Laparoscopic Treatment of Splenomegaly A Case for Hand-Assisted Laparoscopic Surgery

ORIGINAL ARTICLE
Laparoscopic Treatment of Splenomegaly
A Case for Hand-Assisted Laparoscopic Surgery
Andrea Pietrabissa, MD; Luca Morelli, MD; Andrea Peri, MD; Luigi Pugliese, MD; Sandro Zonta, MD;
Paolo Dionigi, MD; Franco Mosca, MD
Hypothesis: Hand-assisted laparoscopic surgery (HALS)
is a safe therapeutic approach to remove megaspleens of
any size. Conventional laparoscopic splenectomy for
splenomegaly is difficult because of limited exposure
and complex vascular control, with increased risk of intraoperative bleeding and conversion to open surgery.
HALS can overcome some of these limitations, reducing
the risk of conversion to open surgery and resulting in a
postoperative course similar to that of conventional
laparoscopy.
pared between patients undergoing HALS vs conventional laparoscopy.
Results: Splenomegaly was present in 85 patients, of
Design: Single-institution single-surgeon retrospective review.
whom 43 underwent HALS splenectomy and 42 underwent conventional laparoscopic splenectomy. The HALS
group had larger spleens. Rates of conversion to open surgery and operative mortality were similar in the HALS
group vs the conventional laparoscopy group (2.3% [1
of 43] vs 2.4% [1 of 42] and 2.3% [1 of 43] vs 0.0% [0 of
42], respectively), with no difference in hospital length
of stay in the absence of morbidity. Portal system thrombosis was the most serious complication.
Setting: University hospital.
Conclusions: HALS can minimize surgical trauma in pa-
Patients: An analysis was performed of all patients with
splenomegaly (splenic weight, ⬎700 g) seen during a 10year period.
Main Outcome Measures: Preoperative data, indications for splenectomy, splenic weight, operative variables, clinical outcome, and rates of conversion to open
surgery, complications, and operative mortality were com-
M
Author Affiliations: Chirurgia
Generale, Università di Pisa,
Pisa (Drs Pietrabissa, Morelli,
Peri, Pugliese, and Mosca) and
Chirurgia Generale, Università
di Pavia, Fondazione IRCCS
Policlinico San Matteo, Pavia
(Drs Zonta and Dionigi), Italy.
Dr Pietrabissa is now with
Chirurgia Generale, Università
di Pavia, Fondazione IRCCS
Policlinico San Matteo, Pavia.
tients with massive splenomegaly who otherwise would
be candidates only for open surgery and results in a clinical outcome similar to that of conventional laparoscopy. With the availability of HALS, any patient with splenomegaly can be offered a minimally invasive surgical
option. Portal system thrombosis is common, regardless of the surgical technique.
Arch Surg. 2011;146(7):818-823
INIMALLY INVASIVE SUR-
gical treatment of patients with splenomegaly is associated
with high risk of intraoperative bleeding and conversion to open
surgery.1 The adoption of hand-assisted
laparoscopic surgery (HALS) in this setting has been advocated to reduce the rate
of conversion to laparotomy and to improve the postoperative course of patients who otherwise would be candidates only for open surgery.2 However, the
use of HALS has been reported at few dedicated centers,3-5 and some investigators
question the value of a minimally invasive surgical approach to treat patients with
splenomegaly.6,7
In this study, we retrospectively reviewed a 10-year single-surgeon experience in minimally invasive surgical treatment of splenomegaly. Regardless of the
ARCH SURG/ VOL 146 (NO. 7), JULY 2011
818
size of his or her spleen, every patient seen
with splenomegaly had been offered a
minimally invasive surgical approach by
HALS splenectomy or by conventional
laparoscopic splenectomy. Outcome measures were compared between patients
managed with the 2 techniques in an attempt to elucidate their risks and benefits in this setting.
