Eduard M. Targarona

Prospective randomized trial comparing conventional laparoscopic colectomy with hand-assisted laparoscopic colectomy

Background: Hand-assisted laparoscopic surgery (HALS) represents a useful alternative to conventional laparoscopic surgery (LS). Its potential advantages—(a quicker, safer procedure and less need to convert to open surgery) are due to the recovery of tactile feedback. However, HALS requires the performance of a mini-laparotomy when surgery commences, and the wound is stretched and compressed throughout the procedure. In addition, it is associated with a more intense manipulation of the intraabdominal viscera. All of these factors increase the surgical trauma, it is not known whether HALS maintains the minimally invasive characteristics of conventional LS. Therefore, we set out to study the applicability, immediate clinical outcome, inflammatory response, and cost of HALS compared with conventional LS using colectomy as a model. Methods: We performed a prospective randomized trial comparing laparoscopic-assisted colectomy with HAL colectomy. The aims of the study were to assess (a) perioperative features, including time, advantages, and conversion; (b) the patient’s immediate clinical response, including recovery of bowel sounds, refeeding time, postoperative pain, local and general morbidity, and hospital stay; (c) the effect on the inflammatory response, using interleukin-6 (ILG) and C-reactive protein (CRP) measurements; (d) oncological issues, including intraoperative cytology and features of the specimen; and (d) the relative costs of the two procedures. Results: A total of 54 patients were enrolled in the study, 27 laparoscopic and 27 HALS. The operative times were similar but HALS was associated with a far lower conversion rate-7% vs 23%. Immediate clinical outcomes, oncological features, and costs were similar for the two procedures, but HALS was associated with a significantly greater increase in IL6 and CRP than the conventional laparoscopic procedure. Conclusion: This comparative study shows that HALS simplifies difficult intraoperative situations, reducing the need for conversion. Although it is a more aggressive procedure, HALS preserves the features of a minimally invasive approach, maintains all of the oncological features of conventional laparoscopic surgery, and does not increase the cost. HALS should therefore be considered as a useful adjunct when difficult situations arise during conventional laparoscopic colectomy.

Splenomegaly should not be considered a contraindication for laparoscopic splenectomy.

OBJECTIVEnTo analyze the impact of spleen size on operative and immediate clinical outcome in a series of 74 laparoscopic splenectomies (LS).nnnSUMMARY BACKGROUND DATAnLS is gaining acceptance as an alternative to open splenectomy. However, splenomegaly hinders LS, and massive splenomegaly has been considered a contraindication.nnnMETHODSnBetween February 1993 and September 1997, 74 patients with a wide range of splenic disorders were treated by laparoscopy and prospectively recorded. They were classified into three groups according to spleen weight: group I, <400 g (n = 52); group II, 400 to 1000 g (n = 9); and group III, >1000 g (n = 13). Age, operative time, number of trocars required, need for perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia requirements, length of hospital stay, and morbidity rates were recorded.nnnRESULTSnLS was completed in 69 patients, and the conversion rate was thus 6.7%. Operative time was significantly longer in patients with larger spleens, and an accessory incision was more frequently required. However, there were no significant differences in transfusion rate, length of stay, severe morbidity, or conversion rate.nnnCONCLUSIONSnPreliminary evaluation of LS for patients with large spleens suggests that it requires a longer operative time, but it is feasible and may potentially offer the same advantages (shorter stay and faster recovery) as it does to those with smaller spleens.

Effect of spleen size on splenectomy outcome. A comparison of open and laparoscopic surgery.

AbstractBackground: Laparoscopic splenectomy (LS) is gaining acceptance as an alternative to open splenectomy (OS). However, splenomegaly presents an obstacle to LS, and massive splenomegaly has been considered a contraindication. Analyses comparing the procedure with the open approach are lacking. The purpose of this study was to analyze the effect of spleen size on operative and immediate clinical outcome in a series of 105 LS compared with a series of 81 cases surgically treated by an open approach.n Methods: Between January 1990 and November 1998, 186 patients underwent a splenectomy for a wide range of splenic disorders. Of these patients, 105 were treated by laparoscopy (group I, LS; data prospectively recorded) and 81 were treated by an open approach (group II, OS analyzed retrospectively). Patients also were classified into three groups according to spleen weight: group A, <400 g; group B, 400–1000 g; and group C, >1000 g. Age, gender, operative time, perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia, length of stay, and morbidity were recorded in both main groups.n Results: Operative time was significantly longer for LS than for OS. However, LS morbidity, mortality, and postoperative stay were all lower at similar spleen weights. Spleens weighing more than 3,200 g required conversion to open surgery in all cases. When LS outcome for hematologic malignant diagnosis was compared with LS outcome for a benign diagnosis, malignancy did not increase conversion rate, morbidity, and transfusion, even though malignant spleens were larger and accessory incisions were required more frequently. Postoperative hospital stay was significantly longer in malignant than in benign diagnosis (5 ± 2.4 days vs. 4 ± 2.3 days; p < 0.05).n Conclusions: In patients with enlarged spleens, LS is feasible and followed by lower morbidity, transfusion rate, and shorter hospital stay than when the open approach is used. For the treatment of this subset of patients, who usually present with more severe hematologic diseases related to greater morbidity, LS presents potential advantages.

