REVIEW ARTICLE ANZJSurg.com
Hand-assisted versus conventional laparoscopic splenectomy: a systematic review and meta-analysis Daohai Qian,* Zhigang He,* Jie Hua, Jian Gong, Shengping Lin and Zhenshun Song Department of General Surgery, Shanghai Tenth People’s Hospital, Tongji University of Medicine, Shanghai, China
Key words hand-assisted, laparoscopic, meta-analysis, splenectomy, splenomegaly. Correspondence Dr Zhenshun Song, Department of General Surgery, Shanghai Tenth People’s Hospital, Tongji University of Medicine, 301 Yanchang Middle Road, Shanghai 200072, China. Email: [email protected] D. Qian MD, PhD; Z. He MD; J. Hua MD; J. Gong MD; S. Lin MD; Z. Song MD, PhD. *These two authors contributed equally to this work. Accepted for publication 3 March 2014. doi: 10.1111/ans.12597
Abstract Background: Hand-assisted laparoscopic splenectomy (HALS) has been widely applied for the resection of larger spleens. We conducted a systematic review and meta-analysis to evaluate the safety and feasibility of HALS compared with conventional laparoscopic splenectomy (CLS). Methods: A comprehensive literature search in MEDLINE, EMBASE and Cochrane Library databases was performed to compare clinical outcomes of CLS and HALS. Data were extracted by two independent reviewers. Pooled odds ratios and weighted mean differences with 95% confidence intervals were calculated by meta-analytic software. Results: Nine non-randomized controlled studies for a total of 463 patients were selected to satisfy the inclusion criteria (HALS versus CLS: 170 versus 293, respectively). The groups were similar in operative time, estimated operative blood loss, length of hospital stay, mortality and intraoperative and post-operative complications. There was a significantly reduced conversion rate in the HALS versus CLS group (odds ratio: 2.98; 95% confidence interval 1.28 to 6.93; P = 0.01). Splenic weights in the HALS group were higher than in the CLS group (weighted mean differences: −0.93; 95% confidence interval −1.74 to −0.11; P = 0.03). Conclusion: HALS may be preferable to CLS for the treatment of patients with enlarged spleens. The result needs to be certified by further random controlled trials.
Introduction Laparoscopic surgery has rapidly developed in the past 20 years.1,2 The concept of minimally invasive treatment has been widely accepted by most surgeons and patients. As techniques and instruments advance, some contraindications, which had previously been considered insurmountable barriers to using the laparoscopic approach in the past, have been continually broken. Splenomegaly is a good example.3–5 Since it was initially described by Delaitre et al. in 1991,6 laparoscopic splenectomy (LS) had been largely applied for benign and malignant diseases7 and became the gold standard for the treatment of normal size or slightly enlarged spleens.8,9 The superiority of LS was not only reflected in shorter hospital stays, less post-operative pain and faster return to normal activity, but also in smaller operative wounds compared with open splenectomy (OS). However, the benefits of laparoscopic splenectomy were not offered to all patients who required splenectomy. Splenomegaly was often considered a therapeutic challenge because of dense adhesions and increased tissue vascularity, making retrieval difficult, with the necessity of making a longer incision to retrieve the specimen. © 2014 Royal Australasian College of Surgeons
Therefore, the presence of a big spleen inevitably impaired the application of minimally invasive techniques. Fortunately, conventional laparoscopic splenectomy (CLS) was replaced by handassisted laparoscopic splenectomy (HALS), which has a shorter learning curve and requires 7–8 cm incision for the hand port. HALS was the bridge between CLS and OS, with the ability to control haemorrhage as in open surgery, while maintaining the advantage of minimal trauma. In addition, some researchers reported that HALS was safer and more effective for patients with larger spleens compared with CLS.10–13 Their clinical outcomes revealed that patients in the HALS group had shorter operative times, lower conversion rates and less post-operative morbidity. Given the lack of studies comparing HALS and CLS, we conducted this meta-analysis to evaluate the safety and feasibility of HALS compared with CLS techniques.
Methods Search criteria The analysis of previous studies was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and ANZ J Surg 84 (2014) 915–920
916
eta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines. A comprehensive search was performed of all trials comparing clinical outcomes between HALS and CLS before September 2013, using the key words hand assisted, hand port, laparoscopic and splenectomy in MEDLINE, EMBASE and Cochrane Library electronic databases. Reference lists of all retrieved articles were manually searched for additional studies. The search was restricted to articles in English (Fig. 1).
Inclusion criteria Data were extracted by two independent reviewers (Qian DH and He ZG). All studies had to conform to the following criteria: (i) comparison of HALS and CLS techniques; (ii) report on at least one of the clinical outcome measures mentioned below and provide the standard deviation of the mean for continuous outcomes of interest (or provide enough data to calculate the standard deviation); (iii) clearly report the surgical indications for HALS or CLS; (iv) regarding dual (or multiple) studies by the same institution and/or authors, either the studies of higher quality or the most recent publications were included. Abstracts, letters, editorials, expert opinions, reviews, case reports and studies without control groups were excluded.
