Port placement for hand-assisted laparoscopic splenectomy.
Sequential steps for specimen retrieval in hand-assisted laparoscopic splenectomy.
Rosen M, Brody F, Walsh RM, Ponsky J. Hand-Assisted Laparoscopic Splenectomy vs Conventional Laparoscopic Splenectomy in Cases of Splenomegaly. Arch Surg. 2002;137(12):1348–1352. doi:10.1001/archsurg.137.12.1348
Laparoscopic splenectomy (LS) is the procedure of choice for elective splenectomy. Splenomegaly may preclude safe mobilization and hilar control using conventional laparoscopic techniques. Hand-assisted LS (HALS) may offer the same benefits of minimally invasive surgery for splenomegaly while allowing safe manipulation and splenic dissection.
A retrospective review of patients with splenomegaly undergoing conventional LS or HALS was performed.
Tertiary care referral center.
Hand-assisted LS was performed at the start of the operation for patients with splenomegaly; splenomegaly was determined by palpation of the splenic tip extending to the midline or the iliac crest, or by a craniocaudal splenic length of greater than 22 cm. Splenomegaly was defined as a splenic weight of greater than 700 g after morcellation.
Main Outcome Measures
Patient demographic characteristics, operative indications, splenic weight after morcellation, morbidity, mortality, and clinical outcomes were evaluated.
Forty-five patients with splenomegaly were identified: 31 underwent standard LS and 14 underwent HALS. The HALS group had significantly larger spleens than the conventional LS group (mean weight, 1516 vs 1031 g; P = .02). Mean operative time (177 vs 186 minutes; P = .89), estimated blood loss (602 vs 376 mL; P = .17), and length of hospital stay (5.4 vs 4.2 days; P = .24) and complication rates (5 [36%] of 14 vs 5 [16%] of 31; P = .70) were similar between the HALS and the standard LS groups. No perioperative mortality occurred.
Hand-assisted LS is a safe and efficacious procedure for these extremely difficult cases. Hand-assisted LS provides the benefits of a minimally invasive approach in cases of splenomegaly.
LAPAROSCOPIC splenectomy (LS) is ideal for the removal of normal-sized spleens. Splenomegaly increases the technical challenges of this procedure. In several open splenectomy series,1,2 operative morbidity and mortality increases significantly with splenomegaly. Laparoscopic or open resection of an enlarged spleen can be difficult because of limited retraction and hilar visualization. Splenomegaly increases the risks of bleeding, capsular disruption, and conversions to open splenectomy.3
The introduction of the surgeon's hand into the abdomen maintains tactile sensation and increases manipulation of the organ. Retaining pneumoperitoneum and laparoscopic optics when used in conjunction with this increased exposure allows for success of this minimally invasive procedure.4 Hand-assisted LS (HALS), therefore, provides similar minimally invasive benefits as conventional LS. In addition, hand-assisted laparoscopic techniques may reduce intraoperative complications and decrease operative times. This study retrospectively compares patients with splenomegaly operated on by a standard laparoscopic vs a hand-assisted laparoscopic technique.
Between August 1, 1995, and February 25, 2002, 183 patients underwent LS for a wide variety of hematologic indications at The Cleveland Clinic Foundation. After receiving approval from the foundation's Institutional Review Board, clinical information was accumulated for each patient in a prospective database, including age; sex; body mass index, calculated as weight in kilograms divided by the square of height in meters; American Society of Anesthesiologists' classification; and preoperative diagnosis. Operative data included operative time as measured from first skin incision to the application of dressings, estimated blood loss (EBL), presence of accessory spleens, splenic weight after morcellation, indication for conversion, and postoperative length of hospital stay. Complications were classified as intraoperative or postoperative, and were subjectively subdivided into major and minor.
Forty-five patients with splenomegaly, as defined by a splenic weight of greater than 700 g after morcellation, were identified. Of these patients, 31 were treated with a purely laparoscopic approach (group 1) and 14 underwent HALS (group 2). Data are expressed as mean ± SD and range. Cases that were converted to open surgery were included in the final analysis on an intention-to-treat basis. Groups were compared using Fisher exact tests and Wilcoxon rank sum tests when relevant.
Our operative technique in the lateral position has been previously described.5 At least 1 week before the operation, patients receive a polyvalent pneumococcal, meningococcal, and Haemophilus influenzae type b vaccine, and prophylactic antibiotics are given immediately before surgery. With the patient in the right lateral decubitus position, the operating table is flexed at the umbilicus, increasing the distance between the iliac crest and the costal margin. Typically, three 10-mm ports are used. The lateral port is typically placed at the level of the 11th rib tip, the medial port is close to the midline, and the middle port is halfway between these 2, ideally 2 to 4 cm below the inferior tip of the spleen. The spleen is mobilized from an inferior to superior direction using the ultrasonic dissector. After the spleen is fully mobilized, the remaining hilar pedicle is divided with a vascular endostapler. The spleen is then placed in an impermeable retrieval bag and morcellation is performed for removal.
