Dear Editor, we read with great interest the article by Tiang et al., entitled “Splenic Bed laparoscopic splenectomy approach for massive splenomegaly secondary to portal hypertension and liver cirrhosis” recently published on American Surgeon [1]. The number of laparoscopic surgical operations is increasing worldwide. Laparoscopic splenectomy (LS) is nowadays considered the gold standard in case of normal to moderately enlarged spleens. However, in case of splenomegaly, this minimally invasive approach is associated with high risk of intra-and post-operative bleeding; particularly in conditions such as the hypersplenism secondary to liver cirrhosis, where collateral vessels and coagulopathy increase the technical difficulties of LS [2]. The indications for splenectomy in these cases are quite selected and included bleeding tendency due to thrombocytopenia, gastric varices resistant to standard treatments or patients unsuitable for chemotherapy for hepatocarcinoma due to coagulation disorders. In this setting, although the benefits of minimally invasive procedures include shorter hospital stay and no impairment of liver function in Child A and B patients, some studies have shown longer operative time in LS group when compared to open surgery [3,4]. This may be related to the difficulties in hilum dissection and in controlling short gastric vessels or other collaterals usually present in portal hypertension. Moreover, in case of splenomegaly, the posterior ligaments with diaphragm are difficult to expose, requiring an extra time to divide them avoiding spleen capsule lacerations. As rightly explained and discussed in the article, an alternative to the standard anterior approach is the postero-lateral one that consist in dividing all the ligaments from the lower to the upper pole of the spleen thus enabling a complete isolation of the splenic pedicle and a safer entrance of the Endo-stapler. Moreover, the mobilized spleen is also pulled downward by gravity, which stretches the gastro-splenic ligament and allows the transaction of short gastric vessels in a safer manner. The authors have described some benefits related to this approach respect to standard anterior laparoscopic splenectomy in terms of operative time, hemorrhage risk and pancreatic leak. They also correctly admit the limits of the article, such as the small sample size and the lack of randomized control trials comparing splenic bed laparoscopic splenectomy with the conventional technique, preventing to draw definitive conclusions. In our surgical center, we routinely use with success this approach in complex cases for several years, particularly in cirrhotic patients with portal hypertension, as well as for huge splenomegaly of other nature, because we experienced that it reduces the risk of bleeding and improves the hilum control. Furthermore, we would like to add that, in such complex cases, a further level of safety can be obtained with the combination of the described postero-lateral approach with the Hand Assisted Laparoscopic Surgery (HALS) technique, that permits the restoration of the tactile feedback [5]. Indeed, we think that HALS can be a very appropriate option because the use of the non-dominant hand increases local control, exposure and manipulation. For these reasons this approach can increase safety, reduce conversion rate and maintain similar post-operative outcomes if compared to the standard approach in terms of hospitalization and complications, thus maintaining all the advantages of minimally invasive management. In conclusion, LS in hypersplenism due to portal hypertension is a demanding but feasible procedure, with a level of safety that can be increased by the routine use of postero-lateral approach as cited in this article. The use of HALS technique should be also strongly recommended in the most complex cases like cirrhosis and huge splenomegalies, because capable to increase intraoperative control and manipulation, with a post-operative course similar to conventional pure laparoscopy.
Hand-assisted splenic bed laparoscopic splenectomy for massive splenomegaly secondary to portal hypertension and liver cirrhosis
Guadagni S.;Gianardi D.;Morelli L.
2019-01-01
Abstract
Dear Editor, we read with great interest the article by Tiang et al., entitled “Splenic Bed laparoscopic splenectomy approach for massive splenomegaly secondary to portal hypertension and liver cirrhosis” recently published on American Surgeon [1]. The number of laparoscopic surgical operations is increasing worldwide. Laparoscopic splenectomy (LS) is nowadays considered the gold standard in case of normal to moderately enlarged spleens. However, in case of splenomegaly, this minimally invasive approach is associated with high risk of intra-and post-operative bleeding; particularly in conditions such as the hypersplenism secondary to liver cirrhosis, where collateral vessels and coagulopathy increase the technical difficulties of LS [2]. The indications for splenectomy in these cases are quite selected and included bleeding tendency due to thrombocytopenia, gastric varices resistant to standard treatments or patients unsuitable for chemotherapy for hepatocarcinoma due to coagulation disorders. In this setting, although the benefits of minimally invasive procedures include shorter hospital stay and no impairment of liver function in Child A and B patients, some studies have shown longer operative time in LS group when compared to open surgery [3,4]. This may be related to the difficulties in hilum dissection and in controlling short gastric vessels or other collaterals usually present in portal hypertension. Moreover, in case of splenomegaly, the posterior ligaments with diaphragm are difficult to expose, requiring an extra time to divide them avoiding spleen capsule lacerations. As rightly explained and discussed in the article, an alternative to the standard anterior approach is the postero-lateral one that consist in dividing all the ligaments from the lower to the upper pole of the spleen thus enabling a complete isolation of the splenic pedicle and a safer entrance of the Endo-stapler. Moreover, the mobilized spleen is also pulled downward by gravity, which stretches the gastro-splenic ligament and allows the transaction of short gastric vessels in a safer manner. The authors have described some benefits related to this approach respect to standard anterior laparoscopic splenectomy in terms of operative time, hemorrhage risk and pancreatic leak. They also correctly admit the limits of the article, such as the small sample size and the lack of randomized control trials comparing splenic bed laparoscopic splenectomy with the conventional technique, preventing to draw definitive conclusions. In our surgical center, we routinely use with success this approach in complex cases for several years, particularly in cirrhotic patients with portal hypertension, as well as for huge splenomegaly of other nature, because we experienced that it reduces the risk of bleeding and improves the hilum control. Furthermore, we would like to add that, in such complex cases, a further level of safety can be obtained with the combination of the described postero-lateral approach with the Hand Assisted Laparoscopic Surgery (HALS) technique, that permits the restoration of the tactile feedback [5]. Indeed, we think that HALS can be a very appropriate option because the use of the non-dominant hand increases local control, exposure and manipulation. For these reasons this approach can increase safety, reduce conversion rate and maintain similar post-operative outcomes if compared to the standard approach in terms of hospitalization and complications, thus maintaining all the advantages of minimally invasive management. In conclusion, LS in hypersplenism due to portal hypertension is a demanding but feasible procedure, with a level of safety that can be increased by the routine use of postero-lateral approach as cited in this article. The use of HALS technique should be also strongly recommended in the most complex cases like cirrhosis and huge splenomegalies, because capable to increase intraoperative control and manipulation, with a post-operative course similar to conventional pure laparoscopy.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