Outcomes of interest Clinical outcomes of interest included splenic weight, intraoperative (operative time, operative blood loss, intraoperative complications – primarily bleeding, requirement for blood transfusion and conversion to open) and post-operative outcomes (postoperative complications – bleeding, wound infection and dehiscence, intestinal obstruction and others), length of hospital stay and mortality.
Qian et al.
Statistical analysis This meta-analysis was performed using Review Manager (RevMan) software, version 5.0 (Nordic Cochrane Centre, Copenhagen, Denmark). We analysed dichotomous variables by estimating the odds ratios (OR) and continuous variables using weighted mean difference (WMD), both with a 95% confidence interval (95% CI). The pooled effect was calculated using either the fixed or randomeffects models. Heterogeneity was measured using the Q-test and a difference of heterogeneity existed when I2 > 50%. A P value of less than 0.05 was considered statistically significant. The NewcastleOttawa Scale was used to assess the quality of the studies.
Results Included studies Ten studies3,4,10–17 were identified and assessed for eligibility. Nine studies3,4,11–17 finally matched the selection criteria, for a total of 463 patients (170 HALS versus 293 CLS). Four studies were conducted in United States, one in Japan, one in Spain, one in Saudi Arabia, one in Italy and two in China. The sample size of each study varied from seven to 103 patients. Study characteristics and patient demographics are summarized in Table 1. Groups were matched according to age, gender, follow-up period, histopathologic diagnosis and operative approach. The Newcastle-Ottawa Scale was utilized to assess the quality of all included non-randomized controlled studies (Table 2).
Splenic weight and operative outcomes In seven of nine studies, splenic weights where greater in the HALS compared with CLS group. Similarly, the pooled results demonstrated a significant difference between groups (WMD: −0.93; 95% CI −1.74 to −0.11; P = 0.03), associated with a significant difference of heterogeneity (I2 = 90%; Fig. 2). With regard to conversion to open rates, there was a significant difference between the groups (OR: 2.98; 95% CI: 1.28 to 6.93; P = 0.01; Fig. 2). However, the groups were similar with regard to intraoperative blood loss or the number of patients requiring blood transfusion (WMD: 43.71; 95% CI: −31.60 to 119.03; P = 0.26, and OR: 1.02, 95% CI: 0.48 to 2.17; P = 0.96; Fig. 2) and significant heterogeneity existed (I2 = 60%; Fig. 2). More importantly, there was no significant difference in intraoperative complications between groups (OR: 2.98; 95% CI: 0.88 to 10.15; P = 0.08; Fig. 2).
Post-operative outcomes
Fig. 1. Searching procedures.
Post-operative mobility is one of the most persuasive indications for assessing whether an operative method is safe and efficacious. In this meta-analysis, we integrated all post-operative outcomes and did not find a statistically significant difference in complications between groups (OR: 0.90; 95% CI: 0.37 to 218; P = 0.69; Fig. 3), while there was significant heterogeneity (I2 = 63%). There was also no significant difference between groups with regard to length of hospital stay (WMD: −0.36; 95% CI: −2.26 to 1.55; P = 0.71; Fig. 3), which was associated with a significant difference in heterogeneity (I2 = 86%). There was no statistically significant difference in mortality rate between groups (OR: 10.63; 95% CI: 0.51 to 222.61; P = 0.13; Fig. 3) and the heterogeneity test was not applicable (because of a low mortality rate of 0 and 1.5% in the spleen-preserving distal © 2014 Royal Australasian College of Surgeons
HALS versus CLS in splenectomy
14 NA NA NA NA NA NA NA NA
© 2014 Royal Australasian College of Surgeons
Study
Kercher et al.4 Smith et al.3 Ailawadi et al.16 Targarona et al.15 Wang et al.14 Altaf et al.13 Pietrabissa et al.17 Wang et al.11 Rosen et al.12
CLS, conventional laparoscopic splenectomy; F, female; HALS, hand-assisted laparoscopic splenectomy; M, male; NA, not available; SD, standard deviation.
NA NA 6/16 4/16 19/0 3/20 19/24 12/8 8/6 26/23 NA 8/11 15/21 20/0 64/16 30/12 8/8 17/14 49 3 16 36 20 80 42 16 31 2002 2003 2002 2001 2012 2012 2011 2007 2002 Kercher et al. Smith et al. Ailawadi et al. Targarona et al. Wang et al. Altaf et al. Pietrabissa et al. Wang et al. Rosen et al.
USA USA USA Spain China Saudi Arabia Italy China Ohio
20/29 NA NA 12/24 11/9 45/35 23/19 9/7 9/22
NA NA NA 10/10 12/7 9/14 7/36 8/12 7/7
54.4 NA NA 58 ± 13 48 ± 12 53.2 ± 18.3 46.8 ± 21 38 ± 12 54 ± 15
NA NA NA 58 ± 16 48 ± 11 63.6 ± 14.2 66.5 ± 8.7 43 ± 14 37 ± 13
7 4 20 20 19 23 43 20 14
HALS CLS HALS CLS HALS HALS CLS
Year
Country
Gender (F/M)
CLS
Age (years) (mean ± SD)
Study size
Histopathologic diagnosis (benign/malignant)
Follow-up (months)
Table 2 The Newcastle-Ottawa Scale for assessing the quality of non-randomized controlled studies
Author
Table 1 Study characteristics and patient demographics
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Selection
Comparability
Assessment of outcomes
Total scores
2 2 3 3 3 3 3 3 3
1 1 1 2 2 1 1 2 2
3 3 3 3 3 3 3 3 3
6 6 7 8 8 7 7 8 8
pancreatectomy and distal pancreatectomy with splenectomy groups, respectively).
