JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 24, Number 11, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2014.0213
Single-Incision Laparoscopic Splenectomy with Conventional Instruments: Preliminary Experience in Consecutive Patients and Comparison to Standard Multiple-Incision Laparoscopic Splenectomy Ying Fan, MD, PhD, Shuo-Dong Wu, MD, PhD, Jing Kong, MD, PhD, and Weng Chao, MS
Abstract
Aim: To study the feasibility and efficiency of transumbilical single-incision laparoscopic surgery splenectomy (SILS-Sp) using conventional instruments in consecutive patients and to compare outcomes of the procedure with those of standard multiple-incision laparoscopic splenectomy (MLS). Patients and Methods: A retrospective review was conducted to evaluate all SILS-Sp procedures performed by a single surgeon between March 2010 and January 2013. Additionally, patients who underwent MLS by other surgeons in the same surgical group during the same period were evaluated to serve as a control group. Demographic data, operative parameters, and postoperative outcomes were assessed. Results: Thirteen patients underwent successful SILS-Sp during the study period without conversion to an open procedure or requiring additional ports. The median operative time was 165 minutes. There was 7.7% morbidity and no mortality in the study group. Median length of stay was 8.8 days. Additionally, 12 patients who underwent MLS were evaluated for comparison. No significant differences were identified in the preoperative patient characteristics between the two groups. For MLS, the median operative time was 158 minutes. There was 8.3% morbidity and no mortality in the group. Median length of stay was 8.3 days. SILS-Sp using conventional instruments was associated with reduced postoperative pain scores, but this did not reach statistical significance. The operative time, conversion rate, and length of stay were equivalent. The mortality, morbidity, and cost were also similar in the two groups. The umbilical incision of the single-incision group can be easily hidden in the umbilical fold with ideal cosmetic result. Conclusions: SILS-Sp is feasible and efficient in an unselected patient population in the hands of an experienced laparoscopic surgeon. The single-incision technique is comparable to standard laparoscopic splenectomy in terms of operative time and perioperative outcomes. Ideal cosmetic effect may be its potential advantage.
Introduction
hodes et al.1 reported the index case of laparoscopic splenectomy in 1995. Thereafter, this procedure has been widely adapted in clinical practice.2–8 It is now believed that the overall complication rate is higher after open splenectomy compared with laparoscopic splenectomy and that the latter can primarily be attempted in all patients.9 However, its benefits are not as dramatic as expected. One refinement of laparoscopic surgery has recently led to the development of natural orifice translumenal endoscopic
R
surgery (NOTES; American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]). However, despite the outstanding benefit of scarlessness, NOTES has raised the question of whether the risk of visceral injury is justifiable to improve cosmesis. In addition, NOTES lacks reproducibility because the procedure needs highly elaborate equipment still being developed. Another refinement, single-incision laparoscopic surgery (SILS), has advantages over NOTES in that existing laparoscopic instruments can be used and that relatively minor adjustments
Department of the Second General Surgery, Sheng Jing Hospital of China Medical University, Shenyang City, Liaoning Province, China.
799
800
FAN ET AL.
from the conventional multiport laparoscopic technique are needed. Thus far, it has been used for various abdominal procedures, including cholecystectomy,10 appendectomy,11 colectomy,12 and thyroidectomy,13 and recently this technique has been applied to splenic surgery.14 Because of limited numbers of studies reporting SILS splenectomy (SILS-Sp), its clinical significance remains to be elucidated. The purpose of this study is to study the feasibility and efficiency of SILS-Sp using conventional instruments in consecutive patients and to compare outcomes of the procedure with those of standard multiple-incision laparoscopic splenectomy (MLS).
FIG. 1.
Placement of the trocars.