METHODS
STUDY DESIGN
The medical and operative records of all patients scheduled for laparoscopic splenectomy at the Department of General Surgery,
University of Pisa, Pisa, Italy, from June 1, 1999,
through June 1, 2009, had been prospectively
collected in a database. The present retrospective review focuses only on patients with splenomegaly, defined as splenic weight after mor-
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A
B
C
Figure. Surgical field setup in a patient undergoing hand-assisted laparoscopic surgery (HALS) splenectomy. A, Shown are megaspleen and laparotomy lines for
possible conversion to open surgery. B, The HALS access device (Omniport; Advanced Surgical Concepts, Dublin, Ireland) is placed in the right subcostal area,
and 3 additional trocars are positioned. C, Access incisions at the end of the HALS procedure are shown.
cellation exceeding 700 g.3 All operations were performed by
one of us (A. Pietrabissa), who independently decided whether
HALS or conventional laparoscopy would be performed. The
decision was based on several factors, which are discussed herein.
The operative team had experience with both techniques in other
settings.8-10
OPERATIVE TECHNIQUE
Patients were placed in a semilateral decubitus position, without flexing the operative table. For the HALS approach, the procedure started with a 7-cm right subcostal laparotomy to accommodate the HALS access device (Omniport; Advanced
Surgical Concepts, Dublin, Ireland) (Figure). The operating
surgeon wore a brown glove on his left hand to prevent reflective light during endoscopic vision. Two to 3 trocars were then
positioned in the left subcostal area at increasing distances from
the costal margin in accord with the size of the spleen (the larger
the spleen, the more medial the trocars were placed). For the
conventional laparoscopic approach, 3 to 4 trocars were used
in a similar manner after creation of pneumoperitoneum using
a Veress needle.
Surgical dissection began with division of the short gastric
vessels to enter the lesser sac and with early clipping of the
splenic artery, identified along the superior border of the pancreatic tail. In the HALS technique, after some initial blunt
dissection, the hilum of the spleen was encircled between the
middle finger and thumb of the surgeon’s left hand, and a stapler (Endo GIA; Ethicon Endosurgery, Cincinnati, Ohio) was
guided and fired across the pedicle, with no attempt at further
dissection of the included vascular structures (main splenic
artery and vein). In the conventional laparoscopic technique,
division of the main splenic pedicle was usually achieved after
a longer dissection that entailed complete detachment of the
spleen off its ligaments to allow safe placement of the stapler
across the hilum.
Bagging of the spleen was achieved by introducing inside
the abdomen a transparent sterile bowel bag and, once this was
around the spleen, by pulling the incorporated purse string once
the spleen was bagged. The HALS access site was used to extract the specimen, morcellated by hand into large pieces; in
the case of conventional laparoscopy, a minilaparotomy of about
3 cm was created by enlarging the most lateral port wound. A
suction drain was always left in the subphrenic area for 2 days
following the operation or longer if needed.
Patients were retrospectively divided into 2 groups based on
whether HALS or conventional laparoscopy was performed. Data
analysis was performed at the Department of General Surgery,
University of Pavia, Pavia, Italy, where one of us (A. Pietrabissa) has been affiliated since January 2010. To compare the 2
groups, age, sex, body mass index, American Society of Anesthesiologists classification, preoperative platelet count, and splenic
weight were analyzed. Patients were also stratified according to
the weight of their removed spleen for further assessment of splenectomy techniques and operative variables. Operative time (from
creation of pneumoperitoneum to application of dressings), time
required for spleen bagging and retrieval of the specimen, estimated intraoperative blood loss, rates of conversion to open surgery, and need for reoperation were recorded and analyzed. After surgery, patients had been enrolled in a color Doppler
ultrasonographic surveillance program to assess portal system
patency. Operative mortality, hospital length of stay, and complications were noted and evaluated. Continuous data are given
as the mean (SD) and were compared using the t test. Proportional data were compared using Fisher exact test, with P⬍.01
considered statistically significant.