Heterogeneity Significant heterogeneities were found with regard to splenic weight, estimated operative blood loss, post-operative complications and length of hospital stay. However, with regard to operative times, intraoperative complications, conversion to open surgery and blood transfusion, no significant heterogeneities existed.
Discussion In this meta-analysis, the pooled data revealed that the HALS should be a preferred choice for the treatment of patients with enlarged spleens. In addition, HALS is a good replacement for CLS. Laparoscopic techniques are widely used,18–20 with cholecystectomy as one of the most successful applications.19,21 The development of laparoscopic equipment has promoted the advances of minimally invasive surgery, from which patients derived the most benefit by avoiding a large and visible scar. Although laparoscopic splenectomy has many advantages, including shorter hospital stays, less postoperative pain, improved cosmetics and a faster recovery period to normal activity, there are definite technical challenges, including lack of tactile sensation, impaired hand-eye coordination and the loss of three-dimensional visualization of intra-abdominal structures. However, HALS may help to overcome these obstacles to the conventional laparoscopic approach. Currently, hand-assisted laparoscopic surgery is regularly applied in 150 surgical procedures,22 such as nephrectomy,23,24 pancreatectomy,25 resection of ovarian26 and gastrointestinal cancers,27 hepatectomy28 and splenectomy.29 LS has been developed quickly since its first application. Winslow and Braunt8 conducted a meta-analysis to compare clinical outcomes between CLS and OS and revealed that patients undergoing CLS had a significant reduction in post-operative morbidity, although it was associated with longer operative times compared with OS. HALS, first described by Kusminsky et al.30 in 1995, has become an alternative to CLS when performing splenectomy for splenomegaly. Some studies indicated that HALS facilitated complicated procedures while maintaining the advantages of the minimally invasive approach. Barbaros et al.31 reported that HALS significantly improved technical ease of the procedure and reduced hospital stay compared with OS, when applied to larger spleens. Knauer et al.7 attested that the benefits of HALS where similar to those of CLS. Swanson et al.32 argued that
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Qian et al.
Fig. 2. A meta-analysis of splenic weight and operative outcomes: operative time (min), intraoperative complications, estimated operative blood loss (mL) and conversion rate (CI, confidence interval; IV, inverse variance; kg, kilogram; M-H, Mantel-Haenszel; min, minutes; mL, millilitre; SD, standard deviation).
HALS was safe and effective for the management of spleens greater than 20 cm in size. HALS patients had shorter hospital stays and were preferable to OS for massive splenomegaly. In contrast, Grahn et al.5 insisted that CLS was still a safe approach for the resection of massive and supramassive spleens and all elective LS were performed with the conventional method, regardless of spleen size. Rescorla et al.33 also argued that LS was safe and effective for children with haematological disorders and that CLS resulted in less narcotic administration, shorter length of stay and lower total hospital costs, albeit with longer operative times compared with OS. In this meta-analysis, the result indicated that the hand-assisted laparoscopic technique could be applied in splenectomy without lengthening operative times, post-operative recovery, or increasing operative blood loss and risk for blood transfusion, mortality or
complications. Furthermore, HALS patients had lower conversions to open rates, although operative difficulty remained for larger spleens. Although there are several reports about CLS successfully being applied in massive or super splenomegaly,4,34 patients with normal size or slightly enlarged spleens are more suited for conventional laparoscopy.9,35,36 Some authors suggested that CLS was a better choice for patients with spleen sizes of less than 600 g.5,37 If spleen size was greater than 1000 g, there was a higher conversion to open rate.38,39 Laparoscopic resection of massive or supermassive spleens is always a problem because of the limited space in the abdominal cavity and retrieval of a large organ. Some studies indicated that all patients with super splenomegaly should be converted to OS after CLS method was attempted, and even suggested the use of HALS. Some authors advocated the application of HALS for all spleens © 2014 Royal Australasian College of Surgeons
HALS versus CLS in splenectomy
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Fig. 3. A meta-analysis of post-operative outcomes: transfusion rate, hospital stays (days), post-operative complications and mortality (CI, confidence interval; IV, inverse variance; M-H, Mantel-Haenszel; SD, standard deviation).
