BACKGROUND: Laparoscopic splenectomy (LS) has been considered as the standard approach to remove a normal-sized spleen, but sometimes involves various troubles when applied to splenomegaly. To get good view for performing splenectomy for ultra-splenomegaly in Banti syndrome, for example, we developed “antero-lateral approach” with hand-assisted maneuver. We present our new methods in our recent cases to show how this pcocedure is superior in safety and easiness in intraoperative handling. METHODS: In our new approach, semi-lateral decubitus position on the right side is usually placed and as to the position of cannulae, 4 ports are placed on the skin (left side of umbilicus, and the other three are along the subcostal lesion ). For the last 5 years, 10 patients with splenomegaly were treated with operations for splenectomy in our hospital. HALS with transperitoneal “antero-lateral” approach was performed in 4 patients@(group A). Other cases consisted of open splenectomy or conventional LS (group B). The patients’ features, the operative details and the postoperative outcomes in the both groups were compared. RESULTS: In group A, the average hospital stay was 7 days, while 15days in group B. Operation time, intraoperative blood loss did not show any difference. And in the aspects of intraoperative and postoperative complication, there were not any complications in the two groups. In group A, there was one case with the largest spleen that has ever been reported. The patient was a 51-year-old male suffering Banti syndrome. In preoperative volumemetry by CT scan, the weight of spleen was 4500gr with the maximum length of 35cm. The sites of laparoscopic ports and splenic artery were evaluated and marked (on the skin) by ultrasonography before operation. In the operation,@skin incision for 3 ports (all 10 mm), one of which was just left side of umbilicus and the other two were along the subcostal lesion, and one Gel-port (right subcostal lesion) was made. First, the lower pole and the back side of spleen was dissected from retroperitoneum and then splenic artery was clipped just below the marking which was made preoperatively. Next, the lateral side then the upper pole of spleen was detached from the retroperitoneum. Finally, spleen was excised from pancreas tail by endo-GIA 60 x 3 times. The isolated spleen was divided into 5 pieces by surgical scissors and then picked up through the Gel-port. The operative time was 280 minutes with little bleeding. The postoperative course was uneventful. CONCLUSIONS: In the cases of splenomegaly, HALS with transperitoneal “antero-lateral” approach significantly facilitates the surgical procedure and reduces the operational risk, while maintaining the advantages of conventional LS. HALS with transperitoneal ” antero-lateral ” approach is more feasible and more effective than conventional LS or open laparotomy for the removal of ultra-splenomegaly.
Program Number: P306