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The impact of technological progress on minimally invasive splenectomy lessons learned after 15 years

The impact of technological progress on minimally invasive splenectomy lessons learned after 15... Introduction: The laparoscopic approach to splenectomy is at present the gold standard for the treatment of a lot of hematologic disorders in adult and pediatric patients. The dissemination of laparoscopic splenectomy was slower than those of other advanced minimally invasive procedures. We present our experience with the minimally invasive splenectomy pointing out the impact of technological progress on the success of this procedure. Material and Method: In order to assess the impact of technological progress we performed a retrospective analysis of 380 patients who underwent minimally invasive splenectomy between 1996 and September 2010 in our department. Technical advances utilized during this period included the harmonic scalpel, endoscopic staplers, Endocatch bag, Ligasure Vessel Sealing System and the Da Vinci Surgical System. Results: 60 patients aged 6 to 76 years (average 32.6 years) underwent robotic splenectomy; 44 robotic total splenectomies and 16 robotic partial/subtotal splenectomy. 320 patients aged 3 to 76 years (average 29.4 years) underwent laparoscopic splenectomies; 295 total splenectomies and 25 partial/subtotal splenectomies. Conclusion: The advances in minimally invasive surgery have been possible as a result of technological progress and increasing skills of the operators. However, laparoscopic splenectomy does not depend only on technological advances alone. This is and always will be a fine balance between surgical experience, clinical judgment and available technology. Key words: laparoscopic splenectomy; robotic splenectomy; subtotal splenectomy; partial splenectomy; robotic surgery Introduction The laparoscopic approach to splenectomy is at present the gold standard for the treatment of a lot of hematologic disorders in adult and pediatric patients. It is actually a safe and effective technique, resulting in less postoperative pain, a shorter hospital stay, and faster functional recovery than open splenectomy, and perioperative morbidity of the laparoscopic approach is significantly lower.(1) The dissemination of laparoscopic splenectomy was slower than those of other advanced minimally invasive procedures. The reasons are: the exposure of the spleen in the left upper quadrant can be difficult, especially in the obese patients, the control of the splenic blood supply demands advanced technical skills and equipment; the proximity of the tail of the pancreas to the splenic hilum presents the potential for injury, leading to pancreatitis or fistula. Splenomegaly, hypervascularity from portal congestion, thrombocytopenia commonly seen in patients undergoing splenectomy for hematologic disease Address for correspondence: Catalin Vasilescu, Associate Professor of Surgery, MD, PhD, Dan Setlacec Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Fundeni Street no 258, 022328, Bucharest, Romania, e-mail: catvasilescu@gmail.com and splenic tumors add to the risk of morbidity.(2) We present our experience with the minimally invasive splenectomy pointing out the impact of technological progress on the success of this procedure. The milestones of minimally invasive approach of splenectomy in our institution are: first laparoscopic splenectomy was performed in 1996 and published in 2001(3); first laparoscopic subtotal splenectomy was performed in 2002 published in 2003(4) and 2006(5); first robotic splenectomy was performed in 2008 and published in 2010(6). Materials and Methods In order to assess the impact of technological progress we performed a retrospective analysis of 380 patients who underwent minimally invasive splenectomy between 1996 and September 2010 in our department. Results 60 patients aged 6 to 76 years (average 32.6 years) underwent robotic splenectomy; 44 robotic total splenectomies and 16 robotic partial/subtotal splenectomy. 