How, when, and why bile duct injury occurs A comparison between open and laparoscopic cholecystectomy

AbstractBackground: Bile duct injury (BDI) is a severe complication of laparoscopic cholecystectomy (LC). There is general agreement about the increase of this complication after LC vs open cholecystectomy (OC), but comparative studies are scarce. The aim of this paper has been to compare the incidence and clinical features of BDI after LC vs open procedures.n Materials and methods: 3,051 OC, performed from June 1977 to December 1988 were retrospectively analyzed and compared with 1,630 LCs performed from June 91 to August 96, for which data were prospectively recorded. Age, sex, type of BDI, performance of intraoperative cholangiography (IOC), underlying biliary pathology, morbidity, mortality, and late morbidity were all analyzed.n Results: BDI incidence was higher in group II (LC) (N: 16, 0.95%) than in group I, (OC, N: 19, 0.6%). BDI incidence was also higher in the group of patients in which it was necessary to convert to an open procedure (3/109, 2.7%, p < 0.05). BDIs were more frequently diagnosed intraoperatively in group I (OC, 18/19) than in group II (LC, 12/16). In both groups, BDI was more prevalent in cases operated by staff surgeons than residents, mainly in complicated gallbladder patients, with a bile duct of less than 7-mm diameter. Morbidity, postoperative stay, mortality, and late morbidity were similar after a BDI in both types of approach.n Conclusion: (1) BDI increases with LC. (2) BDI after LC carries a similar postoperative morbidity and mortality to those after OC. (3) Incidence of BDI in converted cases increases significantly and this constitutes a high-risk group.

Hand-assisted laparoscopic splenectomy (HALS) in cases of splenomegaly

Background: Laparoscopic splenectomy (LS) is considerably more difficult to perform when the spleen is enlarged. The new technique of hand-assisted designed technique aimed to assist laparoscopic surgery allows the surgeon to insert his or her hand into the abdomen while maintaining the pneumoperitoneum, thus recovering the tactile sensation lost in conventional laparoscopic surgery. Object: In this study, we compared the immediate results of conventional LS and hand-assisted LS (HALS) in cases of splenomegaly. Methods: Between February 1993 and August 2001, 200 LS were attempted at two university hospitals. In 56 cases, splenomegaly (final spleen weight >700 g) was observed clinically or detected on radiological examination. We compared the first 36 patients operated on by conventional LS (group I) with the last consecutive 20 patients, who underwent HALS (group II). The study parameters were operative time, conversion rate, transfusion rate, morbidity and length of hospital stay. Results: The groups were comparable in terms of age (58 ± 13 [ranges, l9–82] vs 58 ± 16 years [range, 44–84] (ns), diagnosis, and spleen weight (1425 ± 884 [range, 700–3400]) vs 1753 ± 1124 g [range, 720–4500] (ns). HALS was associated with less morbidity (36% vs 10%) (ns), a shorter operative time (177 ± 52 [range, 95–300]) vs 135 ± 53 min [range, 85–270] (p <0.009), and a shorter hospital stay (6.3 ± 3.3 [range, 3–14]) vs 4 ± 1.2 [range, 2–7] days (p <0.05). Conclusion: In cases of splenomegaly, HALS assisted laparoscopic surgery significantly facilitates the surgical maneuvers during LS while maintaining the advantages of a purely laparoscopic approach.