Patients and Methods Patient selection and data collection
Thirteen consecutive patients, including 1 case of splenic aneurysm with intense adhesion with pancreatic tail, 1 case of traumatic rupture of the spleen, 1 case of idiopathic thrombocytopenia purpura, 1 case of congenital hemolytic anemia with gallstones, 2 cases of symptomatic splenic hemangioma, 2 cases of splenic cyst, and 5 cases of portal hypertension, who presented to a single senior surgeon (S.-D.W) between March 2010 and January 2013 with an indication for splenectomy underwent SILS-Sp after signing an informed consent form. Concurrent distal pancreatectomy, cholecystectomy, and pericardial devascularization were also performed in indicated cases. In addition, 12 patients, including 1 case of traumatic rupture of the spleen, 1 case of splenic aneurysm with intense adhesion with pancreatic tail, 3 cases of idiopathic thrombocytopenia purpura, 1 case of congenital hemolytic anemia with gallstones, 1 case of splenic hemangioma, 1 case of splenic cyst, and 4 cases of portal hypertension, who underwent MLS performed by other senior surgeons in the same surgical group from March 2010 to January 2013 were evaluated to serve as a control group. Patients were retrospectively identified by searching an electronic database. Medical records regarding characteristics of patients and operative outcomes were reviewed to collect relevant data. Postoperative pain was strictly assessed by using a same visual analog scale in the two groups.15 Complications were graded according to the modified Clavien–Dindo classification scheme of surgical complications.16 This study was approved by the Institutional Review Board at the Shengjing Hospital of China Medical University (Shenyang, China).
three ports were placed within the umbilical incision in an inverted equilateral triangular configuration, 1 cm apart, with the camera placed at the apex (Fig. 1). A 30 10-mm rigid laparoscope (Stryker Endoscopy, San Jose, CA) was used throughout the procedures. A grasper was inserted through the 5-mm trocar, while a Harmonic scalpel (Ethicon EndoSurgery) or LigaSure (Covidien, Mansfield, MA) is inserted through the 12-mm trocar for dissection. For the majority of the cases, once access was obtained, the intraabdominal procedure was virtually the same as for multiport laparoscopy. The first step was to free the inferior pole of the spleen with the dissection of the splenocolic ligament. Second, the gastrosplenic ligament was opened by the Harmonic scalpel, and the lesser sac was explored to expose the splenic hilum. Then, splenorenal and splenophrenic ligaments were also freed. A dissector was used to elevate the lower pole of the spleen, and the splenic pedicle was stapled by a 60-mm endoscopic stapler with a white cartridge (Fig. 2). For the patient with a splenic aneurysm, the lesion was closely attached to the major blood vessels of the spleen and pancreatic tail, making it impossible to preserve the spleen and pancreatic tail. After the spleen was initially freed from its surrounding ligaments, in the order of gastrocolic, gastrosplenic, splenorenal, and splenophrenic ligaments, and the tail of the pancreas was freed from the lower and posterior pancreas, the whole mass, including the tail of the pancreas, the aneurysm, and the normal-sized spleen, were dissected together by a 60-mm endoscopic stapler with a blue cartridge with a single bite at the pancreatic tail. For the patient with
Surgical technique
SILS-Sp procedures were performed with the patient under general anesthesia and in the supine position with legs parted and the left shoulder raised 15–20. The viewing monitor was placed above the patient’s left shoulder, with the surgeon standing between the patient’s legs and the camera operator on the patient’s right side. Pneumoperitoneum was established by using the closed Veress needle technique through the umbilicus. After insufflation of CO2 and maintaining the pressure at 13 mm Hg, a 3-cm periumbilical incision was made, preserving the fascial layer for trocar access. Conventional trocars were used, including a 5-mm and a 10-mm standard trocar and an unbladed trocar (ENDOPATH Xcel B12LT; Ethicon Endo-Surgery, Inc., Blue Ash, OH). The
FIG. 2. The splenic pedicle was dissected using an endoscopic stapler.