320 patients aged 3 to 76 years (average 29.4 years) underwent laparoscopic splenectomies; 295 total splenectomies and 25 partial/subtotal splenectomies. The indications for minimally invasive splenectomy are presented in table 1. The evolution of minimally invasive splenectomy is shown in Figure 1. Table 1 - Indications for minimally invasive splenectomy Laparoscopic Robotic Splenectomy splenectomy Total splenectomy Idiopathic thrombocytopenic purpura Splenomegaly, hypersplenism, liver cirrhosis Splenic tumors or malignant hemopathies Autoimmune hemolytic anemia Other hematologic disorders Partial/subtotal splenectomy Hereditary microspherocytosis Splenic hydatid cysts Splenic non-parasitic cyst Thalassemia Autoimmune hemolytic anemia 195 19 41 13 27 20 3 1 1 14 11 10 9 11 4 1 - Discussions The goal in developing a minimally invasive approach is to provide a safe and feasible alternative that result in reductions in patient discomfort, in utilization of inpatient services, in patient disability, and in cost. Since 1991, several centers have reported their early experience with the laparoscopic approach to splenectomy (7,8,9). One of the most troublesome step in the laparoscopic removal of the spleen is the control of splenic hilum vessel. Pancreatic injury, pancreatic fistula, arterovenous fistula formation, and portal vein that may be related to the technique used to control the splenic artery and vein during the minimal access surgery of the spleen. A proper splenic hilum hemo- Figure 1 - Evolution of minimally invasive splenectomy, the impact of technological progress static control is thereby essential to reduce the incidence of these complications (10). For many years hilar vessels were individually identified and secured by the use of clips or ligatures (11). With the technological progress other technical approaches have been used for transection of the splenic pedicle. The use of staplers to seal splenic vessels seems to be feasible and may solve many hemostatic problems. However, there are some concerns about possible complications such as bleeding, pancreatic injury, arteriovenous fistula formation, and splenic or portal vein thrombosis related to the stapler usage.(12) It is essential that stapler is used with a proper technique. Before applying the device we dissected completely the spleen from the spleno-colic, gastrosplenic, and spleno-diaphragmatic ligaments. We used the endoscopic staplers (Multifire Endo GIA) to transected the splenic artery and vein at the splenic hilum in some cases of difficult minimally invasive splenectomy and especially in the management of hypersplenism in cirrhotic patients. Harmonic scalpel was a significant advance in the practice of laparoscopic splenectomy. The blades of the working instrument oscillate at 55,000 cycles per second generating local heat in between blades. This induces coagulation of proteins (hemostasis) and helps in cutting of tissues and vessels being dissected. Lateral thermal spread is limited to less than 2 mm, allowing the use of the instrument in difficult spaces like the space between the gastric fundus and the spleen. One should be careful however in using this instrument to seal vessels over 4 mm. The harmonic shears has certainly reduced operative time and has lessened blood loss during surgery(13). In 1998, the harmonic scalpel (Ethicon Endosurgery, Cincinnati, OH) was introduced in our department. In all patients who had minimally invasive splenectomy between 1998 and 2003 harmonic scalpel was used to freeing the lower pole of the spleen from its attachments to the colon, to dissect the lateral attachments and to divide the short gastric vessels. Less intraoperative bleeding, shortened operative time and low conversion and morbidity rates were achieved. As a result the numbers of minimally invasive splenectomy approach were increasing as shown in Figure 1. The Ligasure Vessel Sealing System (Valleylab, Boulder, Co, USA), is a new surgical device, an energybased method which works by applying a precise amount of pressure and bipolar energy to the tissue, which permits vessel seal to be achieved by changing the nature of the vessel walls (collagen and elastin within the vessel walls fuse and reform into a single structure obliterating the lumen) and reducing the risk of hemorrhage with easy access to splenic hilum. It creates seals that are stronger than other energybased ligation methods, which are comparable in strength to mechanical ligation techniques.