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Hand-assisted Laparoscopic Splenectomy Advantages Over Complete Laparoscopic Splenectomy For Splenomegaly

Sun, Xiangyu, PhD*; Liu, Zhou, MD; Selim, M.H, MD; Huang, Yong, PhD§

Surgical Laparoscopy Endoscopy & Percutaneous Techniques: April 2019 - Volume 29 - Issue 2 - p 109–112
doi: 10.1097/SLE.0000000000000640
Original Articles
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Background: Laparoscopic splenectomy (LS) is generally applied for splenectomy, However, it also brings some technical challenges, especially for splenomegaly. Hand-assisted laparoscopic splenectomy (HALS) can help to overcome these drawbacks while maintaining the superiority of LS. This study was aimed to evaluate the efficacy and advantage of HALS for splenomegaly.

Materials and Methods: Between January 2014 and November 2017, 91 patients with splenomegaly in 2 surgical centers were randomly assigned to either HALS (n=45) or LS (n=46). The patients’ characteristics, intraoperative details, and the postoperative outcomes in both groups were compared.

Results: Baseline features (sex, age, main diameter, Child-Pugh grade) of both groups had no significant difference (P<0.05). Compared with LS group, the HALS group operation time (141±46 vs. 172±43 min; P=0.001) was shorter, intraoperative blood loss [215 (122.332) vs. 230 (130.740) mL; P=0.026], hospital expenses (5.5±1.5 vs. 6.4±2.4 WanRMB; P=0.022), and conversion rate (1/45 vs. 9/46; P=0.015) were lower. However, there was no significant difference for hospital stay (6.4±2.8 vs. 6.7±3.0 d; P=0.662) and complications (15/45 vs. 12/46; P=0.893) between the 2 groups. In addition, there were no significant differences in postoperative white blood cell (10.6±2.9 vs. 10.9±3.5; P=0.747), AST [61 (47.94) vs. 57 (37.86) U/L; P=0.513], and ALT [68 (54.120) vs. 55 (36.99) U/L; P=0.302] levels.

Conclusions: HALS can maximize the benefits for patients, while maintaining the advantages of LS and open splenectomy. It is the ideal surgical treatment for splenomegaly.

*Department of Minimally Invasive Surgical Centre, Tianjin Nankai Hospital, Tianjin

Department of Internal medicine, The Third People’s Hospital of Jiangxi Province

Nanchang University

§Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China

X.S. and Z.L. contributed equally.

Supported by National Natural Science Foundation of China (no. 81760514) and Youth Science Fund of Jiangxi Provincial Science and Technology Department (no. 20161BAB215252).

The authors declare no conflicts of interest.

Reprints: Yong Huang, PhD, Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China (e-mail: huangyong2004373@163.com).

Received May 2, 2018

Accepted December 31, 2018

With rapidly advancing in laparoscopic techniques, several studies have showed that laparoscopic splenectomy (LS) is safe and effective for splenectomy.1–3 The superiority of LS was not only reflected in less trauma, quicker recovery, but also less postoperative pain compared with open splenectomy (OS).4–6 Furthermore, some studies conducted to compare clinical outcomes between LS and OS and revealed that patients undergoing LS had a significant reduction in postoperative morbidity.7 However, for patients with splenomegaly, they often combined with hypersplenism, frequent coexistence of varices and thickening, perisplenic collateral vessels distortions, splenomegaly due to limited space of abdominal cavity, and thrombocytopenia all lead to an increased risk of intraoperative hemorrhage and conversion to open surgery,8,9 the benefits of LS were not provided to all patients who need splenectomy because of longer operation time, more blood loss, and higher conversion rate.10 Moreover, with the increasing demand for safe and effective surgical treatment, hand-assisted laparoscopic splenectomy (HALS) is advocated by people for bridge the gap between LS and OS. Because it is not only short operative time and low conversion rate, without expanding the incision than LS, but also maintaining a well tactile sense, the ability to palpate, and control of bleeding as OS at the same time.

