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Original Article |

Complications of Laparoscopic Splenectomy FREE

Eduardo M. Targarona, MD, PhD; Juan José Espert, MD; Ernest Bombuy, MD; Oscar Vidal, MD; Gemma Cerdán, MD; Vicente Artigas, MD, PhD; Manuel Trías, MD, PhD
[+] Author Affiliations

From the Services of General and Digestive Surgery, Hospital de Sant Pau, Autonomous University of Barcelona (Drs Targarona, Cerd[[aacute]]n, Artigas, and Tr[[iacute]]as), and Hospital Clinic (Drs Espert, Bombuy, and Vidal), Barcelona, Spain.


Arch Surg. 2000;135(10):1137-1140. doi:10.1001/archsurg.135.10.1137.
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Published online

Hypothesis  Analysis of the type and characteristics of complications after laparoscopic splenectomy may permit the identification of clinical factors with predictive value for the development of complications.

Design  Univariate and multivariate analysis of factors related to complications in a prospective series of laparoscopic splenectomies.

Setting  A large tertiary referral university–teaching general hospital.

Patients  One hundred twenty-two nonselected consecutive patients, in whom laparoscopic splenectomy was attempted between February 1993 and July 1999.

Intervention  Laparoscopic splenectomy.

Main Outcome Measures  Immediate complications classified according to the Clavien score. Univariate and multivariate analyses were performed of complications related to age, sex, body mass index, and malignant nature of the hematologic disease; preoperative hematocrit and platelet count; operative time; operative position; need of accessory incision; transfusion status; learning curve; and existence of comorbid diseases.

Results  One hundred thirteen laparoscopic splenectomies were completed (conversion rate, 7.4%). Twenty patients (18%) developed 23 complications. All were Clavien type I or II, without mortality. One complication was intraoperative (diaphragmatic perforation), and 22 were postoperative: 6 pulmonary (26%), 3 fever (13%), 8 hemorrhagic (35%) (5 episodes of postoperative bleeding and 3 abdominal wall hematomas), and 6 others (26%). Ten (43%) of the 23 were technically related. Univariate analysis showed that complications were only related to age (mean ± SD, 55 ± 15 vs 39 ± 17 years; P<.008) or transfusion (50% vs 11%; P<.001). Multivariate analysis showed that the learning curve (P<.005; 95% confidence interval, 2.46), age (P<.001; 95% confidence interval, 1.04), spleen weight (P<.009; 95% confidence interval, 1.00), and malignant neoplasm diagnosis (P<.007; 95% confidence interval, 3.82) were independent predictors of complications.

Conclusions  Laparoscopic splenectomy is feasible, and the incidence of severe complications is reduced. However, a high proportion of these complications are technique related. Laparoscopic splenectomy requires great technical care but offers major clinical advantages, even in less favorable situations, such as in patients with splenomegaly or with malignant neoplasms.

LAPAROSCOPIC splenectomy (LS) has become increasingly popular in recent years.13 However, it entails technical difficulties due to the spleen's vascular anatomic features and its frail texture. In addition, the specific features of hematologic diseases (low platelet count, splenomegaly, or systemic disease [lymphoma]) may increase postoperative morbidity. The best evaluation of a new procedure is via an analysis of its complications and the advantages it offers; in the case of LS, an important argument in its favor is the reduction of the morbidity rate. Thus, this study analyzes the type and characteristics of complications related to LS in a consecutive series of 122 patients.

Between February 1993 and July 1999, 122 patients with a wide range of splenic disorders (Table 1) requiring splenectomy were approached about undergoing laparoscopy. Clinical data, technical details, and immediate outcome were recorded prospectively. All patients received a preoperative pneumococcal vaccine, and antibiotic prophylaxis was initiated intraoperatively. Laparoscopic splenectomies were performed through an anterior or lateral approach, using techniques previously described.4 Immediate complications were prospectively recorded and classified according to the Clavien score (Table 2).5 Univariate and multivariate analyses were performed of complications related to age, sex, body mass index (calculated as weight in kilograms divided by the square of height in meters), and malignant nature of the hematologic disease; preoperative hematocrit and platelet count; operative time; operative position; need of an accessory incision; transfusion status; learning curve; and the existence of comorbid diseases. The χ2 test was used for comparison of the 2 proportions, and the t test was used to compare differences between the 2 series. Multivariate analysis and a model of logistic regression with backward and forward analysis were used.

