Technique Of Laparoscopic Splenectomy Research Articles

Laparoscopic Splenectomy with Technical Standardization and Selection Criteria for Standard or Hand-Assisted Approach in 390 Patients with Liver Cirrhosis and Portal Hypertension

Laparoscopic splenectomy (LS) is still challenging in patients with liver cirrhosis and portal hypertension. This study was designed to establish safe and less invasive LS in patients with liver cirrhosis and portal hypertension. We analyzed 390 patients with liver cirrhosis and portal hypertension, who underwent LS between 1993 and 2013. Patients were divided into 3 time periods; early (1993 to 2004, n = 106); middle (2005 to 2008, n = 159); and late (2008 to 2013, n = 125). During the middle time period, standardized technique for LS and selection criteria for hand-assisted LS were adopted. Patients with spleen volume ≥ 1,000 mL by CT volumetry, large perisplenic collateral vessels, and/or Child-Pugh score ≥ 9, underwent hand-assisted LS. During the late time period, the selection criteria were refined and patients with spleen volume ≥ 600 mL underwent hand-assisted LS. Conversion to open splenectomy decreased (10.4% in the early time period, 1.9% in the middle time period, and 3.2% in the late time period, p = 0.004), median blood loss decreased (300g, 87g, and 98g, respectively, p < 0.001), and the success rate of pure LS tended to improve (87.2%, 89.5%, and 98.0%, respectively, p = 0.110). Mortality was 0% in each time period, Clavien-Dindo grade IIIb or more complications tended to decrease (5.7%, 2.5%, and 0.8%, respectively, p = 0.081), and technique-related complications decreased significantly (10.4%, 3.8%, and 2.4%, respectively, p = 0.014). Laparoscopic splenectomy is now a safe and less invasive approach, even in patients with liver cirrhosis and portal hypertension, because of its technical standardization with the refined selection criteria for pure or hand-assisted LS.

Primary Versus Secondary Splenic Pedicle Dissection in Laparoscopic Splenectomy for Splenic Diseases

Some areas of laparoscopic splenectomy (LS), such as the approach to splenic pedicle dissection, remain controversial. Here we recommend a technique for dissecting the secondary splenic pedicle vessels on the basis of analysis of retrospective data. A retrospective review (April 2006 to October 2011) of databases at 2 institutions identified 136 patients who had undergone LS. In 34 patients with massive splenomegaly, primary splenic pedicle dissection technique (PSPD) had been used in 19 patients and secondary splenic pedicle dissection technique (SSPD) had been used in 15 patients. In 102 patients with normal-sized spleen or moderate splenomegaly, PSPD had been used in 56 patients and SSPD in 46 patients. We compared perioperative and follow-up data. Laparoscopic splenectomy was completed in 128 patients. In the massive splenomegaly group, the conversion rate was 5.3% for PSPD and 33.3% for SSPD, the complication rate was 42.1% vs 20%, hospital stay was 3.2 ± 2.0 days vs 7.5 ± 3.5 days, and transfusion requirement was 1.1 ± 1.2 U vs 3.2 ± 0.9 U, respectively. However, in the normal or moderate splenomegaly group, except for complications, there were no significant differences between PSPD and SSPD techniques in perioperative findings. In the 2 groups, there were significant differences between the PSPD and SSPD techniques in pancreatic leakage (15.8% vs 0 and 8.9% vs 0, respectively) and postoperative fever (15.8% vs 6.7% and 10.7% vs 2.2%, respectively). Secondary splenic pedicle dissection can decrease the incidence of splenic fever and pancreatic leakage and is a valuable technique for LS for normal-sized spleen or moderate splenomegaly. It is not a safe procedure for massive splenomegaly because of the high conversion rate.

