consecutive series of 64 cases of splenic disorders ap- proached by laparoscopy. Between Feb-1993 and April-. 1997, 64 patients with a wide range of splenic ...
Surgical Endoscopy
Technique Surg Endosc (1998) 12: 66–72
© Springer-Verlag New York Inc. 1998
Laparoscopic surgery for splenic disorders Lessons learned from a series of 64 cases M. Trias,1,2 E. Ma Targarona,1 J. J. Espert,1 C. Balague´1 1 2
Service of General and Digestive Surgery, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain Service of General and Digestive Surgery, Hospital de la Santa Creu i Sant Pau, Avda, Padre Claret 167, 08025 Barcelona, Spain
Received: 29 January 1997/Accepted: 22 May 1997
Abstract. Laparoscopic splenectomy (LS) has recently been gaining acceptance as an alternative to open splenectomy. However, several aspects, such as learning curve, residual splenic function, and management of large spleens, remain controversial. In this paper we present the analysis of technical details and immediate and late outcome of a consecutive series of 64 cases of splenic disorders approached by laparoscopy. Between Feb-1993 and April1997, 64 patients with a wide range of splenic disorders were treated by laparoscopy, and prospectively recorded. Age, body mass index, operative time, number of trocars, perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia, stay and morbidity were analyzed. Late failures after LS were reevaluated with 99mTc-heat-damaged red blood cells scintigraphy and CT. LS was performed in 61 patients, and two cases with splenic cyst and one splenic artery aneurysm received a laparoscopic partial cystectomy and aneurysmectomy. LS was performed through an anterior approach in 12 patients and laterally in 49. Conversion rate was 6.5%. Accessory spleens were found in 7 patients (7/61, 11.5%). Morbidity was 16%. There was no correlation between the weight of the spleen, platelet count or obesity with operative time. A lateral approach was associated with a decrease in operative time (p < 0.002), postoperative stay (p < 0.001), transfusion (p < 0.04) and number of trocars (p < 0.001). Operative time was significantly longer in large spleens (>1000 gr) (p < 0.001). However, there were no differences in transfusion rate, stay, morbidity or conversion rate. After a follow up of 12 m, 10 patients revealed a low platelet count. Scintigraphy showed residual
Presented as a free paper in the 1997 meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), San Diego, California, USA, 19–21 March 1997 Correspondence to: M. Trias, Service of General and Digestive Surgery, Hospital de la Santa Creu i Sant Pau, Avda, Padre Claret 167, 08025 Barcelona, Spain
splenic tissue in 3 (ITP). A wide range of splenic disorders can be treated by laparoscopy, including enlarged spleens. This technique should be continually audited, but initial results reflect the approach’s safety and advantages provided that great technical care is taken and an exhaustive search for accessory spleens is conducted. Key words: Splenic disorder — Open splenectomy — Laparoscopic splenectomy
In the last 5 years, anecdotal and initial series have shown that laparoscopic splenectomy (LS) may be a safe alternative to open splenectomy [1–9, 11, 14–17, 19–21, 24–26, 29, 30, 33, 34, 36–39]. However, many aspects of LS such as preoperative embolization, patient position and access, laparoscopic management of large spleens, role of accessory spleens, and costs are controversial or not well defined. Hematological diseases that require removal of the spleen are associated with multiple clinical factors that influence surgical procedure and outcome (size of the spleen, platelet count, preoperative chronic corticoid treatment, associated diseases) [12]. The best way to analyze the results of new techniques is through prospective randomized trials, but splenectomy is not frequently performed in surgical units, and its wide range of indications means that it is poorly suited to this type of study. The aim of this paper is to evaluate the applicability and the short- and long-term results of laparoscopic splenic surgery in a series of 64 cases with diverse splenic disorders.