Table Graphic Jump LocationTable 1. Hematologic Diagnosis in 122 Cases of Attempted Laparoscopic Splenectomy*
Table Graphic Jump LocationTable 2. Clavien Classification for Surgical Complications*

One hundred thirteen LSs were completed (conversion, 9 [7.4%] of 122); the clinical details are as follows:

No conversions were related to intraoperative complications. Twenty patients (18%) in the successful LS group developed 23 complications. All of them were Clavien type I or II, and there was no mortality. Complications and their type are described in Table 3. Of the 23 complications, 10 (43%) were technically related to the procedure, 8 (35%) were hemorrhagic complications, 6 (26%) were pulmonary complications, 3 (13%) were infectious complications, and 6 (26%) were other types of complications. Complications were not related to the diagnosis of a malignant neoplasm (malignant vs benign, 37% vs 21%), spleen weight (patients with complications vs those without complications, 717 ± 504 vs 474 ± 628 g), or operative time (patients with complications vs those without complications, 172 ± 75 vs 147 ± 54 minutes; P<.06) (data are given as mean ± SD unless otherwise indicated). However, patients with complications were significantly older and required more blood (53% vs 13%; P<.001); complications had a direct impact on postoperative stay (mean ± SD, 9 ± 5 vs 3 ± 1 days; P<.001) (Table 4).

Table Graphic Jump LocationTable 3. Postoperative Complications After Successful Laparoscopic Splenectomy
Table Graphic Jump LocationTable 4. Results of Univariate Analysis of Clinical Factors Related to Complications After Laparoscopic Splenectomy

Logistic regression analysis indicated that factors with predictive power for morbidity were age, spleen weight, malignant nature of the disease, and procedures performed early in our experience (learning curve) (Table 5).

Table Graphic Jump LocationTable 5. Results of Multivariate Analysis of Clinical Factors Related to Complications After Laparoscopic Splenectomy

The reasons for the 9 conversions were as follows: diffuse oozing (n = 2), spleen size (n = 6), and adhesions (n = 1). The characteristics of the 9 patients are as follows:

Open splenectomy is not usually technically demanding, except for the treatment of a massively enlarged spleen.6 However, it requires a wide laparotomy to gain access to the left hypochondriac region fossa. The spleen's rich vascularization and its intimate anatomic relations with intra-abdominal organs, along with the traction and maneuvers necessary for exposure, mean that the procedure is associated with complications in 5% to 60% of patients.710 The complications are mainly secondary to pancreatic tail injury or bleeding, or are pulmonary in origin. Splenectomy for malignant diseases or enlarged spleen is associated with a morbidity of 40% to 60%.710

Potential advantages of laparoscopy are a decrease in the complication rate due to the less aggressive nature of the approach and the great visual detail obtained; also, it avoids manipulation of the left side of the diaphragm. Large series of LSs available report a significant decrease in complications compared with open surgery, although most of these studies are retrospective and randomized trials are lacking.1113

In our series, we observed a morbidity rate of 18% in an unselected group of 122 LSs. Forty-three percent were clearly technique related, and most were of hemorrhagic origin. In univariate analysis, the only factor that showed a significant difference comparing complicated with noncomplicated cases was age. However, multivariate analysis showed that the learning curve, age, malignant neoplasm, and spleen weight were predictive factors for complications.