As we know, a high incidence of the patients with chronic hepatitis B and C infections worldwide, especially in China,11 have portal hypertension secondary to liver cirrhosis. Hypersplenism and splenomegaly, which are common major complications of liver cirrhosis, occur in ∼24% to 80% of cases.12,13 Splenomegaly was undoubtedly considered a therapeutic challenge because of dense adhesions and increased tissue vascularity, making retrieval difficult, with the necessity of making a longer incision to retrieve the specimen. Therefore, the presence of a big spleen inevitably impaired the application of minimally invasive techniques. There were several trials6,10,14,15 and meta-analysis7,11 comparing HALS versus LS; however, there was still lack multicenter prospective randomized controlled clinical trials, even the results of meta-analysis7,11 contradicted each other between the 2 approaches. In addition, some surgeons just believe that HALS is a regressive of surgical technique and abandon it. Hence, the aim of this prospective randomized trial is to provide a high confidence evidence.

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MATERIALS AND METHODS

Patients and Grouping

Between January 2014 and November 2017, 91 patients (Table 1) with splenomegaly (maximal diameter exceeding 18 cm) were identified clinically either by palpation of the spleen below the coastal margin or by radiologic examination of computed tomographic scans in Tianjin Nankai Hospital and the Second Affiliated Hospital of Nanchang University. The indications for splenectomy included bleeding tendency due to thrombocytopenia, or hepatitis due to thrombocytopenia, and high risk of esophageal variceal hemorrhage due to server portal hypertension, hematological disease, diagnostic surgery, or splenomegaly of unknown origin. Diagnosis for splenectomy of 2 groups are given in Table 2. The patients were selected randomly according to numbers on a random table and assigned to 1 of the 2 different surgical procedures: HALS (n=45) or LS (n=46). The study plan was reviewed and approved by our institutional ethical committee, and informed consent was obtained for all the patients.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

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HALS Procedure

Patients were placed in semilateral decubitus position, without flexing the operative table. The first 10-mm trocar, used for the 30 camera was placed in the lower umbilicus. The hand port was inserted through a subxiphoid midline incision ∼5 to 6 cm in length. The operating surgeon can insert his left hand to help complete the surgery. One 12-mm bladeless trocar was placed at the left midclavicular line below the inferior margin of the spleen (the larger the spleen, the more medial the trocars were placed). Splenic attachments and ligaments were divided using an ultrasound dissector or LigaSure vessel sealing system in the order of splenogastric ligament, splenocolic ligament, splenorenal ligament, and splenophrenic ligament. After the spleen was mobilized from the attachments and ligaments, the splenic hilar pedicles were transected with an endoscopic linear vascular stapler. The resected spleen was placed into a retrieval bag and extracted from the hand-assisted incision. A drainage tube was placed in the splenic fossa.

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LS Procedure

Under general anesthesia, the patient was placed in a supine position. For LS approach, 4 trocars were used in a similar manner after creation of pneumoperitoneum using a Veress needle. Operative procedures were identical to those of HALS. A 5-cm right subcostal laparotomy was made to remove the spleen at the end of operation.

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Statistical Analysis

Statistical analysis was performed with SPSS software, version 17.0 (SPSS Inc., Chicago, IL). Continuous variables were expressed as mean±SD or median (range), and categorical variables were expressed as numbers. Continuous variables were compared using the student t test or the Mann-Whitney U test, and categorical variables were compared using the χ2 test or the Fisher exact test. P<0.05 was considered statistically significant.

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RESULTS

Patient Characteristics

Patient demographic and clinical/laboratory data are presented in Table 1 and indications for splenectomy are given in Table 2. Baseline characteristics of the 2 groups were comparable. There were no significant differences in (sex, P=0.989; age, P=0.451; main diameter, P=0.585; Child-Pugh grade, P=0.503; Table 1) between the 2 groups.