Materials and methods Between February 1993 and April 1997, 64 patients with a wide range of splenic disorders (Table 1) requiring surgical therapy were treated by lap-
67 Table 1. Clinical diagnosis of 64 cases of laparoscopic disorders approached by laparoscopy Thrombopenia Idiopathic thrombopenic purpura Idiopathic thrombopenic purpura + myelodysplasic syndrome AIDS-related thrombopenia Leucopenia and thrombopenia autoimmune Waldestrom’s macroglobulinemia Anemia Spherocytosis Autoimmune hemolytic anemia Refractory anemia with presence of blasts Myelofibrosis Neoplastic diseases Splenic tumor + myelofibrosis Chronic lymphatic leukemia + autoimmune hemolytic anemia Chronic lymphatic leukemia Non-Hodgkin’s lymphoma Others Splenomegaly of unknown origin Post-traumatic splenic cyst Splenic artery aneurysm
31 1 5 1 1 7 4 1 1 1 1 1 5 1 2 1
aroscopy, and clinical data was prospectively recorded. All patients scheduled for LS received a preoperative pneumococcal vaccine, and antibiotic prophylaxis was initiated intraoperatively. LS was performed through an anterior or lateral approach using techniques previously described in detail elsewhere [36] and briefly summarized here:
Anterior approach [36] The patient lies in supine decubitus. The trocars are inserted at the umbilicus, the middle point between the umbilicus and the xyphoid process, and a 5-mm trocar is inserted just below the xyphoid. Abdominal access is completed with a 12-mm trocar in left iliac fossa, at the midaxilar line. The scope is inserted through the trocar located in the middle line. The table is rotated to the right with a forced anti-Trendelenburg position. The gastrosplenic epiplon is sectioned and the omental pouch is reached. This step permits location and ligation of the splenic artery on the superior border of the pancreas. The artery is then sectioned and the distal cuff is used for traction cranially to expose the splenic vein. The vein is tied and cut in a similar fashion to the artery. Once the splenic vessels are controlled, the remaining short vessels are cut through the upper pole of the spleen. The next step is the dissection of the splenic flexure of the colon. At this point the dissection of the posterior face of the spleen begins, and the spleen is freed from the peritoneal attachments and from the pancreatic tail.
Lateral approach [36] The patient is positioned in lateral right decubitus, with a lateral flexion of the spine to open the costopelvic space (Fig. 1). The trocars are inserted below the costal margin in the anterior, middle, and posterior axilar line. Further trocars are inserted if necessary. The surgeon stands to the right of the patient. The scope can be placed in any of the trocars, depending on the operative needs. The splenic flexure of the colon is dissected away thanks to traction induced by the weight of the intestine. After location of the stomach and traction of the short vessels, the omental pouch is reached. At this step, short vessels are sectioned with an endosuture device. The splenic artery can be located and ligated in the upper border of the pancreas to decrease the size of the spleen and the risk of hemorrhage (Fig. 2A,B). After left tilt of the table, the posterolateral face of the spleen is exposed and the attachment to the parietal peritoneum and retroperitoneum is sectioned (Fig. 3A,B). The weight of the spleen, which is fixed exclusively by the pedicle, facilitates its individualization; it is completely excised after several applications of the endostapler through the splenic hilum (Fig. 4) or after individualized clipping and section of the vascular structures of the splenic hilum, avoiding injury to the pancreatic tail. Once the spleen is totally free in the abdominal cavity, a bag (Lapsac, Cook Espan˜a S.A., or EndoCatch II, AutoSuture, USSC, Norwalk, USA) is
introduced into the abdomen and the spleen is then morcellated and retrieved. A drain is placed if required. Accessory incision is performed when the spleen is required intact for histological analysis, or due to its size. Age, body mass index, operative time, number of trocars used, perioperative transfusion, spleen weight, conversion rate, mode of retrieval of the spleen (bag or accessory incision), postoperative requirements of analgesia, stay, and morbidity were all analyzed. All patients have been followed to date, and late failures after LS were reevaluated with 99mTcheat-damaged red blood cell scintigraphy and CT scan, looking for residual splenic function. In order to identify factors that influence operative length, a correlation test was performed between preoperative platelet count, body mass index, and spleen weight. Finally, the main perioperative and outcome characteristics were evaluated in relation to the main groups of hematologic diseases (idiopathic thrombocytopenic purpura [ITP], spherocytosis, AIDS-related thrombopenia, autoimmune hemolytic anemia [AIHA], and other indications). Data were expressed as mean and range. All data were evaluated on an intention-to-treat basis, and converted cases were included in the final analysis. Two young women in whom postraumatic (after delivery) and nonparasitic cysts were diagnosed were treated with laparoscopic-guided unroofing of the cyst, preserving the spleen. In a third patient, a splenic artery aneurysm was diagnosed in a control CT for a previous sigmoid cancer. Laparoscopy was attempted, but the patient had to be converted due to the firm adhesions of the aneurysm. Correlation tests were used to compare two variable series. The chisquare test was used for comparison of two proportions and the Student t-test was used to compare differences between two series.