We began to use LS in early 1993, and we have included all our patients in this series; we thus include our early learning curve, before we mastered the technique. The demonstration that the learning curve is an independent factor for complication should be highlighted. However, at present, LS is a well-systematized procedure that can be taught and learned by trainees or inexperienced surgeons, thus reducing morbidity due to the learning curve. Several researchers1,14,15 have shown that the procedure can be performed in a teaching environment, with most of the procedures being performed by residents.

In our experience, another factor has favored the reduction of the incidence of complications: the switch from the anterior to the lateral approach.4 The lateral approach facilitates dissection and mobilization of the spleen, reduces operative time, and avoids the manipulation of the spleen and tears or capsule fractures. In this series, there was no massive intraoperative bleeding, nor injury to great splenic vessels, which in most patients were controlled by an endostapler.16 An important reason for this was the use of the lateral approach, which permits mobilization of the spleen and the placement of the stapler without tension. Two cases were converted early in our experience due to bleeding originating in epiploon vessels. Technical results have also been improved by the development of instruments that facilitate the dissection maneuvers during LS, such as the harmonic scalpel.17 The use of this scalpel does not require clips, which may become dislodged, and simplifies the control of low-caliber epiploon vessels.

One severe hemorrhagic complication is postoperative bleeding, which occurred 4 times (3%): 3 times after successful LS, and a fourth after conversion. A potential hazard when using mechanical devices to control splenic vessels is the risk of bleeding due to a high-pressure flux on a row of staples. We try to interrupt the arterial flux with a clip to reduce the spleen size. This maneuver also has a certain autotransfusion effect.

One dangerous technical complication is diaphragmatic perforation, which is rare during open surgery. A small cautery injury of the diaphragm dome, mainly in the muscled part, may enlarge as a consequence of the pneumoperitoneum and develop into a hole. This has been described by other researchers16; it can usually be controlled by laparoscopy.

Age, the malignant nature of the hematologic disease, and increased spleen weight are well-known factors related to complications after open splenectomy, and all 3 usually are interrelated.610 Several medical complications occurred in our patients, which were unrelated to the laparoscopic technique (Sweet syndrome, gout attack, and hypophysial insufficiency). Central line infection and urinary sepsis were also observed in this subgroup of patients, who usually underwent more manipulation than the easier patients (ie, those who were younger and healthier). Laparoscopic management of splenomegaly entails a more demanding technique, and manipulation of a large organ and extraction of the viscera may be more difficult.18,19 Splenomegaly has been classically associated with increased morbidity after open splenectomy.610 However, in our experience, LS for splenomegaly, when successful (LS success rates of 85% for patients with spleens >400 g and 75% for those with spleens >1000 g), presented the same advantages as LS for smaller spleens, and yielded better results than open splenectomy.

The laparoscopic approach has intrinsic potential complications due to the type of access (trocars and pneumoperitoneum).20 An unusual bleeding complication during open surgery is abdominal wall hematoma. Trocar placement is performed through several muscular planes when the lateral approach is used, and subsequent pneumoperitoneum may dissect these anatomic planes. Despite careful suture of portholes, we observed a postoperative decrease of hematocrit and blood accumulation in the abdominal wall in 3 patients. All of them had a low platelet count and a slow elevation of platelet count.

Laparoscopic splenectomy is feasible, and the incidence of severe complications is reduced. However, a high proportion of these complications are technique related. Laparoscopic splenectomy requires great technical care but offers major clinical advantages, even in less favorable situations, such as in patients with splenomegaly or with malignant neoplasms.

This study was supported by grant 97/970 from the Fondo de Investigaciones Sanitarias, Madrid, Spain.

Presented as a poster at the 1999 Scientific Meeting of Sages, San Antonio, Tex, April 25-27, 1999; and as a free paper at the European Association of Endoscopic Surgery Annual Meeting, Linz, Austria, June 23-26, 1999.

We thank M. T. Puig, MD, and J. Gich, MD, for their help with the statistical analysis.

Reprints: Manuel Trías, MD, PhD, Service of General and Digestive Surgery, Hospital de Sant Pau, Avda P Claret 167, 08025 Barcelona, Spain (e-mail: 7366@hsp.santpau.es).