In patients with splenomegaly, as determined by palpation of the splenic edge tip extending to the iliac crest or across the midline, or by a craniocaudal length of greater than 22 cm, a hand-assisted technique was chosen at the start of the operation. For HALS, the patient is placed in a modified right lateral decubitus position at 45°. The length of the incision is determined by the glove size; usually it is 7 cm. The pneumosleeve (Smith & Nephew, Largo, Fla) is applied to the abdominal wall, and the abdomen is insufflated to 15 mm Hg with carbon dioxide. The surgeon's left hand is placed through the sleeve. A 10-mm port and a 5-mm port are placed parallel to the splenic margin. The surgeon's left hand is used to protect the visceral organs and retract the spleen (Figure 1). The conduct of the operation is otherwise unaltered. With the spleen circumferentially mobilized, the splenic pedicle is encircled between the middle finger and thumb, and the tail of the pancreas is bluntly dissected free if necessary. The hilum is divided with an endovascular stapler and removed from the abdomen in a specimen retrieval bag. Splenic retrieval begins by placing an atraumatic grasper through the lateral 5-mm trocar and out the hand-assisted port site. A specimen retrieval bag is inverted over the surgeon's hand and the grasping instrument is placed on the edge of the specimen retrieval bag. The hand is introduced into the abdomen, and the spleen is held with the surgeon's hand. The grasping instrument is brought out through the lateral trocar, pulling the edge of the retrieval bag laterally. This maneuver completely encircles the spleen. The bag is tightened and positioned at the hand-assisted port site for morcellation (Figure 2).
Patient demographic characteristics comparing the 2 groups are displayed in Table 1. There were 22 men and 9 women in group 1 and 7 men and 7 women in group 2. Both groups were comparable for age (54 ± 15 years [range, 22-76 years] vs 57 ± 13 years [range, 38-73 years]), body mass index (28 ± 7 [range, 20-48] vs 25 ± 3 [range, 21-29]), and American Society of Anesthesiologists classification (2.7 ± 0.6 [range, 1-4] vs 2.9 ± 0.3 [range, 2-3]). The most common indication for splenectomy was hematologic malignancy, followed by splenomegaly, lymphoproliferative or myeloproliferative disorder, autoimmune hemolytic anemia, hereditary spherocytosis, Felty syndrome, idiopathic thrombocytopenic purpura, myelofibrosis, splenic abscess, and splenic cyst (Table 2).
The conventional LS group had significantly smaller spleens than the HALS group. Despite this difference, operative time, EBL, length of hospital stay, and complication rates were not significantly different between the 2 groups (Table 3). Conversions were required in 7 patients in group 1 and in 1 patient in group 2. In group 1, a small gastrotomy was created in 1 patient with splenomegaly (1234 g) during dissection of the short gastric vessels. This was noted intraoperatively, and the procedure was converted to an open laparotomy for an uncomplicated repair. The remaining 6 conversions were due to retraction and visualization difficulties. The average splenic weight of the patients who underwent these 6 conversions was 1135 g (range, 815-2100 g). In group 2, 1 patient required conversion to open splenectomy for control of diffuse hemorrhaging (EBL, 2200 mL; and splenic weight after morcellation, 3500 g).
Five postoperative complications (16%) occurred in group 1. Two of these patients had minor complications. One patient had postoperative fevers secondary to atelectasis. Another patient was readmitted to the hospital for 5 days because of an ileus that eventually resolved with conservative measures. Three patients had major postoperative complications. Of these 3 patients, 2 had deep venous thromboses requiring long-term anticoagulation. Another patient developed a subphrenic abscess that required percutaneous drainage. In group 2, 5 patients (36%) developed postoperative complications. Two minor complications occurred, and included a superficial wound infection at the hand-assisted port site; one patient required readmission for a fever and diarrhea that eventually resolved with hydration. Three major complications occurred. Two patients developed subphrenic abscesses requiring percutaneous drainage, and 1 patient required emergency reexploration for hemorrhaging at the hilar staple line. There was no mortality in this series.
Laparoscopic splenectomy is the preferred approach for the removal of normal-sized spleens. Splenomegaly presents significant surgical challenges that can limit application of this laparoscopic technique. With the development of various systems (HandPort), surgeons can insert their hand into the abdomen while maintaining pneumoperitoneum. The addition of the surgeon's hand into the operating field provides the necessary assistance to complete LS for splenomegaly while maintaining the same recovery benefits.
