influence of splenic tissue on the survival and TCD4 and TCD8 lymphocyte rates in rats subjected to fecal peritonitis induction.

Purpose:Comparing survival rates of rats subjected to spleen procedures after fecal peritonitis induction. Assessing changes in TCD4 and CD8 lymphocyte rates before and after the procedures. Correlating animal survival with CD4 and CD8 lymphocytes.Methods:Thirty male Wistar rats were distributed into 3 groups of ten: spleen manipulation (SM); total splenectomy (TS); subtotal splenectomy with preservation of the inferior pole (IP). Rats were subjected to surgical procedure depending on the group. Seven days after surgery they underwent induction of peritonitis and survival time was recorded. All animals were subjected to two blood collections: before surgery and 70 days after it for TCD4/TCD8 lymphocyte counting.Results:Mean survival time was longer in the IP and SM groups and shorter in the TS group; there was significant difference between them. The comparison of the median number of CD4 did not present changes, whereas the comparison of the median number of CD8 decreased in the SM and IP groups. The correlation between the median number of TCD4 and TCD8 lymphocytes and the animals’ survival was not significant.Conclusion:The maintenance of splenic tissue contributed to increase the survival of rats and there was a change in the number of TCD8 lymphocytes.

Feasibility and Safety of Laparoscopic Partial Splenectomy: A Systematic Review.

Laparoscopic partial splenectomy (LPS) is a challenging procedure. The aim of this review was to evaluate its feasibility, safety, and potential benefits. We conducted a comprehensive review for the years 1995-2018 to retrieve all relevant articles. A total of 44 studies with 252 patients undergoing LPS were reviewed. Six studies described combined operations. Ranges of operative time and estimated blood loss were 50-225min and 0-1200ml, respectively. There are eight patients need blood transfusion in 231 patients with available data. The conversion rate was 3.6% (9/252). Overall, 27 patients (10.7%;27/252) developed postoperative or intraoperative complications. Overall mortality was 0% (0/252). The length of postoperative stay (POS) varied (1-11days). Among four comparative studies, one showed LPS could reduce POS than laparoscopic total splenectomy (LTS) (LTS 5.4 ± 1.8days, LPS 4.2 ± 0.8days, p = 0.027) and complications (pleural effusion (LTS 9/22, LPS 0/15, p = 0.005), splenic vein thrombosis (LTS 10/22, LPS 0/15, p = 0.002)). Another comparative study showed LPS may benefit emergency patients. However, one comparative study showed LPS was associated with more pain, longer time to oral intake, and longer POS in children with hereditary spherocytosis. The fourth comparative study showed robotic subtotal splenectomy was comparable to laparoscopy in terms of POS and complication. The main benefits were lower blood loss, vascular dissection time, and a better evaluation of splenic remnant volume. In early series of highly selected patients, LPS appears to be feasible and safe when performed by experienced laparoscopic surgeons.

The Spleen and Spleen Surgery in the Elderly

The spleen is a very important organ with many essential functions, not only in the defense of the organism, but also in its metabolic, immunological and haematological systems. The most common manifestations of the splenic disturbances include splenomegaly and a decrease in the number of blood elements. After the removal of the spleen, 2% of adults present severe sepsis, while more than 10% of the elderly are at risk of death due to septic conditions. Most splenic diseases can be treated conservatively. Operative procedures should be considered in special conditions, when all conservative options have been unsuccessfully depleted. Even in the presence of a severe trauma to the spleen or advanced haematological diseases, the best approach is a non-operative procedure. When the operation is unavoidable, partial and subtotal splenectomies or implants of autogenous splenic tissue onto the greater omentum should be performed. At least 25% of a normal spleen should be left with drainage to the portal system to preserve the complete efficacy of all splenic functions. The technological advances and the progressive development of new surgical devices are responsible for laparoscopy with or without robotic assistance. These surgical approaches lead to less pain, faster postoperative recovery and better cosmetic results, without decreasing the therapeutic efficacy. The conservative splenic approach, whether clinical or surgical, is the best way to prevent post-splenectomy infection, by preserving the spleen’s role in immunity.