Kathkouda  NHurtwitz  MBRivera  RT  et al.  Laparoscopic splenectomy: outcome and efficacy in 103 consecutive cases. Ann Surg. 1998;228568- 578
Link to Article
Gigot  JFLengele  BGianello  PEtienne  JClaeys  N Present status of laparoscopic splenectomy for hematological diseases: certitudes and unresolved issues. Semin Laparosc Surg. 1998;5147- 167
Klinger  PJTsiotos  GGGlaser  KSHinder  RA Laparoscopic splenectomy and current status. Surg Laparosc Endosc. 1999;91- 8
Link to Article
Trias  MTargarona  EMEspert  JJBalagué  C Laparoscopic surgery for splenic disorders: lessons learned from a series of 64 cases. Surg Endosc. 1998;1266- 72
Link to Article
Clavien  PASanabria  JRStrasberg  JM Proposed classification of complications of surgery with example of utility in cholecystectomy. Surgery. 1992;111518- 526
Hiatt  JRAllins  AKong  LR Open splenectomy. Hiatt  JRPhillips  EHMorgenstern  Leds.Surgical Diseases of the Spleen. Berlin, Germany Springer1997;197- 210
McRae  HMYakimets  WWReynolds  T Perioperative complications of splenectomy for hematologic disease. Can J Surg. 1992;35432- 436
Aksnes  JAbdelnoor  MMathisen  O Risk factors associated with mortality and morbidity after elective splenectomy. Eur J Surg. 1995;161253- 258
Horowitz  JSmith  JLWeber  TKRodriguez-Bigas  MAPetrelli  NJ Postoperative complications after splenectomy for hematologic malignancies. Ann Surg. 1996;223290- 296
Link to Article
Coon  W Surgical aspects of splenic disease and lymphoma. Curr Probl Surg. 1998;35543- 646
Link to Article
Friedman  RLHiatt  JRKorman  JLFacklis  KCymerman  JPhillips  EH Laparoscopic or open splenectomy for hematological disease: which approach is superior? J Am Coll Surg. 1997;18549- 54
Link to Article
Targarona  EMEspert  JJ Effect of spleen size on splenectomy outcome: a comparison of open and laparoscopic surgery. Surg Endosc. 1999;13559- 562
Link to Article
Park  AMarcaccio  MSternbach  MWitzke  DFitzgerald  P Laparoscopic versus open splenectomy. Arch Surg. 1999;1341263- 1269
Link to Article
Poulin  EMamamzza  J Laparoscopic splenectomy: lessons from the learning curve. Can J Surg. 1998;4128- 36
Rege  RVJoehl  RJ A learning curve for laparoscopic splenectomy at an academic institution. J Surg Res. 1999;8127- 32
Link to Article
Navarro  RAKorman  JEPhillips  EH Complications of laparoscopic splenectomy. Semin Laparosc Surg. 1997;4182- 189
Gossot  DFritsch  SCelerier  M Laparoscopic splenectomy: optimal vascular control using the lateral approach and ultrasonic dissection. Surg Endosc. 1999;1321- 25
Link to Article
Terrossu  GDonini  ABaccarini  U  et al.  Laparoscopic versus open splenectomy in the management of splenomegaly: our preliminary experience. Surgery. 1998;124839- 843
Link to Article
Targarona  EMEspert  JJBalagué  CPiulachs  JArtigas  VTrias  M Splenomegaly should not be considered a contraindication for laparoscopic splenomegaly. Ann Surg. 1998;22835- 39
Link to Article
McMahon  MJ Complications of laparoscopic access. Semin Laparosc Surg. 1997;4139- 146