RESULTS
During the 10-year period of this study, 85 consecutive
patients with splenomegaly (splenic weight after morcellation, ⬎700 g) were considered for laparoscopic splenectomy at the Department of General Surgery, University of Pisa, Pisa, Italy. The chosen operative technique
was HALS splenectomy in 43 patients and conventional
laparoscopic splenectomy in 42 patients. Characteristics of patients in the 2 study groups are given in Table 1,
and indications for splenectomy are given in Table 2.
Patients in this retrospective review were not randomly assigned to one treatment or the other, and statistical analysis of the variables in Table 1 showed that
the HALS group contained significantly more men, older
patients, patients with larger spleens (as expected), and
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Table 1. Characteristics of Patients in the 2 Study Groups
Variable
Age, mean (SD), y
Male sex, No. (%)
BMI, mean (SD)
ASA classification 3 or
4, No. (%)
Preoperative platelet
count, mean (SD),
⫻103/µL
Splenic weight, mean
(SD), kg
Conventional
Laparoscopy
Group
(n = 42)
HALS
Group
(n = 43)
P
Value
46.8 (21.0)
19 (45.2)
24.0 (4.6)
18 (42.9)
66.5 (8.7)
36 (83.7)
24.1 (6.6)
28 (65.1)
.001
.003
.93 a
.004
171.7 (108.7)
142.0 (138.7)
.29 a
1.15 (0.69)
2.46 (1.50)
.005
Table 2. Indications for Splenectomy in the 2 Study Groups
Indication
Non-Hodgkin lymphoma
with gross spleen
involvement
Autoimmune
thrombocytopenia
Splenic mass
Myelofibrosis
Spherocytosis
Chronic lymphatic leukemia
Autoimmune hemolytic
anemia
Myeloid metaplasia
Hodgkin lymphoma
Idiopathic
thrombocytopenic
purpura
Splenic infarction due to
arterial thrombosis
Multiple splenic abscesses
Beta-thalassemia
Waldenstro¨m
macroglobulinemia
Myelomonocytic leukemia
Essential thrombocytemia
Abbreviations: ASA, American Society of Anesthesiologists; BMI, body
mass index (calculated as weight in kilograms divided by height in meters
squared); HALS, hand-assisted laparoscopic surgery.
SI conversion factor: To convert platelet count to ⫻109/L, multiply by 1.0.
a Statistically nonsignificant. All other differences between study groups
are statistically significant.
patients with American Society of Anesthesiologists classification 3 or 4. The 2 groups were similar by body mass
index and preoperative platelet count. The mean operative times were not significantly different between the 2
groups (176 [18] vs 184 [22] min).
In the stratification of our patients according to the
weight of their removed spleen, HALS technique use increased in association with heavier spleens (Table 3),
limiting our statistical comparisons of operative time and
estimated intraoperative blood loss between the 2 groups.
Larger spleens were associated with longer procedures
and with greater risk of intraoperative bleeding. Conventional laparoscopy for spleens weighing more than 2
kg was considered in only 3 of 25 patients. One patient
undergoing HALS had a 7.2-kg spleen removed.
Conversion to open surgery occurred because of intraoperative bleeding in 1 HALS group patient (for a conversion rate of 2.3%) and in 1 conventional laparoscopy
group patient (for a conversion rate of 2.4%). Two patients in the HALS group required reoperation within the
first 48 hours to control postoperative bleeding compared with no patients in the conventional laparoscopy
group. The mean time required to bag the spleen and deliver the specimen outside of the abdomen was 12 minutes (range, 5-22 minutes) for HALS vs 23 minutes (range,
9-36 minutes) for conventional laparoscopy.
