Efficacy of hand-assisted laparoscopic splenectomy for portal hypertension patients with thrombocytopenia

Michiya Kobayashi, MD, PhD¹, Ken Okamoto, MD, PhD¹, Hiromichi Maeda, MD, PhD², Hiroyuki Kitagawa, MD, PhD³, Tsutomu Namikawa, MD, PhD³, Ken Dabanaka, MD, PhD³, Kazuhiro Hanazaki, MD, PhD³, Daisuke Nakamura, MD⁴, Koji Oba, PhD⁵. ¹Department of Surgery, Clinical Oncology and Minimally Invasive Surgery, Kochi Medical School, ²Cancer Treatment Center, Kochi Medical School Hospital, ³Department of Surgery 1, Kochi Medical School, ⁴Chikamori Hospital, ⁵Department of Biostatistics, School of Public Health, The University of Tokyo

We perform hand-assisted laparoscopic (HALS) splenectomy to increase thrombocyte numbers in patients with hypersplenism due to chronic liver disease.

From March 2006 to August 2011, we performed HALS splenectomy in 34 patients. Five cases underwent the Hassab operation. Peg-interferon and ribavirine therapy was planned for 17 of these cases. An 8 cm median skin incision was made in the upper abdomen and GelPort^TM was placed in the incision. Three trocars were placed at the left side of the umbilicus. The spleen was mobilized with spatula type electric cautery and LCS. The surgeon’s left hand made a good operation field. The splenic vessels were ligated using the intracorporeal one hand ligation technique, and the splenic hilus was sealed and cut with LigaSure^TM. The spleen was taken out in a plastic bag through the median incision.

Mean splenic weight, operating time, and blood loss for all cases were 501g, 175.7min and 75ml, respectively. The surgeon’s left hand was able to control the bleeding using the HALS procedure. No serious post-operative complications were encountered. Five cases were converted to open surgery to control the bleeding, four of which had a history of interventional therapies for esophageal varices or hepatocellular carcinoma. Among 29 cases who had HALS splenectomy without conversion, seven cases had a history of preoperative interventions. A higher percentage of open conversion cases had a history of preoperative interventions. Univariate analysis showed that being male (p=0.011), having a history of preoperative interventions such as EIS, PSE, TAE, and RF (p=0.029), and higher spleen volume (p<0.033), were factors associate with open conversion. However, multivariate analysis revealed that there were no significant factors associated with open conversion. However, cases with preoperative interventions showed significantly more bleeding compared with those without (p<0.0001). As there were no factors which predicted open conversion following bleeding, HALS splenectomy is an efficient technique for controlling bleeding during the procedure of open conversion.