COMPARISON STUDY BETWEEN SILS-SP AND MLS
801
traumatic rupture of the spleen, in order to control the bleeding first, the splenic artery was ligated first as we have described in the literature.17 For patients with gallstones or portal hypertension, concurrent cholecystectomy or pericardial devascularization was also performed as we have reported in the literature.18 For all cases, a specimen bag was finally inserted through the 12-mm trocar, and the spleen was placed in it to be removed piecemeal from the abdominal cavity. Statistical analysis
Continuous data are presented as the mean – standard deviation, median, and range. Categorical variables are expressed as numbers and percentages for the group from which they were derived. Continuous variables were compared between the single-incision and standard laparoscopic splenectomy groups using an unpaired-sample Student’s t test and the Mann–Whitney test. Results were considered statistically significant for P < .05. Results
Patient characteristics of both groups are listed in Table 1. All preoperative patient characteristics of the SILS-Sp group were compared with those of the patients who underwent MLS, and there were no statistically significant differences between the groups (Table 1). Operative data are given in Table 2. In the SILS-Sp group, all operations were successfully completed with a single incision without conversion to open procedures or placement of additional ports. The median operative time (SILS-Sp,
165.38 – 41.51 minutes; MLS, 158.50 – 40.66 minutes; P = .68) and median estimated blood loss (SILS-Sp, 143.8 5 – 56.94 mL; MLS, 139.17 – 48.33 mL; P = .827) did not significantly differ between the two groups. Six patients (46.2%) in the SILS-Sp group and 5 (41.7%) in the MLS group required intraoperative transfusion of blood supplements (including platelet transfusions); these rates were similar. The median length of stay was 8.8 days for the SILSSp group and 8.3 days for the MLS group. There was no mortality in either group. The complication rate in the SILSSp group was 7.7%, with 1 patient who developed a postoperative splenic bed bleeding and was re-operated on laparoscopically (Grade 3), and 8.3% in the MLS group, with 1 patient who developed a postoperative deep vein thrombosis (Grade 2). The complication rates were similar in both groups. The media cost for the SILS-Sp group was 36,800 Chinese yuan (roughly equivalent to $5993 U.S.) versus 37,400 Chinese yuan (roughly equivalent to $6091 U.S.) for the MLS group, which did not significantly differ between the two groups (P = .911). SILS-Sp using conventional instruments was associated with reduced postoperative pain scores, but this did not reach statistical significance (3.2 – 0.2 versus 3.6 – 0.9 for postoperative Day 1 [P > .05]; 1.8 – 0.1 versus 2.0 – 0.45 for postoperative Day 2 [P > .05]) (Table 3). There were no incisional hernias in the SILS-Sp group during the average 2 years of follow-up. Discussion
This series demonstrates SILS-Sp using conventional instruments to be feasible in 13 consecutive unselected patients
Table 1. Characteristics of Patients Who Underwent Single-Incision and Standard Laparoscopic Splenectomy SILS-Sp (n = 13) Gender [n (%)] Male Female Diagnosis [n (%)] Splenic aneurysm Traumatic rupture of the spleen ITP Congenital hemolytic anemia with gallstones Splenic hemangioma Splenic cyst Portal hypertension ASA grade [n (%)] 1 2 3 4 Prior abdominal surgery [n (%)] Surgical procedure [n (%)] Splenectomy + distal pancreatectomy + cholecystectomy + pericardial devascularization Age (years) [mean – SD (range)] Body mass index (kg/m2) [mean – SD (range)] ASA [mean – SD (range)]
MLS (n = 12)
P .91
10 (76.92) 3 (23.08)
9 (75) 3 (25) .712
1 1 1 1 2 2 5
(7.7) (7.7) (7.7) (7.7) (15.4) (15.4) (38.4)
1 1 3 1 1 1 4
(8.3) (8.3) (25) (8.3) (8.3) (8.3) (33.3)
4 5 4 0 0
(30.8) (38.4) (30.8) (0) (0)
4 4 4 0 0
(33.3) (33.3) (33.3) (0) (0)
.189
> .9 6 1 1 5 42.15 – 14.62 23.38 – 2.49 2 – 0.82
(46.2) (7.7) (7.7) (38.4) (17–73) (18.6–26.6) (1–3)
6 1 1 4 41.67 – 14.08 23.29 – 2.69 2 – 0.85
(50) (8.3) (8.3) (33.4) (23–74) (19.1–27.8) (1–3)
.933 .929 > .9
ASA, American Society of Anesthesiologists; ITP, idiopathic thrombocytopenia purpura; MLS, multiple-incision laparoscopic splenectomy; SD, standard deviation; SILS-Sp, single-incision laparoscopic surgery splenectomy.