One patient in the HALS group died of congestive heart
failure 15 days after splenectomy; no deaths occurred in
the conventional laparoscopy group. In the absence of
morbidity, the mean hospital length of stay was 5 (2) days
for patients in the HALS group and 4 (3) days for patients in the conventional laparoscopy group. Complications occurred among 29 patients in the HALS group
and among 13 patients in the conventional laparoscopy
group. Postoperative bleeding was observed in 3 HALS
group patients and in 1 conventional laparoscopy group
patient.
In both groups, portal system thrombosis was the most
important factor affecting the postoperative course and
the hospital length of stay (mean, 11.3 days) and corre-
Conventional
Laparoscopy
Group
(n = 42)
HALS
Group
(n = 43)
Total
(N = 85)
10
19
29
9
0
9
6
2
7
1
2
2
6
0
4
1
8
8
7
5
3
1
1
1
2
1
1
3
2
2
0
2
2
0
1
0
2
0
1
2
1
1
0
1
1
1
1
2
Abbreviation: HALS, hand-assisted laparoscopic surgery.
lated with splenic weight ( Table 4 ). This lifethreatening complication was observed in 14.3% (5 of
35) of patients with splenic weight less than 1 kg, in 40.0%
(10 of 25) to 45.5% (5 of 11) of patients with splenic
weight between 1 and 3 kg, and in 71.4% (10 of 14) of
patients with splenic weight exceeding 3 kg. Despite early
treatment with intravenous anticoagulation therapy,
13.3% (4 of 30) of patients who developed a thrombus
in the portal system progressed to complete thrombosis
of the portal vein with formation of a cavernoma.
COMMENT
Current trends in minimally invasive surgery seek to reduce access trauma. Examples are the development of
single-port surgery (known by many acronyms)11 and
natural orifices transluminal endoscopic surgery.12 However, most procedures performed today in general surgery use conventional open techniques, with only a small
proportion of patients benefiting from the minimally invasive surgical approach.
This is owing in part to a lack of training in advanced
laparoscopic techniques, as well as to the fact that surgical procedures can be performed laparoscopically in select instances, usually restricted to early stages of a given
disease. The case for splenectomy is no exception. Laparoscopy is considered the standard treatment for a normalsized spleen,13 but most surgeons would be reluctant to
approach splenomegaly in the same way.6,7,14 Indeed, current practice does not support the routine use of endoscopic surgery for splenomegaly by nonexpert surgeons
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Table 3. Relationships Among Splenic Weight, Surgical Technique, and Related Operative Time
and Estimated Intraoperative Blood Loss
Conventional Laparoscopy Group
(n = 42)
Splenic
Weight
700 g to
⬍1 kg
1 to 2 kg
⬎2 to 3 kg
⬎3 kg
No. of
Patients
Operative
Time,
Mean
(SD), min
Estimated
Intraoperative
Blood Loss,
Mean (SD), mL
29
167 (53)
38 (18)
10
2
1
188 (37)
155 (21)
180 (36)
41 (11)
140 (14)
180 (55)
HALS Group
(n = 43)
P Value a
Operative
Time,
Mean
(SD), min
Estimated
Intraoperative
Blood Loss,
Mean (SD), mL
Operative
Time
Estimated
Intraoperative
Blood Loss
6
153 (50)
80 (31)
.57
.06
15
9
13
162 (40)
193 (63)
220 (49)
72 (49)
170 (39)
179 (16)
.11
.43
.45
.06
.33
.96
No. of
Patients
Abbreviation: HALS, hand-assisted laparoscopic surgery.
differences between study groups are statistically significant.