Results Hematological diagnoses, main demographic features, and immediate outcome are summarized in Tables 2 and 3. Eight patients had been previously operated (five hysterectomies, 2 sigmoidectomies, and one appendectomy). Eight patients presented associated pathological conditions that were operated simultaneously (six gallstones, one ovarian cyst, and one hiatal hernia). LS was performed through an anterior approach in 12 patients and laterally in the remaining 49 and was completed in 57 cases (conversion rate 6.5%). Conversion was necessary in two patients (ITP and AIDS-related thrombopenia) due to diffuse oozing and difficulty in handling the spleen. In two patients with massive splenomegaly (spherocytosis and non-Hodgkin’s lymphoma with spleen weighing 3,500 g) conversion was necessary due to difficulties in the intraabdominal manipulation of the spleen. The artery was ligated early in 73% (38/52) of LS. The splenic hilum was controlled with the help of an endostapler in 41 out of 52 cases (67%). Accessory spleens were found in seven patients (7/52, 11.5%). Six of them were easily located, but one (a converted case) was found in the mesocolon, only felt by palpation, and completely hidden from view. The spleen was extracted through a bag in 42 cases, and a laparotomy was done in 15 (17%); the mean length was 9 cm (range 2–14 cm). The bag was accidentally perforated in four cases, but all the spleen pieces were recovered. Postoperative complications occurred in 10 patients (15%) (Table 3), although none died. There was no correlation between the weight of the spleen, platelet count, or obesity with operative time. The learning curve (Fig. 5) When all the cases were distributed chronologically in three groups (1–16, 17–32, and 32–61), we observed that opera-
68 Fig. 1. Patient position for laparoscopic splenectomy using the lateral approach. The patient lies in lateral right decubitus with forced lateral flexion to open the costophrenic space. Fig. 2. A The right lateral tilt of the table permits access to the gastrosplenic ligament. B After opening the retrogastric pouch, the splenic artery can be located easily in the upper border of the pancreas, and clipped. Fig. 3. A The dissection of the retrosplenic attachments is facilitated with a left lateral tilt of the table. B The splenophrenic and splenorenal attachments are sectioned and the spleen is completely freed. Fig. 4. Splenectomy is finished with endostapling; the endostapler is placed without tension along the splenic hilum, avoiding injuries to the splenic vessels.
tive time (214 vs 151 vs 155 min, p < 0.01), transfusion (50 vs 25 vs 11%), complication rate (31 vs 18 vs 4%), and postoperative stay (5.7 vs 3 vs 3.6) decreased progressively in parallel to the learning curve. All these parameters improved after the switch from an anterior to a lateral approach, which was made early on, during the first 16 cases.
Operative position (Table 4) There were no differences between patients operated anteriorly or laterally as far as age, sex, obesity, spleen weight, or platelet count was concerned; however, with the lateral approach there was a significant decrease in operative time
69
tients improved their hematological status (83%), but 10 revealed a low platelet count (one AIDS and nine ITP). All these 10 patients were assessed by scintigraphy and CT scan. Scintigraphy showed residual splenic function in three (ITP). Two showed a hot-spotted image confirmed by CT scan as an accessory spleen. In one of these patients another accessory spleen had been retrieved during the LS. Scintigraphy showed multiple images in the splenic fossa in a third patient who was converted due to difficult handling during LS; CT scan confirmed them as implants. LS. In none of these patients did a previous rupture of the bag occur during spleen retrieval. Fig. 5. The learning curve. Progressive experience was followed by a significative decrease of operative time (p < 0.01) and stay (p < 0.01), in spite of a significant increase in weight of spleens (p < 0.01) approached by laparoscopy (values expressed as means).
