Matthew T Major, BS, Daniel T McKenna, MD, Jennifer N Choi, MD, Don J Selzer, MD, MS. Indiana University School of Medicine
Background: Laparoscopic splenectomy (LS) is proven to preserve the benefits of minimally invasive techniques compared to traditional open surgical procedures. Portal vein thrombosis (PVT) is a well-documented complication following splenectomy. The overall incidence of PVT is estimated in up to 55%. It has been postulated that PVT is more common following LS compared to the open splenectomy (OS). It is hypothesized that any extended exposure to pneumoperitoneum increases the risk of PVT. Hand-assisted laparoscopic splenectomy (HALS) was introduced to provide an alternative minimally invasive approach and extend these benefits to a larger patient population. It is not clear if this hybrid approach of HALS will impact the incidence of PVT. The aim of this study is to document and compare the incidence of symptomatic PVT following different surgical techniques (LS, HALS, and OS).
Methods: A retrospective review was performed on 165 patients who underwent splenectomy for primary hematological disorders over a period of 13 years. Due to the impact of an initial pneumoperitoneum in both LS and HALS, conversions from LS to OS or HALS to OS were considered LS or HALS, respectively. Examination for PVT was determined based upon symptomatology. PVT was diagnosed by postoperative contrasted CT scan. Analysis of variance and a double-sided t test were used to compare age, splenic size, and splenic weight. Chi-square was used to compare gender and ASA. Multivariate logistic regression was used to evaluate PVT occurrence.
Results: One hundred one patients underwent LS, 20 underwent HALS, and 44 underwent OS. Eight patients were converted from LS to OS. One patient was converted from LS to HALS to OS. The most common reason for conversion was the challenge in manipulating a large spleen. PVT was diagnosed in 9 patients (LS 1, HALS 4, OS 4). Comparing of groups demonstrates statistically more women underwent LS versus OS and HALS. There was no statistical difference in age and ASA. OS and HALS more commonly involved in the removal of large spleens and experienced statistically more PVT than LS. Multivariate logistic regression confirmed PVT was not dependent on surgical technique. Rather, it was more commonly dependent on splenic size and pathology.
Conclusions: Symptomatic PVT does not occur more commonly in LS or HALS. The incidence of PVT is more commonly associated with splenic size rather than surgical technique. LS and HALS can be considered as a safe, minimally invasive approach to patients with normal and large spleens, respectively.