Juan José Espert

Splenomegaly should not be considered a contraindication for laparoscopic splenectomy.

OBJECTIVE To analyze the impact of spleen size on operative and immediate clinical outcome in a series of 74 laparoscopic splenectomies (LS). SUMMARY BACKGROUND DATA LS is gaining acceptance as an alternative to open splenectomy. However, splenomegaly hinders LS, and massive splenomegaly has been considered a contraindication. METHODS Between 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. RESULTS LS 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. CONCLUSIONS Preliminary 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. 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. 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). 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.

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.

Laparoscopic surgery for splenic disorders

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 April-1997, 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 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 approachs safety and advantages provided that great technical care is taken and an exhaustive search for accessory spleens is conducted.

Peritoneal response to a septic challenge. Comparison between open laparotomy, pneumoperitoneum laparoscopy, and wall lift laparoscopy.

AbstractBackground: Laparoscopic surgery has a lower incidence of surgical infection than open surgery. Differential factors that may modify the bacterial biology and explain this finding to some extent include CO2 atmosphere, less desiccation of intraabdominal structures, fewer temperature changes, and a better preserved peritoneal and systemic immune response. Previous data suggest that the immune response and acute phase response are better preserved after laparoscopy. Therefore, we designed a study to evaluate the early peritoneal response to sepsis in an experimental peritonitis model comparing open surgery with CO2 and abdominal wall lift laparoscopy. Methods: The study subjects comprised 360 mice distributed into the following four groups: group 1, n= 72 (controls); group 2, n= 96 (open surgery), 2–3 cm laparotomy, with abdominal cavity exposed to the air for 30 min; group 3, n= 96, CO2 laparoscopy (5 mmHg pneumoperitoneum) for 30 min; group 4, n= 96, wall lift laparoscopy for 30 min. Intraabdominal contamination in the four groups was induced with 1 ml of E. coli suspension (1 × 104 CFU/ml) 10 min before abdomen closure. Peritoneal fluid and blood samples were obtained 1.5, 3, 24, and 72 h after surgery, and TNF, IL-1, and IL-6 were measured (via ELISA), as well as quantitative culture. Results: The number of CFU (colony-forming units) obtained in peritoneal fluid and positive blood culture rates were significantly lower in the laparoscopic groups than in the open group. IL-1 peritoneal levels were significantly lower after 24 h and 72 h in the laparoscopy groups. IL-6 levels decreased sharply in the laparoscopy groups at 24 h and 72 h. There were no differences between the two types of laparoscopy models (CO2 and wall lift). Conclusions: Peritoneal response to sepsis is better preserved after laparoscopy than after open surgery. CO2 does not seem to influence bacterial growth. According to these findings, laparoscopy entails less local trauma and better preserved intraabdominal conditions.

Laparoendoscopic single-site cholecystectomy: a safe and reproducible alternative.

BACKGROUND Laparoscopic cholecystectomy via the three-trocar technique is widely used for symptomatic gallbladder stones. In this article, we describe the initial experience with laparoendoscopic single-site surgery (LESS) cholecystectomy. PATIENTS AND METHODS Between February and April 2009, patients referred for cholecystectomy to the General Surgery Unit of our institution who agreed to undergo LESS were included in a prospective study. All operations were performed by the same surgical team that was specially trained in this type of surgery. The umbilicus was the sole point of entry for all patients. The same operative technique was used in all patients. Data of patients undergoing LESS cholecystectomy were compared with those from an uncontrolled group of patients undergoing standard laparoscopic cholecystectomy during the same study period. RESULTS The LESS and standard cholecystectomy groups included 19 patients each. LESS was successfully performed in all patients and none required conversion to an open procedure or a conventional laparoscopic cholecystectomy by adding more entry ports. The median operating time of 62 minutes in the LESS group was not significantly different than that in the standard laparoscopic cholecystectomy group. CONCLUSIONS LESS cholecystectomy was technically feasible, safe, and represents a reproducible alternative to standard laparoscopic cholecystectomy.

Acute Phase is the Only Significantly Reduced Component of the Injury Response after Laparoscopic Cholecystectomy

AbstractThe objective demonstration of improved postoperative recovery suggests that the surgical injury response induced by the laparoscopic approach is less intense than that after open surgery. Twenty-five patients diagnosed as having noncomplicated gallstones were studied prospectively. They were operated by laparoscopy (group I, n = 12) or open surgery (group II, n = 13). Analgesia requirements (p < 0.026) and postoperative stay (p < 0.001) were significantly less in group I. Cholecystectomy performed by either technical options induced a significant increase over basal values of glucose, lactate, white blood cell count, prolactin, ACTH, cortisol, interleukin 6, C-reactive protein, and PCO2. Both surgical procedures induced a significant reduction of total proteins, albumin, prealbumin, free fatty acids hemoglobin, hematocrit, and pH. There were no differences between the levels of growth hormone, insulin, glucagon, or PO2 during any of the periods studied. Comparison of the results of the two cholecystectomy techniques showed that laparoscopic cholecystectomy induced a significantly less intense acute-phase response (area under the curve) of interleukin 6 (17 ± 17 versus 47 ± 26 pg/ml × hr × 102; p < 0.003), C-reactive protein (16 ± 12 versus 35 ± 16 mg/dl × hr × 10; p < 0.004), and prealbumin (16 ± 2.7 versus 13.8 ± 2.3 mg/dl × hr × 102; p < 0.05). The surgical injury response after laparoscopic cholecystectomy is similar to that after open cholecystectomy, but the acute-phase response component is less intense. This finding may be a consequence of the reduced size of the operative wound with laparoscopic cholecystectomy.

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. 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. 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). 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.

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

Single-incision versus standard laparoscopic cholecystectomy: comparison of surgical outcomes from a single institution.

BACKGROUND Laparoscopic cholecystectomy via the three-trocar technique is widely used for symptomatic gallbladder stones. Single-incision laparoscopic surgery (SILS) for cholecystectomy is a well-established procedure and represents the next step in developing the concept of mini-invasive surgery. We here described our 24-month experience SILS cholecystectomy. METHODS Between February 2009 and 2011, patients referred for cholecystectomy to the General and Endocrine Unit of our institution who agreed to undergo SILS were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of surgery. The umbilicus was the sole point of entry for all patients. The same operative technique was used in all patients. Data of patients undergoing SILS cholecystectomy were compared with those from an uncontrolled group of patients undergoing standard laparoscopic cholecystectomy during the same study period. RESULTS The SILS and standard cholecystectomy groups included 120 patients each. SILS was performed in all patients and none of them required conversion to an open procedure. The median operating time of 45 minutes in the SILS group was not significantly different from that in the standard laparoscopic cholecystectomy group. We suture fascial edge with simple stitches under direct vision, thus reducing the risk of incisional hernia in SILS group (P=.046). CONCLUSIONS SILS cholecystectomy was technically feasible and safe and represents a reproducible alternative to standard laparoscopic cholecystectomy in selected patients. The definitive clinical, esthetic, and functional advantages of this technique require further analysis.