(p < 0.002), postoperative stay (p < 0.001), requirements of transfusion (p < 0.04), and number of trocars used (p < 0.001). Transfusion requirements Preoperative transfusion was necessary in 15 patients (28%). No patients suffered massive hemorrhage during operation secondary to large vessel injury, and one patient was reoperated for hemoperitoneum. Blood transfusion was more prevalent in patients operated with an anterior approach (50 vs 13%, p < 0.04), and during longer operations (227 vs 151 min, p < 0.002), but it was not related to spleen weight or platelet count. Transfusion correlated significantly with patients who developed complications (53 vs 6%, p < 0.002) and patients with longer stay (6.7 vs 3 days, p < 0.001). Spleen weight When LS were classified in three groups according to spleen weight (normal 1,000 g), we observed that operative time was significantly longer in groups with enlarged spleens (159 vs 257 vs 250 min, p < 0.001) and the number of trocars was significantly higher (4 vs 4.6 vs 4.2, p < 0.001). However, there were no differences in transfusion rate, stay, morbidity, or conversion rate between the groups. Requirement of an accessory incision Accessory incision was significantly more frequent in patients with enlarged spleens than in those with normal ones (1121 vs 345 g, p < 0.03). However, the presence of an accessory incision did not affect operative time, stay, analgesia requirements, morbidity, or transfusion rate. Follow up After a mean follow-up of 12 months (range 1–50), one patient developed a trocar hernia. Fifty-one out of 61 pa-
Discussion LS is currently performed more frequently due to the observation of an immediate postoperative recovery similar to laparoscopic cholecystectomy, with in-hospital stay shorter than 3 days and smooth recovery—mainly in young and healthy patients with ITP [8]. However, splenic disorders that require a splenectomy include a wide number of diseases with clinical and anatomic characteristics that can influence the technical performance of the LS. The aim of this paper is to analyze the LS learning curve and to identify factors that can influence the preoperative and postoperative outcome. LS is a more demanding technique than other laparoscopic procedures but one that can be performed by a trained laparoscopic team. This is borne out by the low conversion rate observed in other LS series [19, 20, 25], and the figure of 6.5% observed in ours. Analysis of the learning curve in our series (Fig. 5) of 61 LS performed by two surgeons revealed a rapid decrease in operating time, blood requirements, conversion rate, morbidity, and postoperative stay after one-third of the cases; we were thus able to deal simultaneously with more difficult cases or enlarged spleens. These improved results were associated with the switch from an anterior to a lateral approach early in our study. The spleen is a solid and fragile organ with a rich vasculature that increases the risk of bleeding and makes handling and removal difficult. As a result, there is no general agreement about the best technique for LS. All techniques described include a variable degree of lateral tilt of the left flank in order to gain access to the posterior face of the spleen [8, 11, 20, 30]. In our hands, the full lateral approach is associated with a decrease in operative time and number of trocars used, and it has allowed satisfactory treatment of spleens of up to 3,000 g. The lateral approach has been criticized for hampering the realization of simultaneous procedures, preventing early ligature of the artery, and offering poorer access to the abdominal cavity in cases in which quick conversion is required [16, 39]. However, lateral movement of the operative table allows the opening of the lesser sac in all cases and the exploration of the transgastric space. We successfully identified and ligated the splenic artery in 43 out of 61 (70%) patients operated laterally. We recommend this maneuver because it permits a perioperative rise in the platelet count, decreases spleen volume, favors autotransfusion, and diminishes the risk of parechymal bleeding, but it can be more difficult in obese patients. However, the wide mobilization that is obtained with the
70 Table 2. Demographic features and main results according to hematological diagnoses in 61 LSa
n Age Sex Platelets (×108) Operative time (min) Stay (days) Spleen weight (g) Transfusion Conversion Morbidity
ITP
HIV
Spherocytosis
AIHA
Others
Overall
33 32 (16–63) 6m/27f 47 (5–188) 150 (80–240) 4 (2–14) 156 (60–370) 21% 3% 15%
5 37 (31–53) 4m/1f 16 (12–23) 178 (90–240) 3.8 (2–6) 336 (152–630) 40% 20% 20%
7 40 (23–61) 5m/2f 218 (112–330)b,c 237 (120–400)c 4.4 (2–7) 856 (137–3450)e 28% 14% 28%
6 47 (16–69) 3m/3f 147 (62–271)b,c 140 (115–180) 4.2 (2–6) 373 (183–610)e 16% 0% 16%
10 56 (35–72) 4m/6f 105 (20–236) 200 (150–270)c 4.7 (3–10) 1,575 (331–3,500)e,d 33% 10% 10%
61 39 (16–72) 22m/39f 80 (5–330) 170 (80–400) 4 (2–14) 505 (60–3,500) 24% 6.5% 16%
a
Mean (range), ITP: idiopathic thrombocytopenic purpura, AIHA: autoimmune hemolytic anemia, SD: supine decubitus, LD: lateral decubitus; Others: myelofibrosis (1), spleen tumor (1), lymphoma (5), splenomegaly (1), lymphatic chronic leukemia (1), macroglobulinemia (1).