Laparoscopic splenectomy using conventional instruments

Introduction:Laparoscopic splenectomy (LS) is an accepted procedure for elective splenectomy. Advancement in technology has extended the possibility of LS in massive splenomegaly [Choy et al., J Laparoendosc Adv Surg Tech A 14(4), 197–200 (2004)], trauma [Ren et al., Surg Endosc 15(3), 324 (2001); Mostafa et al., Surg Laparosc Endosc Percutan Tech 12(4), 283–286 (2002)], and cirrhosis with portal hypertension [Hashizume et al., Hepatogastroenterology 49(45), 847–852 (2002)]. In a developing country, these advanced gadgets may not be always available. We performed LS using conventional and reusable instruments in a public teaching the hospital without the use of the advanced technology. The technique of LS and the outcome in these patients is reported.Materials and Methods:Patients undergoing LS for various hematological disorders from 1998 to 2004 were included. Electrocoagulation, clips, and intracorporeal knotting were the techniques used for tackling short-gastric vessels and splenic pedicle. Specimen was delivered through a Pfannensteil incision.Results:A total of 26 patients underwent LS. Twenty-two (85%) of patients had spleen size more than 500 g (average weight being 942.55 g). Mean operative time was 214 min (45–390 min). The conversion rate was 11.5% (n = 3). Average duration of stay was 5.65 days (3–30 days). Accessory spleen was detected and successfully removed in two patients. One patient developed subphrenic abscess. There was no mortality. There was no recurrence of hematological disease.Conclusion:Laparoscopic splenectomy using conventional equipment and instruments is safe and effective. Advanced technology has a definite advantage but is not a deterrent to the practice of LS.

Pediatric Laparoscopic Splenectomy: The Anterior Approach

Background and Purpose: Splenectomy is frequently performed in children for various hematologic and autoimmune diseases. We review our indications for splenectomy, our technique of laparoscopic splenectomy using an anterior approach, and our results. Patient and Methods: Between January 1996 and May 2000, 35 children aged 1 to 14 years (mean 7 years) underwent laparoscopic splenectomy. We use an anterior pedicle approach and elective vessel endoligature in order to avoid any exogenous material. Results: Eight patients also had a concomitant cholecystectomy. Fourteen children had hereditary spherocytosis, nine were affected by sickle-cell disease, three had idiopathic thrombocytopenia purpura, two had beta-thalassemia, and seven had another hemolytic disease. One patient was converted to open surgery. The mean operative time was 170 minutes (range 115-230 minutes). Hospital stays ranged from 3 to 15 days (mean 6 days). Five patients had complications (three pneumonia and two deep abscess with successful antibiotic treatment). The median follow-up was 20 months (range 2 months-4 years) without problems related to the procedure. Conclusion: With this technique consisting of first elective arterial and secondary venous ligature, we avoided splenic sequestration of blood and preserved the pancreatic tail. The procedure is safer than the traditional approach. For us, considering the low complication rate for this type of patient and the advantages of minimizing abdominal trauma in the postoperative period, the laparoscopic approach for elective splenectomy and eventual cholecystectomy in hematologic disorders is a technique of choice.

Splénectomies cœlioscopiques chez l’enfant : expérience et résultats

Pediatric laparoscopic splenectomy is a relatively new surgical procedure. Advances in instrumentation and technique now make this procedure possible. Splenectomy is frequently performed in children for various hematologic and autoimmune diseases. Patients and methods. – This article reviews the indication for splenectomy, the technique of laparoscopic splenectomy and our results. Between January 1996 and January 2000, 23 children underwent laparoscopic splenectomy. Three of them also had a concomitant cholecystectomy. Their ages ranged from three to 14 years. Nine children had hereditary spherocytosis, four were affected by sickle cell disease, three had an idiopathic thrombocytopenia and three a hemolytic disease. One patient was converted. Results. – Mean operative time was 170 min (range, 115–230 min). Hospital stay ranged from three to 15 days (median, 6). Five patients had complications (three pneumonia and two deep abcesses). Median follow-up was 20 months (two months to four years) without problems regarding procedure. Conclusion. – Regarding the low complication rate for this type of patient and the advantages of a small abdominal trauma in the postoperative period, the laparoscopic approach for elective splenectomy in hematological disorders is the technique of choice.

Role of laparoscopy for Hodgkin's and non-Hodgkin's lymphoma.

An efficacious approach to the diagnosis and treatment of lymphoma requires the expertise of both physicians and surgeons. The surgeon frequently is required to provide an adequate tissue diagnosis, stage the disease, and treat complications of the disease such as splenomegaly. Often, abdominal and retroperitoneal operations are required which may be unnecessarily morbid. Minimally invasive surgical techniques may favorably impact on the work-up and treatment of lymphoma. Laparoscopy can expeditiously access retroperitoneal lymphadenopathy, sample abdominal lymph node groups, and perform splenectomy with low morbidity and rapid recovery. In Hodgkin's disease, laparoscopic staging with splenectomy may be the best modality for infradiaphragmatic staging to tailor initial treatment. Laparoscopic splenectomy is also effective in the treatment of the symptoms and hematologic derangements of splenomegaly or primary splenic lymphoma. The technique of laparoscopic splenectomy is emphasized.