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Perioperative Outcome

The surgical outcomes are shown in Table 1. The patients for HALS had shorter operative times (141±46 vs. 172±43 min; P=0.001), lower intraoperative blood loss [215 (122.332) vs. 230 (130.740) mL; P=0.026], less hospital expenses (5.5±1.5 vs. 6.4±2.4 WanRMB; P=0.022), and lower conversion rate (1/45 vs. 9/46; P=0.015) than those patients for LS. However, there was no significant difference for hospital stay (6.4±2.8 vs. 6.7±3.0 d; P=0.662) and complications (15/45 vs. 12/46; P=0.864) between the 2 groups. In addition, there were no significant differences in postoperative white blood cell (10.6±2.9 vs. 10.9±3.5; P=0.747), AST [61 (47.94) vs. 57 (37.86) U/L; P=0.513], and ALT [68 (54.120) vs. 55 (36.99) U/L; P=0.302] levels. These suggest that there was no difference in postoperative patient emergency status.

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DISCUSSION

Because of the high incidence of chronic hepatitis B and C infections worldwide, a large number of those patients have portal hypertension secondary to liver cirrhosis and need splenectomy.11 More and more patient consider the safety of the operation, while ensuring minimally invasive surgery. Although LS has many advantages and has been considered as the mature treatment,1–3 it has longer operation time, more blood loss, and higher conversion rate due to lack of tactile sensation, impaired hand-eye coordination, and the loss of 3-dimensional visualization of intra-abdominal structures.7 There were several trials6,10,14,15 reported that HALS can overcome these drawbacks, while maintaining the advantages of LS. However, there was still lack of multicenter prospective randomized controlled clinical trials, even the results of research were contradicted with each other.7,11 Hence, this multicenter prospective randomized trial was carried out.

The objective of our research was to analyze a multicenter experience among a series of 91 patients with splenomegaly treated by a minimally invasive surgical approach using HALS or LS. When the baseline features (sex, age, main diameter, Child-Pugh grade) of both groups had no significant difference, Our surgical outcomes are shown that the HALS group operation time was shorter, blood loss, hospital expenses, and conversion rate were lower than LS group. Hand-assisted laparoscopic technique allows the surgeon to place one hand into the abdominal cavity while maintaining the pneumoperitoneum, recovering direct tactile sense, and improving the accuracy of manipulation. By retaining tactile feedback and hand-eye coordination, the surgeon’s left hand can bluntly dissect the space beneath the tail of the pancreas and encircle the pedicle of the spleen early in the dissection.14 This step, together with preventive ligation or clipping of the splenic artery, will limit the consequences of any possible injury that might occur during the subsequent dissection, as the surgeon will then be able to control the vascular pedicle with his fingers at any time.14 Bagging these enlarged spleens was easy with the assistance of hand and also reduce operation time. After all, the surgeon’s hand is superior to any laparoscopic instruments. Our results provide powerful and convincing evidence-based medical evidence for previous studies.6,10,15 With the aid of the intraperitoneal hand, this maneuver is facilitated and can be accomplished in a faster and safer manner. Therefore, it was not surprising for patients with HALS to have shorter operation time and lower blood loss than patients without LS, as seen in our study. As for lower hospital expenses, it was understandable, because HALS operation time was shorter, less medications are needed. The most important is that HALS need less assistants and trocars. For open conversion patients, almost all of the reasons from our data were massive intraoperative hemorrhage. And one patient died of complications of hemorrhagic shock. When an uncontrolled bleeding occurred, then all operations were expanded around the rapid control of bleeding and ignoring other problems. That would bring potentially dangerous for the patients. HALS can reduce this uncertainty of surgical just right. If bleeding occurs, it is easy to be controlled by compression of the left hand on splenic vascular pedicle or the injury of spleen, thereby reducing conversion rate. In addition, HALS also has a shorter learning curve,16 less trocar and less assistant, while the incision is the same with LS.

Excluding these advantages for HALS, our results also show that there was no significant difference for hospital stay, complications, and postoperative white blood cell, AST, ALT levels between the 2 groups. These indicate that there was no difference in postoperative patient emergency status, and ensured the same rapid recovery as LS. Because HALS did not increase the surgical trauma compared with LS, both 2 groups have a 5 cm length accessory incision. The incision in LS group was made at the end of the operation for spleen retrieval. However, in HALS group it was made at the beginning of operation for hand-assisted port. From the above results, HALS not only retained the advantages of LS and OS, but also overcome the disadvantages of LS and OS, it can achieve the perfect combination of surgical minimally invasive and safety.

