Michiya Kobayashi, MD, PhD, Ken Okamoto, MD, PhD, Hiromichi Maeda, MD, PhD, Hiroyuki Kitagawa, MD, PhD, Tsutomu Namikawa, MD, PhD, Ken Dabanaka, MD, PhD, Daisuke Nakamura, MD, Koji Oba, PhD, Kazuhiro Hanazaki, MD, PhD. Department of Human Health and Medical Sciences, Kochi Medical School, Nankoku, Japan.
We have established hand-assisted laparoscopic (HALS) splenectomy for patients with thrombocytopenia due to chronic viral liver disease and presented this procedure at the SAGES meeting in 2009. We have also applied HALS splenectomy to four cases of splenic malignant lymphoma.
Our standard procedure for HALS splenectomy is as follows. An 8 cm median skin incision is made in the upper abdomen and the GelPortTM device is placed. Three trocars are placed at the left side of the umbilicus. The spleen is then mobilized with spatula type electric cautery and LCS. The surgeon’s left hand makes a good operation field. The splenic vessels are ligated using the intracorporeal one hand ligation technique, and the splenic hilus is sealed and cut with LigaSureTM. The spleen is then taken out in a plastic bag through the skin incision.
For the current cases, the volume of the spleen was estimated by preoperative CT scan. The average volume was 1802.4cm3 and for the three cases over 1000g (huge group) the average volume was 2322.3cm3. The volume of the spleen in the remaining case was 242.4cm3. The case with the largest spleen had a history of liver transplantation nine years ago. The average operation time and blood loss for the huge group were 289.3min and 2400ml, respectively, and for the other case were 140min and 90ml, respectively.
The three cases in the huge group each required blood transfusion due to blood loss. Two of these cases required L-shaped laparotomy for ligation of the splenic hilus. One case required a linear stapler to dissect the splenic hilus after laparoscopic mobilization of the spleen, and vessel ligation was done after open conversion in one case. Dissection of the splenic hilus was extremely difficult in the huge group, perhaps due to inflammation in the splenic hilus.
Two cases among the huge group showed prolonged ascites after surgery, however no serious post-operative complications were encountered.
HALS splenectomy can be applied to splenic malignant lymphoma cases; however the open conversion rate is high for the huge spleen. In addition, for some cases dissection of the splenic hilus was difficult due to inflammation.
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