The spleen was extracted through a Pfannenstiel incision in nine cases (four cases in group A and five cases in group B) and through retrieval bags in 21 cases (11 cases in group A and 10 cases in group B).
The duration of hospital stay ranged from 36 to 48 h; only one case in each group had a duration of hospital stay more than 48 h. Associated cholecystectomy was performed in only one case, which was in group A (Table 2).
The mean lipase and amylase enzyme levels in group A were 50.33+22.84 and 35.80+21.65 U/l, respectively, whereas in group B, these were 45.66+20.17 and 41.66+19.10 U/l, respectively. The mean level of lactate dehydrogenase was 291.73+73.81 U/l in group A. In group B, it was 306.73±109.14 U/l. The mean total leukocyte count in group A was 9.27+2.55×103/mm3, whereas in group B, it was 9.609.60+2.41×103/mm3, with no significant difference between both groups. In group A, no cases presented with subphrenic collection. However, only one case in group B presented with subphrenic collection (Table 3).
Since the 1980s, minimally invasive surgical techniques have become popular in all surgical specialties and have gradually replaced conventional open surgery 5.
LS was first described in 1991 by Delaitre and Maignien; since then, many studies have shown that the advantages of the laparoscopic approach over open splenectomy include shorter hospital stay, lower blood loss, faster recovery, and better quality of life LS, and it has become the gold-standard approach for splenectomy in benign hematologic conditions, such as immune thrombocytopenia, thalassemia, and spherocytosis 6–8.
The main concern related to LS is an increased risk of intraoperative bleeding because of both rich blood supply of that organ and sometimes technical difficulties in vascular control of splenic hilum, especially in cases of splenomegaly. There are several methods to achieve hemostasis and reduce blood loss, including clips, sutures, vascular staplers, and various energy devices, e.g. ultrasonic sealing as well as monopolar, bipolar coagulation, and BSDs 9,10.
Intraoperative bleeding is the main challenge and the leading cause for conversion during LS. The mean intraoperative blood loss reported in some series is high, between 138 and 524 ml, and the conversion rate ranges between 5 and 10% 11–13.
According to the study of Pugliese et al. 14, the estimated amount of blood loss was 160 ml and it was found that the amount increased with the increase in the size of the spleen. In cases of splenomegaly, Rosen et al. 15 reported an estimated blood loss of 376 ml and the amount increased with the use of the hand port for hand-assessed LS. Wang et al. 16, showed that the estimated blood loss in the laparoscopic approach was 350 ml. This amount increased to 550 ml with the use of the hand port.
In our study, the estimated amount of blood loss was 72.27±16.65 ml in group A; however, it was 80.67±13.78 ml in group B, with an insignificant difference between both groups. These differences in calculating the estimated amount of blood loss may be attributed to the fact that all our patients were children, whereas in other studies, there were many adult patients.
Another crucial factor that may play a role to reducing the overall estimated amount of blood loss is the use of BSDs during the entire procedure. In our study, this was associated with lower blood loss compared with cases where staplers were used (Table 4).
BSDs (LigaSure) can divide up to 7 mm diameter vessels safely, whereas the harmonic shears can only divide 3 mm diameter vessels 17.
Miles et al. 28, in their preliminary report of the use of endoscopic staplers, showed that they tend to shorten and facilitate hilar dissection compared with ligation or clipping.
However, stapling techniques for transecting the splenic pedicle require proper positioning of the device for the hilar vascular control and accurate hilar dissection with meticulous skeletonization to exclude extraneous tissues, positioning as close to the spleen as possible away from the tail of the pancreas. Prominent splenic vessels, perihilar fat, and relatively narrow jaw opening may lead to excess bleeding from the staple line. Moreover, the tail of the pancreas can be retained between the jaws of the stapler, causing pancreatic fistula or clinical pancreatitis 17,29.
In the same context, we found that the operative time was markedly reduced when LigaSure was used to control the pedicle compared with the use of the staplers.
Our results were close to those of Romano et al. 20, who reported that the use of LigaSure was safe, reducing blood loss, shortening the operative time, and resulting in lower costs than staplers.
However, we found no significant difference between both devices in terms of the amount of blood loss.
In this study, five cases needed blood transfusion (two cases in group A and three cases in group B); the need for transfusion was not related to the splenic size as only one patient with splenomegaly required blood transfusion in each group.
During the early postoperative period of the current study, we checked the levels of amylase and lipase in children of both groups to detect the effect of the hemostatic procedure on the nearby pancreas as the use of LigaSure or staplers required dissection of the pedicle close to the tail of the pancreas. Although there were no statistical differences between both groups, hyperlipasemia and hyperamylasemia were found in some patients of group B. However, frank pancreatitis did not develop in any of our patients.
Chand et al. 30, reported that the incidence of pancreatic injury during LS was 15% and this was characterized by isolated hyperamylasemia, peripanceatic fluid collections, and pancreatic abscess. This was mainly attributed to the use of stapling devices across the hilum during the procedure 30.
LS has evolved over the last decade because of the advances of BSDs and endoscopic staplers. According to our data, the use of LigaSure reduces the overall operative time, operative blood loss, and associated complications compared with the use of staplers.
Conflicts of interest
There are no conflicts of interest.
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