(14) After the introduction in our department, in 2003, The LigaSure vessel-sealing system was used in minimally invasive splenectomy as an alternative to suture ligation, hemoclips, staplers, and ultrasonic coagulation for dealing with vessels and soft tissue and practically replaced the Harmonic Scalpel. According to Glasgow RE et al. Ligasure Vessel Sealing System offers some advantages: a) It prevents electric hazards. (b) It ensures minimal sticking, charring, and thermal spread (less than 2 mm). (c) It reduces frequent instrument interchange because it both grasps and coagulates, thus saving time and avoiding accidental capsular lesions, which causes troublesome oozing. (d) In overweight patients with fatty tissues, it makes it possible to seal lower polar vessels without perfect dissection or isolation, which can cause unnecessary bleeding. (e). It permits easy dissection of the spleen, reducing the risk of damage to the pancreatic tail (one can seal the vascular pedicle at the hilum, staying as far as possible from the pancreas). Last but not least, it is easy to use(1). The advantages of Ligasure Vessel Sealing System are obvious mainly in difficult splenectomies as those in portal hypertension. The crucial point of the devascularization in portal hypertension is prevention of brisk bleeding from the dilated vessels in the ligaments and attachments surrounding the spleen, stomach, and esophagus. We find that the LigaSure is safe for the sealing and division of all these ligaments and vessels, including short gastric vessels and secondary branches of splenic pedicle, as long as the diameter is 7 mm. A limit of Ligasure Vessel Sealing System is the possibility to seal blood vessels and tissue even without perfect dissection, isolation, or direct exposure leading to a thermal spread in the surrounding tissues. It presents the possibility to operate more safely and more easily in tight or deep spaces and makes it easier to perform a ligature with difficult vascular pedicles or difficulty in creating a space between 2 vessels, such as lower polar vessels and short gastric vessels, especially in overweight patients with fatty tissues.(15) The Ligasure Vessel Sealing System (Valleylab, Boulder, Co, USA) was introduced in our department in 2003. In all patients who had minimally invazive splenectomy after 2003 Ligasure was used for the dissection of the spleen sealing short gastric vessels and the hilar vessels close to the splenic capsule. This technique provided provide less blood loss, reduces operating time, increasing the number of splenectomy by minimally invasive aprroach (Figure 1). One of the most common technical challenges of minimally invasive splenectomy is the retrieval of the specimen. The upper limit of spleen size remains debatable. The Endocatch bag is a widely used instrument for splenic retrieval, but it has size limitations and it is fragile(16) Removal of the spleen by morcellation has been criticized for 2 main reasons. The first concern is hat disruption of the bag could lead to splenosis. If morcellation is performed with care, avoiding application of undue force and pressure onthe specimen, disruption should not occur. The second concern is the lack of an intact specimen for pathologic review. This is certainly legitimate when splenectomy is performed for a neoplastic condition (i.e., Hodgkin disease), in which case the spleen should be removed either with the open technique or by enlarging one of the laparoscopic incisions. However, most splenectomies are performed for conditions the diagnosis of which is based on preoperative hematologic studies and tissue confirmation is not necessary, such as ITP and spherocytosis.(17) Robotic surgery was developed in response to the limitations and drawbacks of laparoscopic surgery. Since 1997, when the first robotic procedure was performed, various papers pointed the advantages of robotic-assisted laparoscopic surgery- this technique is now a reality and it will probably become the surgery of the future.(18) The introduction of the robotic surgical systems has overcome some technical limitations of minimally invasive surgery by bringing a stabile camera platform, three dimensional imaging, significant decrease limitation in the movement of instruments), tremor filtration and comfortable position for surgeon.(19) (20) The DaVinci system allows an accurate dissection around the splenic hilum and preservation of the splenic remnant vessels in partial splenectomy (21). Robotic splenectomy will probably not replace the laparoscopic splenectomy for the most common indications like ITP, hemolytic anemia. It may be a very useful surgical tool in difficult splenectomy: partial splenectomy, splenectomy in liver cirrhosis, splenic tumors or malignant hemopathies. In these cases the robotic approach may shorten the operative time, decrease the blood loss and the risk of remorrhagic complications during surgery and even make possible a minimally invasive splenectomy very difficult to be performed by classical laparoscopy.