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.
Pietrabissa A, Morelli L, Peri A, Pugliese L, Zonta S, Dionigi P, Mosca F. Laparoscopic Treatment of SplenomegalyA Case for Hand-Assisted Laparoscopic Surgery. Arch Surg. 2011;146(7):818-823. doi:10.1001/archsurg.2011.149
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.
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.
Design Single-institution single-surgeon retrospective review.
Setting University hospital.
Patients An analysis was performed of all patients with splenomegaly (splenic weight, >700 g) seen during a 10-year 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 compared between patients undergoing HALS vs conventional laparoscopy.
Results Splenomegaly was present in 85 patients, of 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.
Conclusions HALS can minimize surgical trauma in patients 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.
Minimally invasive surgical 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 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.
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 morcellation 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
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.
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), andpatients 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  vs 184  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 correlated with splenic weight (Table 4). This life-threatening 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.
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 normal-sized 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 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 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, 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 hospital 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.
Correspondence: Andrea Pietrabissa, MD, Department of General Surgery, University of Pavia, Pavia, Italy (email@example.com).
Accepted for Publication: June 1, 2010.
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.