When splenectomy was implemented, we first need to explore the abdominal cavity to find out the size of the spleen and the condition of adhesions around the spleen. The main difficulties of splenectomy are as following: (1) the surgical field of vision and limited space were affect by splenomegaly; (2) vascular extensive varicose intraperitoneal and vascular wall fragile, it was easy to cause bleeding when separated; (3) ligament around the spleen contracture and adhesions lead to structural unclear by repeated splenic inflammation. HALS technique modification facilitates the performance of difficult laparoscopic procedure. This has been verified in various complicated laparoscopic procedures,17 including gastrointestinal cancers,18,19 pancreatectomy,20,21 nephrectomies,22,23 hepatectomies,24,25 and so on. In the case of a large spleen, the inconstant posterior attachments to the diaphragm can be difficult and sometimes impossible to divide using complete laparoscopy because visual access to this area is limited by the size of the overlying spleen. In HALS, blunt finger dissection of these attachments can usually be accomplished even in areas that are hidden to endoscopic view because of the retained tactile feedback with this technique.26

From a technical point of view, the main technical challenges of HALS are as following: (1) the hand-assisted incision should be choose as the principle of tissue well exposed, easy to operate, tiny tissue trauma, and easy to convey laparotomy. We believe that the hand-assisted incision through a subxiphoid midline is the best choice. It does not hurt the muscles, and is near to the spleen pedicle, stomach, and cardia, which is conducive to separation of the splenic artery and spleen pedicle and stomach short vessel in direct vision. It is not undermining the abdominal collateral circulation of portal hypertension, but also conducive to prolonging the incision and convey laparotomy. (2) Hand-assisted device incision and position of puncture design must be reasonable. It is necessary to avoid piercing hand-puncture puncturing device, and also to provide a space for the left hand. We first observed from the umbilical trocar, and according to the size of the spleen, we choose hand-assisted incision distance. (3) The nondominant hand of the surgeon is easily fatigued during long-term surgical operation. We believe that the spleen and stomach ligament should be separated from top to bottom, this method would not cause a hand fatigue easily, and will provide a good field of vision at the same time. (4) In regard to splenic blood vessels treatment: there are many varicose veins around the spleen in splenomegaly, especially the diameter of splenic vein was so much coarse. Thence, how to prevent bleeding is the focus of splenectomy. The main vessels need to be treated are splenic vessels of lower pole, gastric short vessels of spleen upper edge and splenic pedicles. When there was no enough space in the abdominal cavity due to splenomegaly, we first separated the splenic artery and did a double ligation under direct vision from hand-assisted incision to the upper edge of the pancreas. This will help in reduction of spleen blood reflux and spleen volume, and reduce bleeding. In addition, separation of splenic vascular of lower edge separation was easier with Hem-o-lok, Splenic vascular of upper edge was separated the same as lower edge of spleen after the spleen and stomach ligaments were bluntly dissected by the nondominant hand. However, it should be about 1 cm separated next to the spleen. Once it bleeds, we can clamp it with peptide clamps. Otherwise the patient needs to convey to laparotomy. Spleen pedicle dissection is the key of the operation, there are 3 ways to deal with spleen pedicle: first, If splenomegaly vessels are scattered, we can separate them one by one with Hem-o-lok by help of the nondominant hand. Second, if spleen pedicle vessels trunk concentrated, we can separate them quickly and safely with Endo-GIA. Third, if the spleen pedicle is close to the hand-assisted incision, we can block and double-tie the spleen pedicle with a Sadins forcep after removing the hand-assisted device. (5) LigaSure, ultrasonic scalpel, Endo-GIA, and other equipment is used to simplify the operation, reduce intraoperative bleeding, reduce the difficulty of surgery, shorten the operation time, and improve the safety of surgery.

In conclusion, this multicenter prospective randomized trials shows that HALS can maximize the benefits for patients with splenomegaly, while maintaining the advantages of LS and tactile sense of OS. It also can improve the safety of surgery and to be considered as good alternative.

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Keywords:

hand-assisted; laparoscopic; splenectomy; splenomegaly

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