(6) In 2008, the Da Vinci Surgical System was introduced in our department and the first robotic splenectomy was performed on February 25th. Since than all difficult splenectomies (partial splenectomy, splenectomy in liver cirrhosis, splenic tumors or malignant hemopathies) were performed by robotic approach (Figure 1). Conclusions Many studies have demonstrated the advantages of the minimally invasive approach over open splenectomy including shorter hospital stay, decreased blood loss, faster recovery, better qualityof-life outcomes and should become the surgeon's procedure of choice. Success with normal-sized and mildly enlarged spleens has led to increasing use of laparoscopic splenectomy for patients with splenomegaly and malignancy. The advances in minimally invasive surgery have been possible as a result of technological progress and increasing skills of the operators. Harmonic scalpel, endoscopic staplers, Endocatch bag, Ligasure Vessel Sealing System and the Da Vinci Surgical System have increased the number of minimally invasive splenectomy performed each year and extended the indication of minimally invasive approach to difficult splenectomies (partial splenectomy, splenectomy in liver cirrhosis, splenic tumors or malignant hemopathies). However, laparoscopic splenectomy does not depend only on technological advances alone. This is and always will be a fine balance between surgical experience, clinical judgment and available technology. Reference List 1. Glasgow R. E., Yee L. F.,Mulvihill S. J. Laparoscopic splenectomy. The emerging standard. Surg Endosc, 1997, 11(2):108-112. 2. Glasgow R. E.,Mulvihill S. J. Laparoscopic splenectomy. World J Surg, 1999, 23(4):384-388. 3. Vasilescu C., Tomulescu V., Ciurea S. et al. [Laparoscopic splenectomy--lessons learned from a series of 40 cases. The advantages of the postero-lateral approach]. Chirurgia (Bucur), 2001, 96(2):231-236. 4. Vasilescu C., Stanciulea O., Colita A. et al. [Laparoscopic subtotal splenectomy in the treatment of hereditary spherocytosis]. Chirurgia (Bucur ), 2003, 98(6):571-576. 5. Vasilescu C., Stanciulea O., Tudor S. et al. Laparoscopic subtotal splenectomy in hereditary spherocytosis : to preserve the upper or the lower pole of the spleen? Surg Endosc, 2006, 20(5):748-752. 6. Vasilescu C. [Robotic splenectomy--a personal view]. Chirurgia (Bucur ), 2010, 105(1):83-87. 7. Delaitre B.,Maignien B. [Splenectomy by the laparoscopic approach. Report of a case]. Presse Med, 1991, 20(44):22638. Lefor A. T., Melvin W. S., Bailey R. W. et al. Laparoscopic splenectomy in the management of immune thrombocytopenia purpura. Surgery, 1993, 114(3):613-618. 9. Phillips E. H., Carroll B. J.,Fallas M. J. Laparoscopic splenectomy. Surg Endosc, 1994, 8(8):931-933. 10. Vecchio R., Marchese S., Swehli E. et al. Splenic Hilum Management During Laparoscopic Splenectomy. J Laparoendosc Adv Surg Tech A, 2011, 11. Palanivelu C., Jani K., Malladi V. et al. Early ligation of the splenic artery in the leaning spleen approach to laparoscopic 12. splenectomy. J Laparoendosc Adv Surg Tech A, 2006, 16(4):339-344. Vargun R., Gollu G., Fitoz S. et al. En-bloc stapling of the splenic hilum in laparoscopic splenectomy. Minim Invasive Ther Allied Technol, 2007, 16(6):360-362. Dalvi A. N., Thapar P. M., Deshpande A. A. et al. Laparoscopic splenectomy using conventional instruments. J Minim Access Surg, 2005, 1(2):63-69. Kennedy J. S., Stranahan P. L., Taylor K. D. et al. High-burststrength, feedback-controlled bipolar vessel sealing. Surg Endosc, 1998, 12(6):876-878. Yao H. S., Wang W. J., Wang Q. et al. Randomized clinical trial of vessel sealing system (LigaSure) in esophagogastric devascularization and splenectomy in patients with portal hypertension. Am J Surg, 2011, 202(1):82-90. Zacharoulis D., O'Boyle C., Royston C. M. et al. Splenic retrieval after laparoscopic splenectomy: a new bag. J Laparoendosc Adv Surg Tech A, 2006, 16(2):128-132. Arzouman D. A., Caccavale R. J., Sisler G. E. et al. Endobag. Ann Thorac Surg, 1993, 55(5):1266-1267. Maeso S., Reza M., Mayol J. A. et al. Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis. Ann Surg, 2010, 252(2):254-262. Vasilescu C.,Popescu I. [Robotic surgery--possibilities and perspectives]. Chirurgia (Bucur ), 2008, 103(1):9-11. Vasilescu C., Tudor S., Popa M. et al. Robotic partial splenectomy for hydatid cyst of the spleen. Langenbecks Arch Surg, 2010, 395(8):1169-1174. Tiron A.,Vasilescu C. [Role of the spleen in immunity. Immunologic consequences of splenectomy]. Chirurgia (Bucur), 2008, 103(3):255-263. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Annals of Fundeni Hospital de Gruyter

The impact of technological progress on minimally invasive splenectomy lessons learned after 15 years

Vasilescu, C.
