Laparoscopic splenectomy for hematologic diseases. Report of 275 cases.

Aim of the study: To evaluate the results of laparoscopic splenectomy for h ematologic diseases by a multicenter retrospective study. Patients and methods: Between 1991 and 1998, 275 patients (mean age: 40.4 y ears [18-93]) underwent splenectomy for idiopathic thrombocytopenic purpura (ITP) (n = 209, 76%), for hemolytic anemia (HA) (n = 37) including heredit ary spherocytosis (n = 13) and auto-immune anemia (n = 24), lymphoma (n = 1 2), tumor (n = 6) and uncommon hematologic syndromes (n = 11). Laparoscopic splenectomy was attempted in every patient. The lateral approach was most commonly used with an anterior approach to the splenic hilar vessels, which were cut after hemostasis using a stapling gun; other techniques were also employed. Results: The mean operating time was 165 minutes (45-360); it was shorter i n the case of conversion (144 minutes) and became shorter with the operator 's experience. Conversion was necessary in 55 patients (20%), due to hemorr hage in 2/3 of cases, related to splenic vessels (20 cases), short gastric vessels (9 cases), or injury of the spleen (8 cases). In ten cases (2%), co nversion was necessary for extraction of the spleen. Conversion rate varied from 5.3 to 46.7%, depending on the surgical team. Univariate analysis of factors predisposing to conversion identified four causes: obesity; techniq ue used to achieve hemostasis of the splenic hilar vessels; operator's expe rience; and presence of splenomegaly. An accessory spleen was found in 44 p atients (16%). The weight of the spleen was more than 350 g in 43 patients (15.6%). There were no deaths. There were no significant complications in 2 36 patients (85.8%) and the mean hospital stay was 6.4 days. In comparison with patients who had a conversion, bowel function returned significantly e arlier, use of analgesia was reduced and hospital stay was shorter. The ove rall morbidity rate was 13.8% (n = 38); morbidity rate was only 10.4% (n = 22) for laparoscopic splenectomy. In these 22 patients, the complications w ere: subphrenic collections (n = 5, 2.2%), abdominal wall infections (n = 5 ), thromboembolic events (n = 2), anemia (n = 2), pneumonia (n = 1), peptic ulcer (n = 1), bowel obstruction (n = 1), splenic vein thrombosis (n = 1). Re-operations were required in 4 patients (1.8%) because of hemorrhage, pa ncreatitis and bowel obstruction. Morbidity rate was significantly increase d in the case of conversion (27%), obesity (20%), malignant disease (30%) a nd splenomegaly (21.8%). Forty-four patients (16%) received perioperative o r postoperative blood transfusion and 23 (8.3%) received platelet transfusi on. Mean time to return to normal activity was 21 days and was shorter in t he absence of conversion (18.5 days versus 35 days). In patients with ITP, the mean platelet count was 240,000 after 3 months, and the failure rate wa s 8.3%. Conclusion: Laparoscopic splenectomy is a real alternative to conventional splenectomy for some hematologic diseases, particularly ITP and HA. The adv antages are an uneventful postoperative course, a lower morbidity rate, a s horter hospital stay and an earlier return to normal activity. The limits o f this technique are related to the operator's experience, the size of the spleen, the nature of the underlying disorders and patient characteristics, mainly obesity. (C) 2000 Editions scientifiques et medicales Elsevier SAS.