a No
outside of specialized centers. A few centers have demonstrated that HALS can improve the outcome of this difficult surgery, but the benefits and risks of the technique remain unclear.2,4
The objective of this study was to demonstrate that
selective use of HALS allows surgeons to manage splenomegaly of any size using a minimally invasive surgical approach, which has a clinical outcome similar to
that of conventional laparoscopy. We analyzed a single
surgeon’s experience among a series of 85 patients
with splenomegaly treated by a minimally invasive
surgical approach using HALS or conventional laparoscopy. Although the 2 retrospectively compared
groups were different, their intraoperative and postoperative courses were similar, indicating that the additional trauma of HALS is minimal and does not significantly affect outcome. HALS offers a minimally invasive
surgical option to any patient with splenomegaly, including those with megaspleens weighing more than 2
or 3 kg. The circumstances under which HALS was
used changed throughout the 10-year period of this
study. With increasing familiarity using the technique,
we now consider HALS the preferred technique for any
spleen exceeding 20 cm in maximal diameter, for which
we would anticipate more difficulty in dissection and
longer bagging and extraction time with conventional
laparoscopy.
A patient’s abdominal characteristics are also considered, as conventional laparoscopy is usually more
difficult in obese patients and in men. The reported
data herein reflect our impression that surgical dissection in older men tends to be more difficult to perform, with more patients in this subgroup treated by
HALS. The reason for this difficulty probably lies in
the distribution of intra-abdominal fat, which is age
and sex related.15 While intra-abdominal fat in women
is somewhat independent of increased subcutaneous
fat, the mean thickness of the greater omentum and of
retroperitoneal fat in men parallels the increased maximal thickness of subcutaneous fat, which makes surgical dissection more demanding. In the case of a large
spleen, we prefer a right subcostal incision for the
HALS device over supraumbilical or periumbilical
access to avoid interference between the intra-abdominal
Table 4. Relationship Between Splenic Weight and Portal
System Thrombosis
Portal System
Thrombosis,
No. (%)
Splenic Weight
Absence
Presence
P
Value
700 g to ⬍1 kg (n = 35)
1 to 2 kg (n = 25)
⬎2 to 3 kg (n = 11)
⬎3 kg (n = 14)
30 (85.7)
15 (60.0)
6 (54.5)
4 (28.6)
5 (14.3)
10 (40.0)
5 (45.5)
10 (71.4)
.001 a
.62
.51
.004 a
a Statistically
significant.
hand and the optics. Also, the medial edge of the spleen
was well over the midline in many patients described
herein. In the case of conversion to open surgery, a right
subcostal minilaparotomy can be extended to a bilateral
subcostal incision.
By retaining tactile feedback, the surgeon’s left hand
can bluntly dissect the space beneath the tail of the pancreas and encircle the pedicle of the spleen early in the
dissection. This step, together with preventive ligation
or clipping of the splenic artery, will limit the consequences of any possible injury that might occur during
the subsequent dissection, as the surgeon will then be
able to control the vascular pedicle with his or her fingers at any time. In the case of a large spleen, the inconstant posterior attachments to the diaphragm can be difficult and sometimes impossible to divide using
conventional laparoscopy because visual access to this
area is limited by the size of the overlying spleen. In HALS,
blunt finger dissection of these attachments can usually
be accomplished even in areas that are hidden to endoscopic view because of the retained tactile feedback with
this technique. Bagging these extra-large spleens with the
sole assistance of conventional laparoscopic instruments, particularly when the patient has reduced abdominal compliance, is not only complex because of the
restricted view and limited mobility of the graspers but
also has the risk of breaking the capsule of the spleen,
with consequent spillage of parenchymal cells into the
peritoneal cavity. With the aid of the intraperitoneal hand,
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this maneuver is facilitated and can be accomplished in
a faster and safer manner. In addition, the HALS access
incision allows the spleen to be removed in large pieces,
further reducing the time needed for this step of the procedure.
In reporting a series of 45 patients with splenomegaly, Rosen et al3 concluded that the upper limit of
splenic size that can be approached using HALS
remains unclear. With the adoption of HALS, every
patient with splenomegaly who was referred to our center over the 10-year study period was offered a minimally invasive surgical option, including 14 patients
with a splenic weight exceeding 3 kg and the patient
with exceptional splenic weight of 7.2 kg. In such
patients, the only reasonable alternative to HALS would
be open surgery. The benefits of HALS are similar to
those of conventional laparoscopy, with equivalent
recovery time and hospital length of stay. These risks
are also similar, as evidenced by our finding that portal
system thrombosis was common in our series, regardless of the surgical technique. Instead, the development
of this potentially lethal complication correlated with
splenic weight.