Annals of Fundeni Hospital , Volume 16 – Dec 1, 2011
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Abstract

Introduction: The laparoscopic approach to splenectomy is at present the gold standard for the treatment of a lot of hematologic disorders in adult and pediatric patients. The dissemination of laparoscopic splenectomy was slower than those of other advanced minimally invasive procedures. We present our experience with the minimally invasive splenectomy pointing out the impact of technological progress on the success of this procedure. Material and Method: In order to assess the impact of technological progress we performed a retrospective analysis of 380 patients who underwent minimally invasive splenectomy between 1996 and September 2010 in our department. Technical advances utilized during this period included the harmonic scalpel, endoscopic staplers, Endocatch bag, Ligasure Vessel Sealing System and the Da Vinci Surgical System. Results: 60 patients aged 6 to 76 years (average 32.6 years) underwent robotic splenectomy; 44 robotic total splenectomies and 16 robotic partial/subtotal splenectomy. 320 patients aged 3 to 76 years (average 29.4 years) underwent laparoscopic splenectomies; 295 total splenectomies and 25 partial/subtotal splenectomies. Conclusion: The advances in minimally invasive surgery have been possible as a result of technological progress and increasing skills of the operators. However, laparoscopic splenectomy does not depend only on technological advances alone. This is and always will be a fine balance between surgical experience, clinical judgment and available technology. Key words: laparoscopic splenectomy; robotic splenectomy; subtotal splenectomy; partial splenectomy; robotic surgery Introduction The laparoscopic approach to splenectomy is at present the gold standard for the treatment of a lot of hematologic disorders in adult and pediatric patients. It is actually a safe and effective technique, resulting in less postoperative pain, a shorter hospital stay, and faster functional recovery than open splenectomy, and perioperative morbidity of the laparoscopic approach is significantly lower.(1) The dissemination of laparoscopic splenectomy was slower than those of other advanced minimally invasive procedures. The reasons are: the exposure of the spleen in the left upper quadrant can be difficult, especially in the obese patients, the control of the splenic blood supply demands advanced technical skills and equipment; the proximity of the tail of the pancreas to the splenic hilum presents the potential for injury, leading to pancreatitis or fistula. Splenomegaly, hypervascularity from portal congestion, thrombocytopenia commonly seen in patients undergoing splenectomy for hematologic disease Address for correspondence: Catalin Vasilescu, Associate Professor of Surgery, MD, PhD, Dan Setlacec Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Fundeni Street no 258, 022328, Bucharest, Romania, e-mail: catvasilescu@gmail.com and splenic tumors add to the risk of morbidity.(2) We present our experience with the minimally invasive splenectomy pointing out the impact of technological progress on the success of this procedure. The milestones of minimally invasive approach of splenectomy in our institution are: first laparoscopic splenectomy was performed in 1996 and published in 2001(3); first laparoscopic subtotal splenectomy was performed in 2002 published in 2003(4) and 2006(5); first robotic splenectomy was performed in 2008 and published in 2010(6). Materials and Methods In order to assess the impact of technological progress we performed a retrospective analysis of 380 patients who underwent minimally invasive splenectomy between 1996 and September 2010 in our department. Results 60 patients aged 6 to 76 years (average 32.6 years) underwent robotic splenectomy; 44 robotic total splenectomies and 16 robotic partial/subtotal splenectomy. 