with a width exceeding 19 cm and a length over 224,35 or 23 cm.35 As splenic weight or size increases, technical difficulty in using the laparoscopic approach also increases. Terrosu et al.29 defined the limitations for CLS at a splenic weight of 2000 g or a size of greater than or equal to 23 cm. Ailawadi et al.16 found that the conversion rate had reached 44% when performing CLS in patients with spleens weighing more than 550 g. Patel et al.38 reported that patients with spleens weighing more than 1000 g were 14 times more likely to have post-operative complications. The presence of splenomegaly undoubtedly brings technical challenges to CLS; however, HALS is a feasible alternative to CLS that avoids some of its drawbacks. Kawanaka et al.40 applied HALS for patients with splenomegaly (≧1000 mL), perisplenic collateral vessels or a Child-Pugh score of 9 or more. Through this technical standardization of LS, they found that CLS was feasible and safe in the setting of cirrhosis and portal hypertension. More common was to directly perform HALS when facing massive or super splenomegaly. Of course, there are many indications for using HALS, © 2014 Royal Australasian College of Surgeons
related to experience, economic considerations, body habitus and the availability of advanced devices, among others. There were also several limitations to this meta-analysis. First, all data were retrieved from non-randomized controlled studies, so the conclusions should be considered by surgeons carefully. However, it is very difficult to carry out large prospective randomized controlled trials because of severe complications and poor compliance. Second, it was impossible for the patient characteristics to be completely matched. Third, we only compared differences in clinical outcomes between HALS and CLS groups without conducting stratified analysis about the splenic size. Finally, there was lack of the analysis about post-operative pain or late incisional hernias because of the size of incision for hand port.
Conclusion In conclusion, HALS is a safe and effective approach for removing enlarged spleens compared with CLS, although the operative
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difficulty in HALS was higher than CLS. HALS is a good alternative to CLS.
Acknowledgements This project was supported by the National Natural Science Foundation of China (Grant no. 60171009). Zhigang He is a co-first author, with an equal contribution to this study. The authors are solely responsible for the content. All authors have no conflicts of interest to declare. Thanks to all the authors who contributed to the work.
References 1. Zonca P. Development and status of laparoscopic surgery. Perspectives in surgery: monthly. Czechoslovak Surg. Soc. 2013; 92: 75–6. 2. Lee WJ, Chan CP, Wang BY. Recent advances in laparoscopic surgery. Asian J. Endosc. Surg. 2013; 6: 1–8. 3. Smith L, Luna G, Merg AR et al. Laparoscopic splenectomy for treatment of splenomegaly. Am. J. Surg. 2004; 187: 618–20. 4. Kercher KW, Matthews BD, Walsh RM et al. Laparoscopic splenectomy for massive splenomegaly. Am. J. Surg. 2002; 183: 192–6. 5. Grahn SW, Alvarez J III, Kirkwood K. Trends in laparoscopic splenectomy for massive splenomegaly. Arch. Surg. 2006; 141: 755–61. 6. Delaitre B, Maignien B. Splenectomy by the laparoscopic approach. Report of a case. Presse Med. 1991; 20: 2263. 7. Knauer EM, Ailawadi G, Yahanda A et al. 101 laparoscopic splenectomies for the treatment of benign and malignant hematologic disorders. Am. J. Surg. 2003; 186: 500–4. 8. Winslow ER, Brunt LM. Perioperative outcomes of laparoscopic versus open splenectomy: a meta-analysis with an emphasis on complications. Surgery 2003; 134: 647–53. 9. Habermalz B, Sauerland S, Decker G et al. Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg. Endosc. 2008; 22: 821–48. 10. Wang X, Li Y, Peng B. Hand-assisted laparoscopic technique in the setting of complicated splenectomy: a 9-year experience. World J. Surg. 2013; 37: 2046–52. 11. Wang KX, Hu SY, Zhang GY et al. Hand-assisted laparoscopic splenectomy for splenomegaly: a comparative study with conventional laparoscopic splenectomy. Chin. Med. J. 2007; 120: 41–5. 12. Rosen M, Brody F, Walsh RM et al. Hand-assisted laparoscopic splenectomy versus conventional laparoscopic splenectomy in cases of splenomegaly. Arch. Surg. 2002; 137: 1348–52. 13. Altaf AM, Ellsmere J, Jaap Bonjer H et al. Morbidity of hand-assisted laparoscopic splenectomy compared to conventional laparoscopic splenectomy: a 6-year review. Can. J. Surg. 2012; 55: 227–32. 14. Wang X, Li Y, Zhou J et al. Hand-assisted laparoscopic splenectomy is a better choice for patients with supramassive splenomegaly due to liver cirrhosis. J. Laparoendosc. Adv. Surg. Tech. A 2012; 22: 962–7. 15. Targarona EM, Balague C, Cerdán G et al. Hand-assisted laparoscopic splenectomy (HALS) in cases of splenomegaly. Surg. Endosc. 2002; 16: 426–30. 16. Ailawadi G, Yahanda A, Dimick JB et al. Hand-assisted laparoscopic splenectomy in patients with splenomegaly or prior upper abdominal operation. Surgery 2002; 132: 689–94. 17. Pietrabissa A, Morelli L, Peri A et al. Laparoscopic treatment of splenomegaly: a case for hand-assisted laparoscopic surgery. Arch. Surg. 2011; 146: 818–23. 18. Zhang YS, Li HZ, Ji ZG et al. Complications of laparoscopic surgery: a 11-year single institute experience. Beijing J. Peking Univ. Health Sci. 2013; 45: 584–7.