Impact of hematological diagnosis on early and late outcome after laparoscopic splenectomyrid

AbstractBackground: Laparoscopic splenectomy (LS) is now regarded as the treatment of choice for autoimmune thrombopenia (ITP). However, there have been few reports describing the application of LS to other splenic diseases, such as malignant entities and conditions associated with splenomegaly. Hematological diseases have specific clinical features that can influence immediate outcome after LS. Although the long-term effects of LS are unknown, a risk of splenosis has been suggested. Therefore, we designed a study to analyze the impact of primary hematological disease on immediate and late outcome in a prospective series of LS patients.nn Methods: We performed a prospective analysis of 111 LS done between February 1993 and March 1999. The patients were classified by hematological indications into the following four groups: (a) group 1, low platelet count. This group was further subdivided into group 1A, idiopathic thrombocytopenic purpura (ITP) (n= 48) and group 1B, HIV-related ITP (n= 8); (b) group 2, anemia. This group was further subdivided into group 2A, autoimmune hemolytic anemia (n= 8), and group 2B, spherocytosis (n= 11); (c) group 3, malignancy (n= 28); and (d) group 4, others (n= 8). Immediate outcomes were recorded prospectively. Hematological status and late complications were reviewed after a mean follow-up of 24 ± 18 months.nn Results: There were no significant differences between the groups in terms of conversion, transfusion requirements, and morbidity, although transfusion and morbidity were slightly higher in group 3. However, hospital stay was significantly longer in groups 3 and 4 than in groups 1 and 2. Long-term follow-up showed satisfactory hematological results in ≥75% of patients (group 1A, 82%; group 1B, 88%; group 2A, 88%; group 2B, 100%; group 3, 75%; group 4, 88%). Overall, late morbidity was 8.3% and mortality was 6.2%, mainly due to deaths in group 4 (six of 22 patients).nn Conclusion: LS is a safe and reproducible procedure for most hematological indications, with a similar immediate outcome for benign diseases and a long-term hematological response comparable to the standard results that have been observed in open series.n

Inadequate detection of accessory spleens and splenosis with laparoscopic splenectomy

We read with interest the recent paper by Gigot et al. [3]. In a prospective series of 18 laparoscopic splenectomies (LS), Gigot et al. show the existence of residual splenic tissue, as demonstrated by denaturated red blood cells scintigraphy and single photon emission computerized reconstruction (DRBCS-SPECT), in up to 50% of cases. They also discuss the difficulties associated with the perioperative localization of accessory spleens and the safety issues related to LS for treatment of hematological diseases. For normal-sized or slightly enlarged spleens, LS is a feasible and reproducible procedure that has all the advantages of laparoscopic surgery [5]. However, because of port site recurrences following laparoscopic surgery for malignant conditions, concern exists about the risk of tissue dissemination if the spleen capsule is broken and cell spillage occurs. Another problem is that it is difficult to identify accessory spleens (AS) during LS. We recently have found evidence of the existence of residual splenic tissue after LS. However, both problems need to be analyzed separately and compared with the previous experience in open surgery. Splenic function can be assessed by several means. Image studies can identify fragments of tissue measuring 1 cm (CT scan, US) [1]. DRBCS can show the existence of tissue able to captate the isotope. SPECT reconstructions may be too sensitive to nonbinded isotopes and therefore offer false positive images. Truly functioning splenic architecture is evaluated by the rate of pitted cells or HowellJolly bodies seen in peripheric blood smears. Residual splenic tissue should have enough quantity as well as adequate architecture to restore splenic function and potentially to induce relapsing of the hematological diseases. The treatment of residual accessory spleens after splenectomy for idiopathic thrombocytopenic purpura (ITP) has shown that the disease is cured after accessory splenectomy in only half of the cases [6]. We evaluated spleen function by counting the peripheral pitted cells in a series of 37 LS performed for several hematological conditions. These cases had a mean follow-up of 36 months, and our evaluation was done 2 months after the LS. In all cases but five, pitted cell count was >16%; the lower rate was considered as asplenic [2, 7], and that confirmed the efficacy of splenectomy. We then reevaluated with DRBCS or CT scan 10 patients who had no response (total, <100,000 platelets mm) or partial response (<50,000) after LS. In three we found a hot spot by DRBCS; in two, we observed a splenic nodule by CT. Two of them had no pitted cells in peripheric blood; but in the other seven, we could not identify any splenic function by any of the three methods. One controversial issue is the role of accessory spleens. How can we explain the wide variability in the incidence of AS between series, what is their physiological role, and what is the critical size that will induce relapse of an hematological disease? The incidence of accessory spleens ranges between 0 and 41% in both open and laparoscopic series. In our series, in which we searched carefully for them and opened the omental pouch, the incidence was 12%. On the other hand, reported series of LS for ITP showed a clinical success similar to open series, even though follow-up has not been as long up to now as for open series [3, 4]. Gigot et al. contend that the laparoscopic evaluation of AS is less efficient. However, we seriously doubt that the search for AS during open surgery (a 15-cm subcostal incision for splenectomy for ITP) is any better than the view achieved during LS, where it is possible to have a magnified access to retrogastric pouch and, indeed, to areas that cannot be visualized during open splenectomy, such as the posterior face of the spleen. The seeding of spilled splenic cells in a high-pressure pneumopertineum during the slightly longer operation is a new and specific problem to LS. In our series, one case, which required conversion due to splenic bed oozing, relapsed ITP, and CT, DRBCS and pitted cell count showed residual splenic function. In the Gigot series, in three of four cases where the spleen capsule was turned out, they found splenic seeding. A more worrisome finding was the presence of positive isotopic scans in cases without AS or capsule rupture. The spleen has a capsule, and if it is maintained intact, there is no reason for cell spillage. The current LS technique, with a lateral or semilateral approach, allows the surgeon to open the lesser sac, search for the AS, and clip the artery with minimal handling of the spleen. Mobilization of the posterior face of the spleen and stapling of the hilum can be done without damage to the capsule, thanks to the Surg Endosc (1999) 13: 196–197

