Page 8 - Journal of WALS

WJOLS

Laparoscopic Splenectomy using a Single Incision Access

through the umbilicus and four through the left quadrant along There is no randomized comparative study reported to date
the anterior axillary line at the level of the umbilicus. Time of comparing conventional 4 to 5 port laparoscopic splenectomy
hospital stay was 2 to 5 days (average 3.5 days), weight of the (LS) to single incision laparoscopic (SILS) splenectomy. In this
spleen was reported only in one study of eight patients and review, 26 patients that were reported, they were mainly case
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ranged from 340 to 590 gm (average 485 gm). One intraoperative reports and small series of eight and 20 patients. 7,8 The left
complication in which iatrogenic gastric perforation was lateral position was used by all surgeons, although in three
9
reported but was managed laparoscopically. All reported good cases, a change to supine position had to be adopted during
7,9
cosmetic outcome and patient/parents satisfaction. conversion. The umbilicus was used for access by eight
surgeons while two surgeons preferred left quadrant lateral to
DISCUSSION
the umbilicus as this provided better visualization of the upper
Laparoscopic splenectomy (LS) is now considered a gold dorsal area especially in big spleens. 9,18 I did not come across
standard in splenectomy due to its superior benefits to the an agreed standard mode of reporting specifically laparoscopic
patient, namely small incision, minimal postoperative pain, short splenectomy complication both intraoperative and post-
hospital stay, quick return to work, less infection rates and operative. Using classification that was recommended for
superior cosmetic outcome when compared to open surgical operations by Clavien (Clavien Classification of Surgical
splenectomy. 2,5,6 The search for better cosmetic outcome has Complication, 1992) and modified 2004, 10,11 most of the reported
seen single incision laparoscopic surgery (SILS) gaining ground complications in this review fall in grade I and only one patient
in many areas of surgery, including splenectomy. In SILS was grade IIA as he required postoperative transfusion 10,11
splenectomy, the patient is placed in supine semi left lateral (Tables 2 and 3). The conversion rates depend on among other
position and the surgeon stands on the right side of the patient. factors, the experience and level of confidence of the surgeon.
Access port generally recommended at 5 cm lateral at the level In this review, the conversion rate was 11.5 (3 patients). In a
of the umbilicus, however, this should take into consideration comparison study between open (OS) and conventional
the size of the patient and the spleen, and should follow the laparoscopic splenectomy (LS), in which 25 patients had LS
base ball diamond concept for maximum task performance. 1,4 and 27 had OS, Maurus et al found almost a similar conversion

Table 2: Clavien classification of surgical complications
Grades Complication
I Alteration from the ideal postoperative course, non-life-threatening,
no long lasting disability. Do not prolong hospital stay
II Potentially life-threatening but without residual disability or requiring
hospitalization more than twice the median stay for the procedure
a. Only medical and noninvasive intervention
b. Require invasive intervention
III Life-threatening with residual disability, e.g. organ resection or
persistence of life-threatening condition
IV Death of a patient

Table 3: Modified Clavien classification of surgical complications
Grades Description of complication

I Any deviation from the normal postoperative course without the need
for pharmacological treatment or surgical, endoscopic and
radiological interventions
Allowed therapeutic regimens are: Drugs as antiemetics, analgesics,
antipyretics electrolytes and physiotherapy. Includes wound infection
open at bed side
II Requiring pharmacological treatment with drugs other than those
allowed for grade I complications. Blood transfusion and total
parenteral nutrition (TPN) included
III Requiring surgical, endoscopic or radiological intervention
a. Intervention not under general anesthesia
b. Intervention under general anesthesia
IV Life-threatening (including CNS), requiring IC/ICU management
a. Single organ dysfunction (including dialysis)
b. Multiorgan dysfunction
V Death of a patient
Suffix “d” If patient suffers from a complication at the time of discharge suffix
“d” (for disability) is added to the respective grade of complication

World Journal of Laparoscopic Surgery, May-August 2011;4(2):77-80 79