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19. Brasesco OE, Rosin D, Rosenthal RJ. Laparoscopic surgery of the liver and biliary tract. J. Laparoendosc. Adv. Surg. Tech. A 2002; 12: 91–100. 20. Kaneko H, Takagi S, Shiba T. The current state of laparoscopic surgery for abdominal parenchymatous organs. Japan J. Surg. 2002; 103: 746– 51. 21. Litwin DE, Cahan MA. Laparoscopic cholecystectomy. Surg. Clin. North Am. 2008; 88: 1295–313. 22. Maartense S, Bemelman WA, Gerritsen van der Hoop A et al. Handassisted laparoscopic surgery (HALS): a report of 150 procedures. Surg. Endosc. 2004; 18: 397–401. 23. Kercher KW, Joels CS, Matthews BD et al. Hand-assisted surgery improves outcomes for laparoscopic nephrectomy. Am. Surg. 2003; 69: 1061–6. 24. Mendez-Torres FR, Urena R, Slakey D et al. Donor nephrectomy in the era of hand-assisted laparoscopic urologic surgery. J. Endourol. 2004; 18: 359–63. 25. Klingler PJ, Hinder RA, Menke DM et al. Hand-assisted laparoscopic distal pancreatectomy for pancreatic cystadenoma. Surg. Laparosc. Endosc. 1998; 8: 180–4. 26. Krivak TC, Elkas JC, Rose GS et al. The utility of hand-assisted laparoscopy in ovarian cancer. Gynecol. Oncol. 2005; 96: 72–6. 27. Wang ZQ. Application and indication choice of hand-assisted laparoscopic operation in gastrointestinal surgery. Chin. J. Gastrointest. Surg. 2012; 15: 796–8. 28. Salit Y, Bitterman A, Lefel O et al. Hand-assisted laparoscopic surgery for liver tumors. Isr. Med. Assoc. J. 2010; 12: 424–7. 29. Terrosu G, Baccarani U, Bresadola V et al. The impact of splenic weight on laparoscopic splenectomy for splenomegaly. Surg. Endosc. 2002; 16: 103–7. 30. Kusminsky RE, Boland JP, Tiley EH et al. Hand-assisted laparoscopic splenectomy. Surg. Laparosc. Endosc. 1995; 5: 463–7. 31. Barbaros U, Dinççag˘ A, Sümer A et al. Prospective randomized comparison of clinical results between hand-assisted laparoscopic and open splenectomies. Surg. Endosc. 2010; 24: 25–32. 32. Swanson TW, Meneghetti AT, Sampath S et al. Hand-assisted laparoscopic splenectomy versus open splenectomy for massive splenomegaly: 20-year experience at a Canadian centre. Can. J. Surg. 2011; 54: 189–93. 33. Rescorla FJ, Breitfeld PP, West KW et al. A case controlled comparison of open and laparoscopic splenectomy in children. Surgery 1998; 124: 670–5. 34. Koshenkov VP, Nemeth ZH, Carter MS. Laparoscopic splenectomy: outcome and efficacy for massive and supramassive spleens. Am. J. Surg. 2012; 203: 517–22. 35. Walsh RM, Heniford BT, Brody F et al. The ascendance of laparoscopic splenectomy. Am. Surg. 2001; 67: 48–53. 36. Gamme G, Birch DW, Karmali S. Minimally invasive splenectomy: an update and review. Can. J. Surg. 2013; 56: 280–5. 37. Kaban GK, Czerniach DR, Cohen R et al. Hand-assisted laparoscopic splenectomy in the setting of splenomegaly. Surg. Endosc. 2004; 18: 1340–3. 38. Patel AG, Parker JE, Wallwork B et al. Massive splenomegaly is associated with significant morbidity after laparoscopic splenectomy. Ann. Surg. 2003; 238: 235–40. 39. Targarona EM, Balague C, Piulachs J et al. Splenomegaly should not be considered a contraindication for laparoscopic splenectomy. Ann. Surg. 1998; 228: 35–9. 40. Kawanaka H, Akahoshi T, Kinjo N et al. Technical standardization of laparoscopic splenectomy harmonized with hand-assisted laparoscopic surgery for patients with liver cirrhosis and hypersplenism. J. Hepatobiliary Pancreat. Surg. 2009; 16: 749–57.
© 2014 Royal Australasian College of Surgeons
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Hand-assisted versus conventional laparoscopic splenectomy: a systematic review and meta-analysis Daohai Qian,* Zhigang He,* Jie Hua, Jian Gong, Shengping Lin and Zhenshun Song Department of General Surgery, Shanghai Tenth People’s Hospital, Tongji University of Medicine, Shanghai, China
Key words hand-assisted, laparoscopic, meta-analysis, splenectomy, splenomegaly. Correspondence Dr Zhenshun Song, Department of General Surgery, Shanghai Tenth People’s Hospital, Tongji University of Medicine, 301 Yanchang Middle Road, Shanghai 200072, China. Email: [email protected] D. Qian MD, PhD; Z. He MD; J. Hua MD; J. Gong MD; S. Lin MD; Z. Song MD, PhD. *These two authors contributed equally to this work. Accepted for publication 3 March 2014. doi: 10.1111/ans.12597
Abstract Background: Hand-assisted laparoscopic splenectomy (HALS) has been widely applied for the resection of larger spleens. We conducted a systematic review and meta-analysis to evaluate the safety and feasibility of HALS compared with conventional laparoscopic splenectomy (CLS). Methods: A comprehensive literature search in MEDLINE, EMBASE and Cochrane Library databases was performed to compare clinical outcomes of CLS and HALS. Data were extracted by two independent reviewers. Pooled odds ratios and weighted mean differences with 95% confidence intervals were calculated by meta-analytic software. Results: Nine non-randomized controlled studies for a total of 463 patients were selected to satisfy the inclusion criteria (HALS versus CLS: 170 versus 293, respectively). The groups were similar in operative time, estimated operative blood loss, length of hospital stay, mortality and intraoperative and post-operative complications. There was a significantly reduced conversion rate in the HALS versus CLS group (odds ratio: 2.98; 95% confidence interval 1.28 to 6.93; P = 0.01). Splenic weights in the HALS group were higher than in the CLS group (weighted mean differences: −0.93; 95% confidence interval −1.74 to −0.11; P = 0.03). Conclusion: HALS may be preferable to CLS for the treatment of patients with enlarged spleens. The result needs to be certified by further random controlled trials.