320 patients aged 3 to 76 years (average 29.4 years) underwent laparoscopic splenectomies; 295 total splenectomies and 25 partial/subtotal splenectomies. The indications for minimally invasive splenectomy are presented in table 1. The evolution of minimally invasive splenectomy is shown in Figure 1. Table 1 - Indications for minimally invasive splenectomy Laparoscopic Robotic Splenectomy splenectomy Total splenectomy Idiopathic thrombocytopenic purpura Splenomegaly, hypersplenism, liver cirrhosis Splenic tumors or malignant hemopathies Autoimmune hemolytic anemia Other hematologic disorders Partial/subtotal splenectomy Hereditary microspherocytosis Splenic hydatid cysts Splenic non-parasitic cyst Thalassemia Autoimmune hemolytic anemia 195 19 41 13 27 20 3 1 1 14 11 10 9 11 4 1 - Discussions The goal in developing a minimally invasive approach is to provide a safe and feasible alternative that result in reductions in patient discomfort, in utilization of inpatient services, in patient disability, and in cost. Since 1991, several centers have reported their early experience with the laparoscopic approach to splenectomy (7,8,9). One of the most troublesome step in the laparoscopic removal of the spleen is the control of splenic hilum vessel. Pancreatic injury, pancreatic fistula, arterovenous fistula formation, and portal vein that may be related to the technique used to control the splenic artery and vein during the minimal access surgery of the spleen. A proper splenic hilum hemo- Figure 1 - Evolution of minimally invasive splenectomy, the impact of technological progress static control is thereby essential to reduce the incidence of these complications (10). For many years hilar vessels were individually identified and secured by the use of clips or ligatures (11). With the technological progress other technical approaches have been used for transection of the splenic pedicle. The use of staplers to seal splenic vessels seems to be feasible and may solve many hemostatic problems. However, there are some concerns about possible complications such as bleeding, pancreatic injury, arteriovenous fistula formation, and splenic or portal vein thrombosis related to the stapler usage.(12) It is essential that stapler is used with a proper technique. Before applying the device we dissected completely the spleen from the spleno-colic, gastrosplenic, and spleno-diaphragmatic ligaments. We used the endoscopic staplers (Multifire Endo GIA) to transected the splenic artery and vein at the splenic hilum in some cases of difficult minimally invasive splenectomy and especially in the management of hypersplenism in cirrhotic patients. Harmonic scalpel was a significant advance in the practice of laparoscopic splenectomy. The blades of the working instrument oscillate at 55,000 cycles per second generating local heat in between blades. This induces coagulation of proteins (hemostasis) and helps in cutting of tissues and vessels being dissected. Lateral thermal spread is limited to less than 2 mm, allowing the use of the instrument in difficult spaces like the space between the gastric fundus and the spleen. One should be careful however in using this instrument to seal vessels over 4 mm. The harmonic shears has certainly reduced operative time and has lessened blood loss during surgery(13). In 1998, the harmonic scalpel (Ethicon Endosurgery, Cincinnati, OH) was introduced in our department. In all patients who had minimally invasive splenectomy between 1998 and 2003 harmonic scalpel was used to freeing the lower pole of the spleen from its attachments to the colon, to dissect the lateral attachments and to divide the short gastric vessels. Less intraoperative bleeding, shortened operative time and low conversion and morbidity rates were achieved. As a result the numbers of minimally invasive splenectomy approach were increasing as shown in Figure 1. The Ligasure Vessel Sealing System (Valleylab, Boulder, Co, USA), is a new surgical device, an energybased method which works by applying a precise amount of pressure and bipolar energy to the tissue, which permits vessel seal to be achieved by changing the nature of the vessel walls (collagen and elastin within the vessel walls fuse and reform into a single structure obliterating the lumen) and reducing the risk of hemorrhage with easy access to splenic hilum. It creates seals that are stronger than other energybased ligation methods, which are comparable in strength to mechanical ligation techniques.