Laparoscopic versus open splenectomy in the management of hematologic diseases.
Splenectomy is the best available treatment for severe forms of hereditary spherocytosis, idiopathic thrombocytopenic purpura, and other hematologic conditions when these prove refractory to conservative management. It has been employed for many decades with low mortality and favorable remission rates. The use of laparoscopic splenectomy in recent years has been rapidly and even enthusiastically adopted in this field. However, the exact role of laparoscopic versus open surgery for hematologic diseases is still debated. In this study of 58 adult patients, laparoscopic procedures were compared with conventional splenectomies for similar indications.


METHODS
All patients were operated on within an 8-year period. Subjects underwent similar procedures under the supervision of the same surgical school and were compared regarding age, gender, body mass index, and diagnosis. Laparoscopically managed cases (Group I, n = 30) were prospectively followed according to a written protocol, whereas the same investigation was retrospectively done with regard to traditional laparotomy (Group II, n = 28). Methods included general and demographic findings, duration and technical steps of operation, blood loss, weight of spleen, need for conversion (in minimally invasive subjects), intraoperative and postoperative complications, time until realimentation, postoperative hospitalization, mortality, and late follow-up including recurrence rate.


RESULTS
Idiopathic thrombocytopenic purpura was the surgical indication in over 50% of the patients in both groups, but familial spherocytosis, thalassemia, myelodysplasia, and lymphomas were also represented in this series. Laparoscopic procedures took more time to perform (P = 0.004), and postoperative hospitalization was 2 days shorter, but this difference was not statistically significant. Postoperative hematocrit and volume of blood transfusions was equivalent, although the laparoscopic cases had a somewhat lower preoperative hematocrit (NS) and displayed better recovery for this measurement (P = 0.03). More patients in Group I were able to accept oral food on the first day than subjects undergoing conventional operations (P < 0.05). Relatively few conversions were necessary during the minimally invasive surgeries (13.3%), and postoperative early and late complications as well as recurrences occurred in similar proportions. Also, the mean weight of the spleen was not statistically different between the groups, although there was a marked numerical tendency toward larger masses in conventional procedures. No spleen in Group I exceeded 2.0 kg, whereas in Group II values up to 4.0 kg occurred, and the mean weight was 50% higher in the latter group.


CONCLUSIONS
1) Minimally invasive splenectomy was essentially comparable to open surgery with regard to safety, efficacy, and late results; 2) Advantages concerning shorter postoperative hospitalization could not be shown, despite earlier food intake and a non-significant tendency toward earlier discharge; 3) This new modality should be considered an option in cases of hematologic conditions whenever the spleen is not hugely enlarged.
Sapucahy
Manuela V
MV
Division of Surgery of the Digestive Tract, Department of Gastroenterology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo/SP, Brazil.
Faintuch
Joel
J
Bresciani
Cláudio J C
CJ
Bertevello
Pedro L
PL
Habr-Gama
Angelita
A
Gama-Rodrigues
Joaquim José
JJ
D000293:Adolescent; D000328:Adult; D005260:Female; D006402:Hematologic Diseases / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000592:standards*; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D018579:Patient Selection; D016553:Purpura, Thrombocytopenic, Idiopathic / Q000601:surgery; D012189:Retrospective Studies; D013103:Spherocytosis, Hereditary / Q000601:surgery; D013156:Splenectomy / Q000592:standards*