Conversion factors for laparoscopic splenectomy for immune thrombocytopenic purpura

Background: Since 1994, 27 patients at our institution have undergone lapar oscopic splenectomy for immune thrombocytopenic purpura (ITP). Laparoscopic splenectomy was completed in 22 of these patients. We sought to identify f actors that precluded successful laparoscopic splenectomy in the remaining 5 patients. Methods: Retrospective review of 27 patients with ITP undergoing laparoscop ic splenectomy was performed at Duke University Medical Center from August, 1994 to September, 1997. Results: Laparoscopic splenectomy was performed in 16 women and 11 men with a mean age of 47.2 years. Five (18%) of these procedures were converted to open splenectomy. There was no significant difference in age, ASA score, g ender, weight, height, or splenic size between the converted and laparoscop ic groups. However, preoperative and postoperative platelet counts were sig nificantly higher in the laparoscopic group than in the converted group (p < 0.001). Operative times also were significantly longer for the laparoscop ic group than for the converted group (p < 0.001). Adherent adjacent struct ures, associated comorbidities, and technical errors prohibited laparoscopi c completion in five patients. Technical errors with subsequent bleeding re quired conversion in two patients. A thickened greater omentum blanketing t he splenic capsule and a densely adherent pancreatic tail extending well in to the splenic hilum prevented laparoscopic completion in two patients. Inc reased peak airway pressures greater than 60 mmHg after pneumoperitoneum ne cessitated conversion in the remaining patient, who had a previous history of pulmonary insufficiency. Regardless of surgical approach, all patients a chieved a therapeutic response after splenectomy. Splenectomies completed l aparoscopically resulted in a significantly shorter length of hospital stay (p < 0.01). Conclusions: Densely adherent adjacent structures, technical errors, and ca rdiopulmonary instability may preclude successful completion of laparoscopi c splenectomies. Thorough preoperative evaluation with an emphasis on the c ardiopulmonary system may elicit a cohort of individuals with ITP who are u nlikely to undergo laparoscopic splenectomy successfully. This cohort also may include individuals with preoperative platelet counts less than 35,000 mm(-3).