(14) After the introduction in our department, in 2003, The LigaSure vessel-sealing system was used in minimally invasive splenectomy as an alternative to suture ligation, hemoclips, staplers, and ultrasonic coagulation for dealing with vessels and soft tissue and practically replaced the Harmonic Scalpel. According to Glasgow RE et al. Ligasure Vessel Sealing System offers some advantages: a) It prevents electric hazards. (b) It ensures minimal sticking, charring, and thermal spread (less than 2 mm). (c) It reduces frequent instrument interchange because it both grasps and coagulates, thus saving time and avoiding accidental capsular lesions, which causes troublesome oozing. (d) In overweight patients with fatty tissues, it makes it possible to seal lower polar vessels without perfect dissection or isolation, which can cause unnecessary bleeding. (e). It permits easy dissection of the spleen, reducing the risk of damage to the pancreatic tail (one can seal the vascular pedicle at the hilum, staying as far as possible from the pancreas). Last but not least, it is easy to use(1). The advantages of Ligasure Vessel Sealing System are obvious mainly in difficult splenectomies as those in portal hypertension. The crucial point of the devascularization in portal hypertension is prevention of brisk bleeding from the dilated vessels in the ligaments and attachments surrounding the spleen, stomach, and esophagus. We find that the LigaSure is safe for the sealing and division of all these ligaments and vessels, including short gastric vessels and secondary branches of splenic pedicle, as long as the diameter is 7 mm. A limit of Ligasure Vessel Sealing System is the possibility to seal blood vessels and tissue even without perfect dissection, isolation, or direct exposure leading to a thermal spread in the surrounding tissues. It presents the possibility to operate more safely and more easily in tight or deep spaces and makes it easier to perform a ligature with difficult vascular pedicles or difficulty in creating a space between 2 vessels, such as lower polar vessels and short gastric vessels, especially in overweight patients with fatty tissues.(15) The Ligasure Vessel Sealing System (Valleylab, Boulder, Co, USA) was introduced in our department in 2003. In all patients who had minimally invazive splenectomy after 2003 Ligasure was used for the dissection of the spleen sealing short gastric vessels and the hilar vessels close to the splenic capsule. This technique provided provide less blood loss, reduces operating time, increasing the number of splenectomy by minimally invasive aprroach (Figure 1). One of the most common technical challenges of minimally invasive splenectomy is the retrieval of the specimen. The upper limit of spleen size remains debatable. The Endocatch bag is a widely used instrument for splenic retrieval, but it has size limitations and it is fragile(16) Removal of the spleen by morcellation has been criticized for 2 main reasons. The first concern is hat disruption of the bag could lead to splenosis. If morcellation is performed with care, avoiding application of undue force and pressure onthe specimen, disruption should not occur. The second concern is the lack of an intact specimen for pathologic review. This is certainly legitimate when splenectomy is performed for a neoplastic condition (i.e., Hodgkin disease), in which case the spleen should be removed either with the open technique or by enlarging one of the laparoscopic incisions. However, most splenectomies are performed for conditions the diagnosis of which is based on preoperative hematologic studies and tissue confirmation is not necessary, such as ITP and spherocytosis.(17) Robotic surgery was developed in response to the limitations and drawbacks of laparoscopic surgery. Since 1997, when the first robotic procedure was performed, various papers pointed the advantages of robotic-assisted laparoscopic surgery- this technique is now a reality and it will probably become the surgery of the future.(18) The introduction of the robotic surgical systems has overcome some technical limitations of minimally invasive surgery by bringing a stabile camera platform, three dimensional imaging, significant decrease limitation in the movement of instruments), tremor filtration and comfortable position for surgeon.(19) (20) The DaVinci system allows an accurate dissection around the splenic hilum and preservation of the splenic remnant vessels in partial splenectomy (21). Robotic splenectomy will probably not replace the laparoscopic splenectomy for the most common indications like ITP, hemolytic anemia. It may be a very useful surgical tool in difficult splenectomy: partial splenectomy, splenectomy in liver cirrhosis, splenic tumors or malignant hemopathies. In these cases the robotic approach may shorten the operative time, decrease the blood loss and the risk of remorrhagic complications during surgery and even make possible a minimally invasive splenectomy very difficult to be performed by classical laparoscopy.