Introduction Laparoscopic surgery has rapidly developed in the past 20 years.1,2 The concept of minimally invasive treatment has been widely accepted by most surgeons and patients. As techniques and instruments advance, some contraindications, which had previously been considered insurmountable barriers to using the laparoscopic approach in the past, have been continually broken. Splenomegaly is a good example.3–5 Since it was initially described by Delaitre et al. in 1991,6 laparoscopic splenectomy (LS) had been largely applied for benign and malignant diseases7 and became the gold standard for the treatment of normal size or slightly enlarged spleens.8,9 The superiority of LS was not only reflected in shorter hospital stays, less post-operative pain and faster return to normal activity, but also in smaller operative wounds compared with open splenectomy (OS). However, the benefits of laparoscopic splenectomy were not offered to all patients who required splenectomy. Splenomegaly was often considered a therapeutic challenge because of dense adhesions and increased tissue vascularity, making retrieval difficult, with the necessity of making a longer incision to retrieve the specimen. © 2014 Royal Australasian College of Surgeons
Therefore, the presence of a big spleen inevitably impaired the application of minimally invasive techniques. Fortunately, conventional laparoscopic splenectomy (CLS) was replaced by handassisted laparoscopic splenectomy (HALS), which has a shorter learning curve and requires 7–8 cm incision for the hand port. HALS was the bridge between CLS and OS, with the ability to control haemorrhage as in open surgery, while maintaining the advantage of minimal trauma. In addition, some researchers reported that HALS was safer and more effective for patients with larger spleens compared with CLS.10–13 Their clinical outcomes revealed that patients in the HALS group had shorter operative times, lower conversion rates and less post-operative morbidity. Given the lack of studies comparing HALS and CLS, we conducted this meta-analysis to evaluate the safety and feasibility of HALS compared with CLS techniques.
Methods Search criteria The analysis of previous studies was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and ANZ J Surg 84 (2014) 915–920
916
eta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines. A comprehensive search was performed of all trials comparing clinical outcomes between HALS and CLS before September 2013, using the key words hand assisted, hand port, laparoscopic and splenectomy in MEDLINE, EMBASE and Cochrane Library electronic databases. Reference lists of all retrieved articles were manually searched for additional studies. The search was restricted to articles in English (Fig. 1).
Inclusion criteria Data were extracted by two independent reviewers (Qian DH and He ZG). All studies had to conform to the following criteria: (i) comparison of HALS and CLS techniques; (ii) report on at least one of the clinical outcome measures mentioned below and provide the standard deviation of the mean for continuous outcomes of interest (or provide enough data to calculate the standard deviation); (iii) clearly report the surgical indications for HALS or CLS; (iv) regarding dual (or multiple) studies by the same institution and/or authors, either the studies of higher quality or the most recent publications were included. Abstracts, letters, editorials, expert opinions, reviews, case reports and studies without control groups were excluded.
Outcomes of interest Clinical outcomes of interest included splenic weight, intraoperative (operative time, operative blood loss, intraoperative complications – primarily bleeding, requirement for blood transfusion and conversion to open) and post-operative outcomes (postoperative complications – bleeding, wound infection and dehiscence, intestinal obstruction and others), length of hospital stay and mortality.
Qian et al.
Statistical analysis This meta-analysis was performed using Review Manager (RevMan) software, version 5.0 (Nordic Cochrane Centre, Copenhagen, Denmark). We analysed dichotomous variables by estimating the odds ratios (OR) and continuous variables using weighted mean difference (WMD), both with a 95% confidence interval (95% CI). The pooled effect was calculated using either the fixed or randomeffects models. Heterogeneity was measured using the Q-test and a difference of heterogeneity existed when I2 > 50%. A P value of less than 0.05 was considered statistically significant. The NewcastleOttawa Scale was used to assess the quality of the studies.
Results Included studies Ten studies3,4,10–17 were identified and assessed for eligibility. Nine studies3,4,11–17 finally matched the selection criteria, for a total of 463 patients (170 HALS versus 293 CLS). Four studies were conducted in United States, one in Japan, one in Spain, one in Saudi Arabia, one in Italy and two in China. The sample size of each study varied from seven to 103 patients. Study characteristics and patient demographics are summarized in Table 1. Groups were matched according to age, gender, follow-up period, histopathologic diagnosis and operative approach. The Newcastle-Ottawa Scale was utilized to assess the quality of all included non-randomized controlled studies (Table 2).