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FAN ET AL.
Table 2. Operative Outcomes for Single-Incision and Standard Laparoscopic Splenectomy SILS-Sp (n = 13) Operative time (minutes) (mean – SD) 165.38 – 41.51 Estimated blood loss (mL) (mean – SD) 143.85 – 56.94 Blood transfusion [n (%)] 6 (46.2) Conversion to open surgery [n (%)] 0 (0) Weight of spleen (g) (mean – SD) 808 – 152 Intake of liquid diet (days) (mean – SD) 2.3 – 0.7 Mortality [n (%)] 0 (0) Morbidity [n (%)] 1 (7.7) Complications (Clavien–Dindo classification) [n (%)] Grade 1 0 (0) Grade 2 0 (0) Grade 3 1 (7.7) Grade 4 0 (0) Grade 5 0 (0) Hospital stay (days) (mean – SD) 8.8 – 1.2 Cost (U.S. dollars) (mean – SD) 5993 – 570
MLS (n = 12) 158.50 – 40.66 139.17 – 48.33 5 (41.7) 0 (0) 825 – 142 2.6 – 0.9 0 (0) 1 (8.3) 0 (0) 1 (8.3) 0 (0) 0 (0) 0 (0) 8.3 – 1.4 6091 – 407
P .68 .827 .821 .846 > .9
.921 .911
MLS, multiple-incision laparoscopic splenectomy; SD, standard deviation; SILS-Sp, single-incision laparoscopic surgery splenectomy.
with no conversions to open splenectomy or placement of additional ports. Unlike previous reports, our series demonstrates that SILS-Sp can be applied to a diverse patient population, including patients in emergency condition (traumatic rupture of the spleen), who require concurrent operations (distal pancreatectomy, cholecystectomy, or pericardial devascularization), have medical comorbidities (American Society of Anesthesiologists up to grade 3), and have severe thrombocytopenia (preoperative platelet count as low as 35 · 109/L in 1 patient with portal hypertension). Although these examples represented the extremes in our population, these types of patients are seen in everyday practice. We also demonstrated that SILS-Sp is efficient, although our mean operative time of 165 minutes is slightly longer than the times published for MLS19,20 or SILS-Sp.21,22 It should be noted that some complicated concurrent operations have been successfully performed by the surgical team. To ensure efficiency, we think accumulation of SILS experience for a period of time is essential in the beginning for splenic surgeons without extensive SILS experience, or they could team up with a SILS expert for initial operations. We began to perform SILS in 2009, and with the experiences gradually accumulating, 10 months later, we attempted the first SILSSp. In addition, what we still want to highlight is that the average body mass index of the patients in our study is only 23.38 kg/m2, although our consecutive patient study does not specifically restrict this. This may be related to eating habits in China. For patients with a high body mass index, careful consideration should be given before attempting SILS-Sp, as
Table 3. Comparison of Postoperative Pain Scores
Postoperative Day 1 Postoperative Day 2
SILS-Sp (n = 13)
MLS (n = 12)
P
3.20 – 0.20 1.80 – 0.10
3.60 – 0.90 2.00 – 0.45
> .05 > .05
Data are mean – standard deviation values. MLS, multiple-incision laparoscopic splenectomy; SILS-Sp, single-incision laparoscopic surgery splenectomy.