(6) In 2008, the Da Vinci Surgical System was introduced in our department and the first robotic splenectomy was performed on February 25th. Since than all difficult splenectomies (partial splenectomy, splenectomy in liver cirrhosis, splenic tumors or malignant hemopathies) were performed by robotic approach (Figure 1). Conclusions Many studies have demonstrated the advantages of the minimally invasive approach over open splenectomy including shorter hospital stay, decreased blood loss, faster recovery, better qualityof-life outcomes and should become the surgeon's procedure of choice. Success with normal-sized and mildly enlarged spleens has led to increasing use of laparoscopic splenectomy for patients with splenomegaly and malignancy. The advances in minimally invasive surgery have been possible as a result of technological progress and increasing skills of the operators. Harmonic scalpel, endoscopic staplers, Endocatch bag, Ligasure Vessel Sealing System and the Da Vinci Surgical System have increased the number of minimally invasive splenectomy performed each year and extended the indication of minimally invasive approach to difficult splenectomies (partial splenectomy, splenectomy in liver cirrhosis, splenic tumors or malignant hemopathies). However, laparoscopic splenectomy does not depend only on technological advances alone. This is and always will be a fine balance between surgical experience, clinical judgment and available technology. Reference List 1. Glasgow R. E., Yee L. F.,Mulvihill S. J. Laparoscopic splenectomy. The emerging standard. Surg Endosc, 1997, 11(2):108-112. 2. Glasgow R. E.,Mulvihill S. J. Laparoscopic splenectomy. World J Surg, 1999, 23(4):384-388. 3. Vasilescu C., Tomulescu V., Ciurea S. et al. [Laparoscopic splenectomy--lessons learned from a series of 40 cases. The advantages of the postero-lateral approach]. Chirurgia (Bucur), 2001, 96(2):231-236. 4. Vasilescu C., Stanciulea O., Colita A. et al. [Laparoscopic subtotal splenectomy in the treatment of hereditary spherocytosis]. Chirurgia (Bucur ), 2003, 98(6):571-576. 5. Vasilescu C., Stanciulea O., Tudor S. et al. Laparoscopic subtotal splenectomy in hereditary spherocytosis : to preserve the upper or the lower pole of the spleen? Surg Endosc, 2006, 20(5):748-752. 6. Vasilescu C. [Robotic splenectomy--a personal view]. Chirurgia (Bucur ), 2010, 105(1):83-87. 7. Delaitre B.,Maignien B. [Splenectomy by the laparoscopic approach. Report of a case]. Presse Med, 1991, 20(44):22638. Lefor A. T., Melvin W. S., Bailey R. W. et al. Laparoscopic splenectomy in the management of immune thrombocytopenia purpura. Surgery, 1993, 114(3):613-618. 9. Phillips E. H., Carroll B. J.,Fallas M. J. Laparoscopic splenectomy. Surg Endosc, 1994, 8(8):931-933. 10. Vecchio R., Marchese S., Swehli E. et al. Splenic Hilum Management During Laparoscopic Splenectomy. J Laparoendosc Adv Surg Tech A, 2011, 11. Palanivelu C., Jani K., Malladi V. et al. Early ligation of the splenic artery in the leaning spleen approach to laparoscopic 12. splenectomy. J Laparoendosc Adv Surg Tech A, 2006, 16(4):339-344. Vargun R., Gollu G., Fitoz S. et al. En-bloc stapling of the splenic hilum in laparoscopic splenectomy. Minim Invasive Ther Allied Technol, 2007, 16(6):360-362. Dalvi A. N., Thapar P. M., Deshpande A. A. et al. Laparoscopic splenectomy using conventional instruments. J Minim Access Surg, 2005, 1(2):63-69. Kennedy J. S., Stranahan P. L., Taylor K. D. et al. High-burststrength, feedback-controlled bipolar vessel sealing. Surg Endosc, 1998, 12(6):876-878. Yao H. S., Wang W. J., Wang Q. et al. Randomized clinical trial of vessel sealing system (LigaSure) in esophagogastric devascularization and splenectomy in patients with portal hypertension. Am J Surg, 2011, 202(1):82-90. Zacharoulis D., O'Boyle C., Royston C. M. et al. Splenic retrieval after laparoscopic splenectomy: a new bag. J Laparoendosc Adv Surg Tech A, 2006, 16(2):128-132. Arzouman D. A., Caccavale R. J., Sisler G. E. et al. Endobag. Ann Thorac Surg, 1993, 55(5):1266-1267. Maeso S., Reza M., Mayol J. A. et al. 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Journal

Annals of Fundeni Hospital – de Gruyter

Published: Dec 1, 2011

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