Splenic weight and operative outcomes In seven of nine studies, splenic weights where greater in the HALS compared with CLS group. Similarly, the pooled results demonstrated a significant difference between groups (WMD: −0.93; 95% CI −1.74 to −0.11; P = 0.03), associated with a significant difference of heterogeneity (I2 = 90%; Fig. 2). With regard to conversion to open rates, there was a significant difference between the groups (OR: 2.98; 95% CI: 1.28 to 6.93; P = 0.01; Fig. 2). However, the groups were similar with regard to intraoperative blood loss or the number of patients requiring blood transfusion (WMD: 43.71; 95% CI: −31.60 to 119.03; P = 0.26, and OR: 1.02, 95% CI: 0.48 to 2.17; P = 0.96; Fig. 2) and significant heterogeneity existed (I2 = 60%; Fig. 2). More importantly, there was no significant difference in intraoperative complications between groups (OR: 2.98; 95% CI: 0.88 to 10.15; P = 0.08; Fig. 2).
Post-operative outcomes
Fig. 1. Searching procedures.
Post-operative mobility is one of the most persuasive indications for assessing whether an operative method is safe and efficacious. In this meta-analysis, we integrated all post-operative outcomes and did not find a statistically significant difference in complications between groups (OR: 0.90; 95% CI: 0.37 to 218; P = 0.69; Fig. 3), while there was significant heterogeneity (I2 = 63%). There was also no significant difference between groups with regard to length of hospital stay (WMD: −0.36; 95% CI: −2.26 to 1.55; P = 0.71; Fig. 3), which was associated with a significant difference in heterogeneity (I2 = 86%). There was no statistically significant difference in mortality rate between groups (OR: 10.63; 95% CI: 0.51 to 222.61; P = 0.13; Fig. 3) and the heterogeneity test was not applicable (because of a low mortality rate of 0 and 1.5% in the spleen-preserving distal © 2014 Royal Australasian College of Surgeons
HALS versus CLS in splenectomy
14 NA NA NA NA NA NA NA NA
© 2014 Royal Australasian College of Surgeons
Study
Kercher et al.4 Smith et al.3 Ailawadi et al.16 Targarona et al.15 Wang et al.14 Altaf et al.13 Pietrabissa et al.17 Wang et al.11 Rosen et al.12
CLS, conventional laparoscopic splenectomy; F, female; HALS, hand-assisted laparoscopic splenectomy; M, male; NA, not available; SD, standard deviation.
NA NA 6/16 4/16 19/0 3/20 19/24 12/8 8/6 26/23 NA 8/11 15/21 20/0 64/16 30/12 8/8 17/14 49 3 16 36 20 80 42 16 31 2002 2003 2002 2001 2012 2012 2011 2007 2002 Kercher et al. Smith et al. Ailawadi et al. Targarona et al. Wang et al. Altaf et al. Pietrabissa et al. Wang et al. Rosen et al.
USA USA USA Spain China Saudi Arabia Italy China Ohio
20/29 NA NA 12/24 11/9 45/35 23/19 9/7 9/22
NA NA NA 10/10 12/7 9/14 7/36 8/12 7/7
54.4 NA NA 58 ± 13 48 ± 12 53.2 ± 18.3 46.8 ± 21 38 ± 12 54 ± 15
NA NA NA 58 ± 16 48 ± 11 63.6 ± 14.2 66.5 ± 8.7 43 ± 14 37 ± 13
7 4 20 20 19 23 43 20 14
HALS CLS HALS CLS HALS HALS CLS
Year
Country
Gender (F/M)
CLS
Age (years) (mean ± SD)
Study size
Histopathologic diagnosis (benign/malignant)
Follow-up (months)
Table 2 The Newcastle-Ottawa Scale for assessing the quality of non-randomized controlled studies
Author
Table 1 Study characteristics and patient demographics
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Selection
Comparability
Assessment of outcomes
Total scores
2 2 3 3 3 3 3 3 3
1 1 1 2 2 1 1 2 2
3 3 3 3 3 3 3 3 3
6 6 7 8 8 7 7 8 8
pancreatectomy and distal pancreatectomy with splenectomy groups, respectively).
Heterogeneity Significant heterogeneities were found with regard to splenic weight, estimated operative blood loss, post-operative complications and length of hospital stay. However, with regard to operative times, intraoperative complications, conversion to open surgery and blood transfusion, no significant heterogeneities existed.
