Laparoscopic splenectomy - Optimal vascular control using the lateral approach and ultrasonic dissection

Background: Intraoperative bleeding is the main complication and main cause of conversion to open surgery during laparoscopic splenectomy (LS). We pre sent the advantages of the lateral approach and the use of the ultrasonic s hears (US) for achieving a safer vascular control. Methods: We have performed a total of 48 LS using several approaches. In ou r initial experience 10 patients underwent surgery with an anterior approac h. In the second series of 18 patients, we used a manually assisted procedu re. In the last 20 patients, we employed a technique with a full lateral po sition. Only three peas have been used. The major part of the dissection wa s conducted from behind, thus allowing a safer vascular control. The divisi on of short gastric vessels and lower pole Vessels was performed using US. The main vascular pedicle was stapled. The spleen was removed through a sho rt Pfannenstiel incision. There were 9 males and 11 females with a mean age of 36 years (range, 18-71 years). Fourteen had immune thrombocytopenic pur pura (ITP); two had an HIV-infection-related purpura; two had an autoimmune hemolytic anemia; and two had a spherocytosis. Results: All the 20 LS were completed. The average splenic weight was 274 g (range, 162-1,400 g). In all but one patient, the intraoperative blood los s was less than 60 ml, and was none in six patients (average, 51 ml). In ou r initial series of 10 patients surgically treated with an anterior approac h, the average blood loss was 180 ml, and it was 230 mi in the series of ha nd-assisted procedures. The average operative time was 127 min (range, 70-2 20 min), including the time required by the change of position and the Pfan nenstiel incision. There was no mortality. All but one patient had an uneve ntful postoperative course. The HIV-infected patient had a severe postopera tive pancreatitis. In those patients with an uncomplicated course, the aver age postoperative stay was 4.3 days (range, 2-8 days). Conclusions: The lateral position with a posterior approach to splenic vess els allows for safe vascular control. The use of US results in a gain of ti me and safety. The average intraoperative bleeding of this series is much l ower than that observed in our previous experience and in other published s eries.