Figures

Tables

Table Graphic Jump LocationTable 1. Hematologic Diagnosis in 122 Cases of Attempted Laparoscopic Splenectomy*
Table Graphic Jump LocationTable 2. Clavien Classification for Surgical Complications*
Table Graphic Jump LocationTable 3. Postoperative Complications After Successful Laparoscopic Splenectomy
Table Graphic Jump LocationTable 4. Results of Univariate Analysis of Clinical Factors Related to Complications After Laparoscopic Splenectomy
Table Graphic Jump LocationTable 5. Results of Multivariate Analysis of Clinical Factors Related to Complications After Laparoscopic Splenectomy

References

Kathkouda  NHurtwitz  MBRivera  RT  et al.  Laparoscopic splenectomy: outcome and efficacy in 103 consecutive cases. Ann Surg. 1998;228568- 578
Link to Article
Gigot  JFLengele  BGianello  PEtienne  JClaeys  N Present status of laparoscopic splenectomy for hematological diseases: certitudes and unresolved issues. Semin Laparosc Surg. 1998;5147- 167
Klinger  PJTsiotos  GGGlaser  KSHinder  RA Laparoscopic splenectomy and current status. Surg Laparosc Endosc. 1999;91- 8
Link to Article
Trias  MTargarona  EMEspert  JJBalagué  C Laparoscopic surgery for splenic disorders: lessons learned from a series of 64 cases. Surg Endosc. 1998;1266- 72
Link to Article
Clavien  PASanabria  JRStrasberg  JM Proposed classification of complications of surgery with example of utility in cholecystectomy. Surgery. 1992;111518- 526
Hiatt  JRAllins  AKong  LR Open splenectomy. Hiatt  JRPhillips  EHMorgenstern  Leds.Surgical Diseases of the Spleen. Berlin, Germany Springer1997;197- 210
McRae  HMYakimets  WWReynolds  T Perioperative complications of splenectomy for hematologic disease. Can J Surg. 1992;35432- 436
Aksnes  JAbdelnoor  MMathisen  O Risk factors associated with mortality and morbidity after elective splenectomy. Eur J Surg. 1995;161253- 258
Horowitz  JSmith  JLWeber  TKRodriguez-Bigas  MAPetrelli  NJ Postoperative complications after splenectomy for hematologic malignancies. Ann Surg. 1996;223290- 296
Link to Article
Coon  W Surgical aspects of splenic disease and lymphoma. Curr Probl Surg. 1998;35543- 646
Link to Article
Friedman  RLHiatt  JRKorman  JLFacklis  KCymerman  JPhillips  EH Laparoscopic or open splenectomy for hematological disease: which approach is superior? J Am Coll Surg. 1997;18549- 54
Link to Article
Targarona  EMEspert  JJ Effect of spleen size on splenectomy outcome: a comparison of open and laparoscopic surgery. Surg Endosc. 1999;13559- 562
Link to Article
Park  AMarcaccio  MSternbach  MWitzke  DFitzgerald  P Laparoscopic versus open splenectomy. Arch Surg. 1999;1341263- 1269
Link to Article
Poulin  EMamamzza  J Laparoscopic splenectomy: lessons from the learning curve. Can J Surg. 1998;4128- 36
Rege  RVJoehl  RJ A learning curve for laparoscopic splenectomy at an academic institution. J Surg Res. 1999;8127- 32
Link to Article
Navarro  RAKorman  JEPhillips  EH Complications of laparoscopic splenectomy. Semin Laparosc Surg. 1997;4182- 189
Gossot  DFritsch  SCelerier  M Laparoscopic splenectomy: optimal vascular control using the lateral approach and ultrasonic dissection. Surg Endosc. 1999;1321- 25
Link to Article
Terrossu  GDonini  ABaccarini  U  et al.  Laparoscopic versus open splenectomy in the management of splenomegaly: our preliminary experience. Surgery. 1998;124839- 843
Link to Article
Targarona  EMEspert  JJBalagué  CPiulachs  JArtigas  VTrias  M Splenomegaly should not be considered a contraindication for laparoscopic splenomegaly. Ann Surg. 1998;22835- 39
Link to Article
McMahon  MJ Complications of laparoscopic access. Semin Laparosc Surg. 1997;4139- 146

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