Laparoscopic splenectomy in children.

Splenectomy is frequently performed in children for various hematologic and autoimmune diseases. Advanced laparoscopic techniques have now been adapted to the pediatric patient making laparoscopic splenectomy an effective and desirable technique. This article reviews the indications for splenectomy, the selection criteria for the laparoscopic approach, and the technique of laparoscopic splenectomy in children. A review of surgical results is included.

A New Technique for Laparoscopic Splenectomy in Children with Massive Splenomegaly

ABSTRACT Splenectomy is indicated in several hematologic disorders, and it can be particularly challenging in children with sickle cell disease (SSD), splenomegaly, and recurrent sequestration. The authors report a new technique for laparoscopic splenectomy in children with hypersplenism and splenomegaly using an intracorporeal morcellator. With this technique, splenectomy is accomplished by sequential coring of splenic tissue, which allows for safe and complete laparoscopic removal of very large spleens, even in small children. It provides expedient recovery and minimal postoperative pain and scarring. This new approach should enable surgeons to perform laparoscopic splenectomy even in patients with massive splenomegaly, eliminating the need for large and cumbersome intracorporeal bags or the creation of additional incisions to remove the spleen.

Laparoscopic Splenectomy in Childhood

ABSTRACT Splenectomy is useful in children with hematologic disorders including hereditary spherocytosis, immune thrombocytopenic purpura, and sickle cell disease. Laparoscopic splenectomy in children has developed into a safe and effective procedure, resulting in shorter length of hospital stay, less postoperative discomfort, and improved cosmesis. The operating times are generally longer for a laparoscopic splenectomy than for open splenectomy, and the occurrence of an intraoperative splenic capsular disruption or a missed accessory spleen can lead to reoccurrence of the primary process. This article details the technique of laparoscopic splenectomy and summarizes the results in 75 infants, children, and adolescents who underwent laparoscopic splenectomy for hematologic disorders at a single institution.

Laparoscopic splenectomy and nephrectomy in a rat model. Description of a new technique.

In experimental studies on the effects of laparoscopic procedures on tumor biology, a localized tumor model is desirable. The spleen and the kidney are preferable, because these organs are amenable to tumor placement and subsequent removal. This study describes the technique of laparoscopic splenectomy and nephrectomy in the rat model. Pneumoperitoneum was established by CO2 insufflation. Laparoscopic splenectomy involved two-handed dissection, intracorporeal ligation, and division of gastrosplenic attachments and hilar and short gastric vessels. Laparoscopic nephrectomy was done by intracorporeal ligation and division of the renal vessels and the ureter after mobilization of the kidney. Laparoscopic splenectomy was performed in six rats; laparoscopic nephrectomy was done in six rats. Operative time ranged from 45 to 90 min for splenectomy and from 40 to 65 min for nephrectomy. Postoperatively, two rats died from hemorrhage. Necropsy of the rats after 10 days revealed adhesion in three rats after splenectomy and in four rats after nephrectomy. Inflammatory processes were found around the silk ligatures in all rats after splenectomy; in two rats wound infections occurred at the port sites. Laparoscopic splenectomy and nephrectomy in the rat proved technically feasible and may provide new localized tumor models suitable to be used in further studies on the oncological effects of laparoscopic surgery.

Technical aspects of laparoscopic splenectomy in children

Different authors reported about their experiences in laparoscopic splenectomy. The preparation of vessels and ligaments are feasable without major problems. Nevertheless the handling of the organ during the operation and during splenic extraction can be very difficult, especially in larger organs. The authors report experience with the technique of laparoscopic splenectomy and describe a new technical aspect in handling the spleen during this procedure. A loop of an umbilical band is used for retracting the organ during the preparation and placing the spleen into a sterile bag for the removal of the organ. This device helps prevent damages to the capsule caused by forceps. Large organs can be placed into the pelvis, and the bag is placed and opened in the upper abdomen. The authors used this technique successfully in seven patients. The results are compared with previous experiences.