In a study on this topic, Targarona16 suggested that
portal vein thrombosis may have been underreported before the 1990s and focused on its association with splenomegaly and myeloproliferative disease. In a study of
22 patients undergoing laparoscopic splenectomy, Ikeda
et al17 found that routine computed tomography detected a 55% incidence of postoperative portal system
thrombosis, most of which would otherwise have been
missed. In a more recent study, Danno et al18 showed that
splenic vein diameter can predict the occurrence of
postoperative thrombosis and suggested a threshold of
8 mm, above which the chances of developing this
complication rise to more than 70%. Our data showed
the presence of postoperative portal system thrombosis in 40.0% (10 of 25) of patients with splenic weight
of 1 to 2 kg and in 71.4% (10 of 14) of patients with
splenic weight exceeding 3 kg. Adequate postoperative
monitoring of this condition by successive imaging
(ultrasonography or computed tomography), as well
as pharmacological prophylaxis, should be considered
in all patients with splenomegaly, particularly if the
estimated splenic weight exceeds 1 kg and a hematological malignancy is present.19
Along the same lines, Patel et al1 showed that splenic
weight is the most powerful predictor of morbidity, with
a 14-fold increase in the risk of developing complications for spleens exceeding 1 kg, causing the author to
question the benefits of a minimally invasive surgical approach in patients with splenomegaly. In addition, Ikeda
et al17 suggested that the incidence of portal system thrombosis might be greater among patients with splenomegaly undergoing minimally invasive surgery compared with those undergoing open surgery. Although their
data have not been confirmed, the benefits of endoscopic techniques in this setting remain less clear given
the high morbidity observed among patients with splenomegaly.
In our experience, most portal system thrombosis occurred with few symptoms or none, and prolonged hos-
pital length of stay among these patients was owing to
the need for intravenous anticoagulation therapy and successive monitoring of thrombus by imaging. In other
words, most of these patients would otherwise have been
well enough to leave the hospital much earlier than they
did. Complete recovery occurred in 26 of 30 patients
(86.7%) who developed this complication.
In conclusion, HALS can be selectively offered to
any patient with splenomegaly, irrespective of splenic
size, with low risk of conversion to open surgery. Benefits of HALS include the avoidance of complications
related to major laparotomy and a postoperative
course similar to that of conventional laparoscopy. A
high incidence of portal system thrombosis significantly prolonged the hospital length of stay among
many patients in our series, but the occurrence of this
complication seems to depend more on splenic size
than on operative technique. Although portal system
thrombosis causes little discomfort to the patient,
careful postoperative imaging is required for its early
detection and prompt treatment.
Accepted for Publication: June 1, 2010.
Correspondence: Andrea Pietrabissa, MD, Department
of General Surgery, University of Pavia, Pavia, Italy (andrea
[email protected]).
Author Contributions: Study concept and design: Pietrabissa, Morelli, Peri, Pugliese, Zonta, Dionigi, and Mosca.
Acquisition of data: Pietrabissa, Morelli, Peri, and Pugliese. Analysis and interpretation of data: Pietrabissa, Zonta,
Dionigi, and Mosca. Drafting of the manuscript: Pietrabissa and Pugliese. Critical revision of the manuscript for
important intellectual content: Pietrabissa, Morelli, Peri,
Zonta, Dionigi, and Mosca. Statistical analysis: Pugliese,
Zonta, and Dionigi. Administrative, technical, and material support: Pietrabissa, Morelli, Peri, and Pugliese. Study
supervision: Dionigi and Mosca.
Financial Disclosure: None reported.
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