Should Minimally Splenectomy Be Offered in Patients with Splenomegaly

Matthew T Major, BS, Jennifer N Choi, MD, Daniel T McKenna, MD, Don J Selzer, MD, MS. Indiana University School of Medicine

Background: Hand-assisted laparoscopic splenectomy (HALS) was introduced to provide an alternative minimally invasive approach to open splenectomy (OS) and extend the benefits of laparoscopic splenectomy (LS) to a larger patient population. Although initially offered as a bridge from open to laparoscopic surgery for seasoned surgeons, the role of HALS within the current surgical armamentarium has been primarily relegated to large spleens (>1000 gm). The aim of this study is to document and compare the benefits of LS, HALS, and OS in patients with splenomegaly.

Methods: A retrospective review was performed on 165 patients who underwent splenectomy for primary hematological disorders over a period of 13 years. Of these, 48 patients had a splenic weight greater than 1000 gm. Minimally invasive procedures converted to open were felt to clinically have outcomes similar to procedures initiated and completed in an open fashion. Therefore, conversions from LS or HALS to OS were considered OS for purposes of evaluation. Analysis of variance and a double-sided t test were used to compare age, operative time (OT), estimated blood loss (EBL), length of stay (LOS), and time to oral intake (PO). Chi-square was used to compare gender and ASA. Multivariate logistic regression was used to evaluate for occurrence of major surgical complications.

Results: Twenty-six patients underwent OS, 19 underwent HALS, and 3 underwent LS. Three patients were converted from LS to OS. One patient was converted from LS to HALS to OS. The most common reason for conversion was difficulties manipulating the large spleen. There was no statistical difference in age, EBL, LOS, PO, ASA, gender, or major complications for HALS and OS. OT is statistically longer for HALS than OS. Very few LS were successfully completed. Successful LS was generally completed on smaller spleens, took longer than both HALS and OS, but led to a shorter LOS and PO.

Conclusions: In the end, surgical approach does not appear to impact outcomes as much as the primary pathology. It is clear that LS for large spleens has a very high conversion rate. Although the limited number of completed LS for large spleens makes statistical comparison challenging, the shorter LOS and faster PO would suggest that one should focus on identifying spleens amenable for this approach. Considering the shorter operative time and no obvious impact on peri-operative morbidity in patients with very large spleens (e.g. >2000 gm), OS could be considered. The immediate impact of post-operative pain and the long-term impact of the smaller incision in HALS should be examined to determine the role for this approach in this patient population. Furthermore, considering the longer OT and high conversion rate in LS, HALS may offer the best option for spleens between 1000 gm and 2000 gm.

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