Technique of laparoscopic splenectomy with a powered vascular linear stapler

The spleen may be removed by a laparoscopic technique, although the benefits and associated morbidity of this approach are unknown. This study reports a series of 28 consecutive patients (15 women; median age 39 (range 17-84) years) considered for laparoscopic splenectomy, because of idiopathic thrombocytopenia in 14, human immunodeficiency virus-related thrombocytopenia in seven, autoimmune haemolytic anaemia in four, lymphoma in two and chronic lymphocytic leukaemia in one. In 23 cases dissection was completed laparoscopically, with the patient in the right lateral position, using a four-cannula technique. Vascular isolation was achieved with an Endo-GIA (powered vascular linear stapler). The spleen was removed by morselation within a retrieval bag (18 patients) or via either a Pfannenstiel or subcostal incision (five). The last 14 procedures have all been completed successfully in a mean operating time of 105 min with discharge from hospital within a median of 3 days. One patient developed a clinically apparent deep venous thrombosis 23 days after operation, for which he required readmission. Elective laparoscopic splenectomy is a feasible although technically demanding operation which may be performed safely and without associated mortality by surgeons experienced in laparoscopic techniques.

Technique of laparoscopic splenectomy with a powered vascular linear stapler

Technique of laparoscopic splenectomy with a powered vascular linear stapler

Laparoscopic splenectomy in childhood

The authors describe their technique for laparoscopic splenectomy in childhood. Five ports, including one 12-mm port for an endoscopic stapler, are placed. With the patient in the supine position, the short gastric vessels are divided between clips. The patients is then placed in the lateral decubitus position for mobilization of the splenic flexure of the colon, division of the posterolateral ligamentous attachments, and en masse transection of the splenic hilum using the EndoGIA stapler. The freed spleen is placed in a nylon reinforced Lap Sac, which is exteriorized at the neck. The spleen is morcellated and the sac removed. Concomitant cholecystectomy is performed in patients with hereditary spherocytosis who have cholelithiasis or sludge. The procedure has been performed without complications in six patients who had hematologic disorders. For another patient, the procedure was converted to an open splenectomy to achieve better hemostasis.

Laparoscopic splenectomy

A technique for laparoscopic splenectomy is described. The patient is placed in the right semidecubitus position and pneumoperitoneum is prepared. The splenic artery and vein are exposed near the hilum, using a laparoscopic ultrasonic dissector. The larger vessels are doubly ligated, and the spleen is resected and maneuvered into a nylon surgical sack; the sack is removed through a 2-cm incision along the midaxillary line. This procedure has been used for four patients requiring splenectomy for benign disease, and the outcome has been entirely satisfactory for all concerned.

Laparoscopic Assisted Splenectomy for Treatment of Presumed Immune Thrombocytopenic Purpura: Initial Results

To present the initial results of performance of laparoscopic splenectomy in two patients at Mayo Clinic Scottsdale. We describe two 18-year-old patients with idiopathic immune thrombocytopenic purpura and the technique of laparoscopic splenectomy used for treatment. For adequate visualization of the spleen and exposure of the upper midline area should urgent laparotomy become necessary, we position the patient supine with a sandbag under the left lower costal margin. Insertion of five 10-mm trocars facilitates placement of instruments. Dissection of the spleen is begun inferiorly. The splenic flexure of the colon is reflected inferiorly, and the spleen is rotated anterolaterally to allow division of the gastrosplenic ligament and the splenic hilum. Individual vessels are divided between clips, as are the short gastric vessels. Cautery is used for dividing the splenophrenic ligament. The spleen is placed in a plastic bag, and the open end of the bag is delivered through the umbilical incision, after which the spleen is morcellated and then removed. Considerable care must be exercised to ensure that the plastic bag is not punctured and that no ectopic splenic tissue is present. Both laparoscopic splenectomies were successful, and no intraoperative or postoperative complications occurred. After dismissal on postoperative day 3, the patients quickly resumed all activities. The platelet counts returned to normal. These encouraging results support the use of laparoscopic splenectomy for immune thrombocytopenic purpura and suggest that this procedure may have a role in patients with other conditions of the spleen.