This study indicates that HALS provides a safe and efficacious approach to splenomegaly that might otherwise require laparotomy. Hand-assisted LS resulted in the same minimally invasive benefits as in those patients undergoing conventional LS (a short hospital stay and minimal morbidity), despite significantly larger spleens. Selecting those patients with splenomegaly for mandatory HALS remains unclear. In our series, 12 LSs for spleens weighing more than 1000 g were successfully completed, with an average operative time of 211 minutes. Four spleens weighing more than 1000 g were converted to open splenectomy. Of the 3 spleens weighing more than 1500 g in the laparoscopic group, 2 were converted to open splenectomy. The one successfully completed laparoscopic case required more than 4 hours for removal of a spleen weighing 1875 g. Alternatively, 5 of the 6 spleens weighing more than 1500 g were successfully completed using hand-assisted techniques, with an average operative time of 157 minutes. The hand-assisted technique offered the same minimally invasive benefits as conventional LS, with a significantly shorter operative time in those cases of massive splenomegaly (splenic weight after morcellation >1000 g). Conversely, attempting LS in a patient with splenomegaly may necessitate an open conversion and negate the minimally invasive advantages of a hand-assisted technique. Based on these data, our algorithm for managing splenomegaly includes the initiation of a hand-assisted technique at the onset of the procedure for those spleens measuring greater than 22 cm in craniocaudal length or weighing more than 1500 g. Spleens measuring 22 cm or less or weighing less than 1500 g are attempted laparoscopically. However, we maintain a low threshold to convert to a hand-assisted technique to facilitate splenic dissection or bagging. Kercher et al6 recently reported a similar experience with HALS. These researchers found that for spleens more than 22 cm in craniocaudal length or with a splenic weight of greater than 1600 g after morcellation, a hand-assisted approach was necessary and resulted in decreased operative times for splenic bagging while maintaining the benefits of a minimally invasive approach, with minimal blood loss and short hospital stays.
In an analysis of 13 splenectomies performed for spleens weighing more than 1000 g (average splenic weight after morcellation, 1616 g), Targarona et al7 successfully performed 10 procedures using conventional laparoscopic techniques. These researchers concluded that splenomegaly should not be considered a contraindication for conventional LS. However, an accessory incision was necessary for removal of the spleen in all 10 of these patients. One of the most significant challenges, and often the most difficult part of conventional LS for splenomegaly, is successful bagging of the spleen. These researchers required accessory incisions to bag or remove the enlarged spleens in 100% of their conventional LSs for splenomegaly. Theoretically, if an incision is required at some point during the procedure, then an initial hand-assisted approach might expedite and aid dissection, retraction, and bagging, as documented in our series.
The upper limit of splenic size that can be approached with a hand-assisted technique remains unclear. In our series, the 1 conversion in the HALS group was because of a massively enlarged spleen weighing 3500 g. Hellman et al8 recently described a series of 7 patients with massive splenomegaly (splenic weight after morcellation, 3.5-5.8 kg) undergoing HALS. The mean operative time was 133 minutes, and the EBL ranged from 300 to 5200 mL. These investigators successfully completed 6 procedures using hand-assisted techniques, although 1 patient required reexploration for bleeding 6 hours postoperatively. One of the main advantages cited by these researchers of the hand-assisted technique was manipulation and retraction of the massively enlarged spleens. Their patients remained in the hospital for an average of 7 days. The Hand-Assisted Laparoscopic Surgery Group recently reported their experience with 8 HALSs performed for splenomegaly.9 This group noted favorable results with the hand-assisted technique, with a mean operative time of 177 minutes, an EBL of 463 mL, no conversions to open splenectomy, and an average length of hospital stay of 4.7 days. They believed that the addition of the hand into the abdomen allowed improved manipulation of the spleen and easier bagging for extraction. Another multi-institutional trial10 reported 7 cases of HALS for splenomegaly. Again, HALS was safe and resulted in similar benefits as laparoscopic surgery, with a mean operative time of 171 minutes, 1 conversion, and an average length of hospital stay of 3.8 days.
Targarona et al11 performed a retrospective analysis comparing their results with HALS with their standard LS series for splenomegaly. These researchers compared 36 patients undergoing conventional LS with 20 patients undergoing HALS for splenomegaly. Unlike our series, in this study, splenic weight was comparable between the 2 groups (1425 vs 1753 g; statistically insignificant). Hand-assisted LS was associated with less morbidity, a shorter operative time, and a shorter hospital stay. Based on these results, they conclude that HALS significantly facilitated the intraoperative maneuvers of LS for cases of splenomegaly while maintaining the advantages of a minimally invasive approach, and we concur with these conclusions. In fact, despite the spleens being significantly larger in our HALS group, the operative times, complication rates, and lengths of hospital stay were comparable to those of the conventional LS group. Thus, even for splenomegaly, the HALS group maintained the advantages of a laparoscopic approach.
The hand-assisted technique seems beneficial and safe in cases of splenomegaly. The upper size limit for safe HALS remains unclear. The 1 conversion in our series occurred in a spleen weighing 3500 g. To accurately identify those patients who would most likely benefit from a hand-assisted approach vs an open or laparoscopic technique in cases of splenomegaly, a randomized trial will be necessary. Based on our retrospective analysis, it seems that HALS is a safe approach to splenectomy in cases of splenomegaly and offers the advantages of a minimally invasive approach.
Accepted for publication August 3, 2002.
Corresponding author: Fred Brody, MD, Department of General Surgery, Minimally Invasive Surgery Center, The Cleveland Clinic Foundation, 9500 Euclid Ave, Bldg A-80, Cleveland, OH 44195 (e-mail: email@example.com).