a high body mass index would increase the difficulty and risks of SILS, as well as the wound complication rate.23 So, this approach may not be very applicable in patients with a high body mass index, in whom the transumbilical approach would not be feasible. In this series we compared the initial experience of a single surgeon performing SILS-Sp with other senior surgeons’ experience in the same surgical group. All surgeons are highly experienced laparoscopic surgeons and routinely perform MLS. There were no differences in preoperative patient characteristics between the two groups. SILS-Sp using conventional instruments was associated with reduced postoperative pain scores, but this did not reach statistical significance. The operative time, conversion rate, and length of stay were equivalent. The mortality, morbidity, and cost were also similar in the two groups. Studies comparing postoperative median pain score between SILS-Sp and MLS are still limited with controversial results. A recent meta-analysis that pooled randomized trials comparing single-incision laparoscopic cholecystectomy and multiple-incision laparoscopic cholecystectomy found no difference in short-term postoperative pain intensity.24 We think, in our study, that improvements in pain and analgesia theoretically associated with the reduction of port sites may be offset by a larger incision, more torque through a single site, and greater peritoneum tension. With any new technology, associated cost needs to be considered. Unlike other reports of SILS-Sp requiring purchase of proprietary access devices and additional pieces of equipment, we used conventional instruments during the procedure, which did not increase the economic burden of the patients. Significantly improved cosmesis is an obvious advantage of the procedure. Indeed, when performed through the umbilicus, the procedure is virtually scarless (the umbilicus is a natural scar of the abdomen surface). Overall, our series demonstrates that SILS-Sp is at least equivalent to MLS. Of course, limitations exist in this study. This is a retrospective study with a small number of patients, and only a single surgeon’s experience with a small group of colleagues
COMPARISON STUDY BETWEEN SILS-SP AND MLS
was compared. Lack of representativeness of the general surgeon population is its main limitation. Nevertheless, the study does demonstrate that the procedure is feasible in treating consecutive patients meeting indications for splenectomy in the hands of experienced laparoscopic surgeons. With the gradual accumulation of surgeons’ experience with SILS, it could be attempted in suitable cases where patients have strong concerns about cosmetic appearance; perhaps in the future, improvements in laparoscopic instruments will also render SILS more straightforward. Conclusions
It is our opinion that SILS-Sp is feasible and efficient in an unselected patient population in the hands of an experienced laparoscopic surgeon. The single-incision technique is comparable to standard laparoscopic splenectomy in terms of operative time and perioperative outcomes. Ideal cosmetic effect may be its potential advantage. Disclosure Statement
No competing financial interests exist. References
1. Rhodes M, Rudd M, O’Rourke N, Nathanson L, Fielding G. Laparoscopic splenectomy and and lymph node biopsy for hematologic disorders. Ann Surg 1995;222:43–46. 2. Chowbey PK, Goel A, Panse R, Sharma A, Khullar R, Soni V, Baijal M. Laparoscopic splenectomy for hematologic disorders: Experience with the first fifty patients. J Laparoendosc Adv Surg Tech A 2005;15:28–32. 3. Bresler L, Guerci A, Brunaud L, Ayav A, Sebbag H, Tortuyaux JM, Lederlin P, Boissel P. Laparoscopic splenectomy for idiopathic thrombocytopenic purpura: Outcome and long-term results. World J Surg 2002;26:111–114. 4. Pattenden CJ, Mann CD, Metcalfe MS, Dyer M, Lloyd DM. Laparoscopic splenectomy: A personal series of 140 consecutive cases. Ann R Coll Surg Engl 2010;92:398–402. 5. Kye BH, Park IS, Kim JG, Lee JC, Son GM, Suh YJ, Cho HM, Chun CS. Laparoscopic splenectomy: 3 ports are enough. Surg Laparosc Endosc Percutan Tech 2010;20: 104–108. 6. Wang Y, Zhan X, Zhu Y, Xie Z, Zhu J, Ye Z. Laparoscopic splenectomy in portal hypertension: A single-surgeon 13year experience. Surg Endosc 2010;24:1164–1169. 7. Carobbi A, Romagnani F, Antonelli G, Bianchini M. Laparoscopic splenectomy for severe blunt trauma: Initial experience of ten consecutive cases with a fast hemostatic technique. Surg Endosc 2010;24:1325–1330. 8. Sotomayor-Ramı´rez RK. Efficacy and safety of laparoscopic splenectomy: Review of 14 adult cases using the lateral approach. Bol Asoc Med P R 2009;101:43–49. 9. Maurus CF, Scha¨fer M, Mu¨ller MK. Laparoscopic versus open splenectomy for nontraumatic diseases. World J Surg 2008;32:2444–2449. 10. Wu SD, Han JY, Tian Y. Single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: A retrospective comparative study. J Laparoendosc Adv Surg Tech A 2011;21:25–28. 11. Amos SE, Shuo-Dong W, Fan Y, Tian Y, Chen CC. Singleincision versus conventional three-incision laparoscopic appendectomy: A single centre experience. Surg Today 2012; 42:542–546.