Discussion In this meta-analysis, the pooled data revealed that the HALS should be a preferred choice for the treatment of patients with enlarged spleens. In addition, HALS is a good replacement for CLS. Laparoscopic techniques are widely used,18–20 with cholecystectomy as one of the most successful applications.19,21 The development of laparoscopic equipment has promoted the advances of minimally invasive surgery, from which patients derived the most benefit by avoiding a large and visible scar. Although laparoscopic splenectomy has many advantages, including shorter hospital stays, less postoperative pain, improved cosmetics and a faster recovery period to normal activity, there are definite technical challenges, including lack of tactile sensation, impaired hand-eye coordination and the loss of three-dimensional visualization of intra-abdominal structures. However, HALS may help to overcome these obstacles to the conventional laparoscopic approach. Currently, hand-assisted laparoscopic surgery is regularly applied in 150 surgical procedures,22 such as nephrectomy,23,24 pancreatectomy,25 resection of ovarian26 and gastrointestinal cancers,27 hepatectomy28 and splenectomy.29 LS has been developed quickly since its first application. Winslow and Braunt8 conducted a meta-analysis to compare clinical outcomes between CLS and OS and revealed that patients undergoing CLS had a significant reduction in post-operative morbidity, although it was associated with longer operative times compared with OS. HALS, first described by Kusminsky et al.30 in 1995, has become an alternative to CLS when performing splenectomy for splenomegaly. Some studies indicated that HALS facilitated complicated procedures while maintaining the advantages of the minimally invasive approach. Barbaros et al.31 reported that HALS significantly improved technical ease of the procedure and reduced hospital stay compared with OS, when applied to larger spleens. Knauer et al.7 attested that the benefits of HALS where similar to those of CLS. Swanson et al.32 argued that
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Fig. 2. A meta-analysis of splenic weight and operative outcomes: operative time (min), intraoperative complications, estimated operative blood loss (mL) and conversion rate (CI, confidence interval; IV, inverse variance; kg, kilogram; M-H, Mantel-Haenszel; min, minutes; mL, millilitre; SD, standard deviation).
HALS was safe and effective for the management of spleens greater than 20 cm in size. HALS patients had shorter hospital stays and were preferable to OS for massive splenomegaly. In contrast, Grahn et al.5 insisted that CLS was still a safe approach for the resection of massive and supramassive spleens and all elective LS were performed with the conventional method, regardless of spleen size. Rescorla et al.33 also argued that LS was safe and effective for children with haematological disorders and that CLS resulted in less narcotic administration, shorter length of stay and lower total hospital costs, albeit with longer operative times compared with OS. In this meta-analysis, the result indicated that the hand-assisted laparoscopic technique could be applied in splenectomy without lengthening operative times, post-operative recovery, or increasing operative blood loss and risk for blood transfusion, mortality or
complications. Furthermore, HALS patients had lower conversions to open rates, although operative difficulty remained for larger spleens. Although there are several reports about CLS successfully being applied in massive or super splenomegaly,4,34 patients with normal size or slightly enlarged spleens are more suited for conventional laparoscopy.9,35,36 Some authors suggested that CLS was a better choice for patients with spleen sizes of less than 600 g.5,37 If spleen size was greater than 1000 g, there was a higher conversion to open rate.38,39 Laparoscopic resection of massive or supermassive spleens is always a problem because of the limited space in the abdominal cavity and retrieval of a large organ. Some studies indicated that all patients with super splenomegaly should be converted to OS after CLS method was attempted, and even suggested the use of HALS. Some authors advocated the application of HALS for all spleens © 2014 Royal Australasian College of Surgeons
HALS versus CLS in splenectomy
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Fig. 3. A meta-analysis of post-operative outcomes: transfusion rate, hospital stays (days), post-operative complications and mortality (CI, confidence interval; IV, inverse variance; M-H, Mantel-Haenszel; SD, standard deviation).
with a width exceeding 19 cm and a length over 224,35 or 23 cm.35 As splenic weight or size increases, technical difficulty in using the laparoscopic approach also increases. Terrosu et al.29 defined the limitations for CLS at a splenic weight of 2000 g or a size of greater than or equal to 23 cm. Ailawadi et al.16 found that the conversion rate had reached 44% when performing CLS in patients with spleens weighing more than 550 g. Patel et al.38 reported that patients with spleens weighing more than 1000 g were 14 times more likely to have post-operative complications. The presence of splenomegaly undoubtedly brings technical challenges to CLS; however, HALS is a feasible alternative to CLS that avoids some of its drawbacks. Kawanaka et al.40 applied HALS for patients with splenomegaly (≧1000 mL), perisplenic collateral vessels or a Child-Pugh score of 9 or more. Through this technical standardization of LS, they found that CLS was feasible and safe in the setting of cirrhosis and portal hypertension. More common was to directly perform HALS when facing massive or super splenomegaly. Of course, there are many indications for using HALS, © 2014 Royal Australasian College of Surgeons
related to experience, economic considerations, body habitus and the availability of advanced devices, among others. There were also several limitations to this meta-analysis. First, all data were retrieved from non-randomized controlled studies, so the conclusions should be considered by surgeons carefully. However, it is very difficult to carry out large prospective randomized controlled trials because of severe complications and poor compliance. Second, it was impossible for the patient characteristics to be completely matched. Third, we only compared differences in clinical outcomes between HALS and CLS groups without conducting stratified analysis about the splenic size. Finally, there was lack of the analysis about post-operative pain or late incisional hernias because of the size of incision for hand port.
Conclusion In conclusion, HALS is a safe and effective approach for removing enlarged spleens compared with CLS, although the operative
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difficulty in HALS was higher than CLS. HALS is a good alternative to CLS.
Acknowledgements This project was supported by the National Natural Science Foundation of China (Grant no. 60171009). Zhigang He is a co-first author, with an equal contribution to this study. The authors are solely responsible for the content. All authors have no conflicts of interest to declare. Thanks to all the authors who contributed to the work.
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