Long-term outcome after laparoscopic splenectomy related to hematologic diagnosis

BackgroundLaparoscopic splenectomy (LS) has been demonstrated as an effective and safe treatment for hematological disorders requiring spleen removal, especially in cases of normal-sized spleens. However, although results are promising, long-term outcome data are lacking. We reviewed our clinical experience with LS in a series of 255 cases, with particular attention to the long-term outcome related to the disease process requiring LS.MethodsFrom February 1993 to October 2003, LS was attempted in 255 patients (100 males and 155 females with a mean age of 45 ± 19xa0years) and clinical information was recorded in a prospective database. Indications for splenectomy included idiopathic thrombocytopenic purpura (ITP) (n = 115), HIV-ITP (n = 9), Evans syndrome (n = 6), autoimmune hemolytic anemia (AIHA) (n = 13), hereditary spherocytosis (HS) (n = 19), hematologic malignancy (n = 66), thrombotic thrombocytopenic purpura (n = 1), and others (n = 26). Long-term postoperative follow-up evaluation was obtained through clinical notes, follow-up visits by the referring hematologist, and by phone interviews both with patients and with the referring hematologist.ResultsA total of 186 patients (73%) were available for a mean follow-up of 35xa0months (range, 1–104). Of the ITP patients, 87 (76%) were followed up, with a remission rate of 89% (complete remission in 75%). A similar remission rate was observed in ITP-HIV; in patients available for follow-up (78%), complete remission was achieved in 83%. In Evans, complete remission was achieved in all patients available for follow-up (67%). Clinical response for hemolytic disease ranged between 70% for AIHA and 100% for HS. In the malignant group, the late mortality rate was 22%. The mortality rate in the miscellaneous group was 5%. No cases of splenectomy-related sepsis occurred during follow-up.ConclusionsLS offers advantages for all types of splenic diseases requiring surgery. It provides not only good clinical short-term outcome but also satisfactory long-term hematological results.

Portal Vein Thrombosis After Laparoscopic Splenectomy: The Size of the Risk

Portal vein thrombosis (PVT) after splenectomy is a potentially life-threatening complication. Clinical symptoms may be insidious, and progression can lead to intestinal infarction and portal hypertension. Interest in PVT has increased as a high incidence has been found in the laparoscopic setting. The higher incidence of PVT found in recent prospective studies of laparoscopically operated patients compared with retrospective reports from the 1990s suggests that PVT may have been underreported. Clinical outcome depends on the extension of the thrombus and the underlying disease. Main risk factors may be myeloproliferative diseases requiring splenectomy and splenomegaly, but PVT may occur after splenectomy for any clinical indication. The extent to which laparoscopy is responsible for PVT remains unclear. Laparoscopic surgeons should be aware of the risk of PVT, and it should be suspected in cases with an atypical outcome after laparoscopic splenectomy. Once diagnosed, prompt anticoagulation therapy may resolve the thrombotic event.

Conservative laparoscopic treatment of a posttraumatic splenic cyst

Laparoscopy has recently been demonstrated to be a useful alternative to open surgery for the surgical treatment of spleen disorders, and it can also facilitate a conservative approach for treatment of selected spleen lesions. We present the laparoscopic spleen-preserving treatment of a post-traumatic spleen cyst. A 28-year-old female presented a mass in the left hypochondrium immediately after an uneventful pregnancy. CT revealed a splenic cyst of 10×8 cm. Laparoscopic exploration showed a cyst located in the lower pole of the spleen. All the cyst wall not covered by spleen tissue (70%) was excised, and the fragment of cyst wall was recovered through a bag. The patient recovered uneventfully and was discharged 72 hours later. The laparoscopic approach should be considered for evaluation and treatment of selected benign cystic lesions of liver, retroperitoneum or spleen origin.