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12. Gash KJ, Goede AC, Chambers W, Greenslade GL, Dixon AR. Laparoendoscopic single-site surgery is feasible in complex colorectal resections and could enable day case colectomy. Surg Endosc 2011;25:835–840. 13. Fan Y, Wu SD, Kong J. Single-port access transaxillary totally endoscopic thyroidectomy: A new approach for minimally invasive thyroid operation. J Laparoendosc Adv Surg Tech A 2011;21:243–247. 14. Barbaros U, Dinc¸c¸ag˘ A. Single incision laparoscopic splenectomy: The first two cases. J Gastrointest Surg 2009;13:1520–1523. 15. Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health 1990;13:227–236. 16. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santiban˜es E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M. The Clavien-Dindo classification of surgical complications: Five-year experience. Ann Surg 2009;250:187–196. 17. Fan Y, Wu SD, Siwo EA. Emergency transumbilical singleincision laparoscopic splenectomy for the treatment of traumatic rupture of the spleen: Report of the first case and literature review. Surg Innov 2011;18:185–188. 18. Wu SD, Fan Y, Kong J, Su Y. Transumbilical single-incision laparoscopic splenectomy plus pericardial devascularization using conventional instruments: Initial experience of 5 cases. J Laparoendosc Adv Surg Tech A 2013;23:150–153. 19. Mattioli G, Pini Prato A, Cheli M, Esposito C, Garzi A, LiVoti G, Mastroianni L, Porreca A, Riccipetitoni G, Scalisi F, Buluggiu A, Avanzini S, Rizzo A, Boeri E, Jasonni V. Italian multicentric survey on laparoscopic spleen surgery in the pediatric population. Surg Endosc 2007; 21:527–531. 20. Park AE, Birgisson G, Mastrangelo MJ, Marcaccio MJ, Witzke DB. Laparoscopic splenectomy: Outcomes and lessons learned from over 200 cases. Surgery 2000;128: 660–667. 21. Misawa T, Sakamoto T, Ito R, Shiba H, Gocho T, Wakiyama S, Ishida Y, Yanaga K. Single-incision laparoscopic splenectomy using the ‘‘tug-exposure technique’’ in adults: Results of ten initial cases. Surg Endosc 2011;25:3222–3227. 22. Targarona EM, Pallares JL, Balague C, Luppi CR, Marinello F, Hernandez P, Martinez C, Trias M. Single incision approach for splenic diseases: A preliminary report on a series of 8 cases. Surg Endosc 2010;24:2236–2240. 23. Yilmaz H, Alptekin H, Acar F, Calisir A, Sahin M. Singleincision laparoscopic cholecystectomy and overweight patients. Obes Surg 2014;24:123–127. 24. Trastulli S, Cirocchi R, Desiderio J, Guarino S, Santoro A, Parisi A, Noya G, Boselli C. Systematic review and metaanalysis of randomized clinical trials comparing singleincision versus conventional laparoscopic cholecystectomy. Br J Surg 2013;100:191–208.
Address correspondence to: Shuo-Dong Wu, MD, PhD Department of the Second General Surgery Sheng Jing Hospital of China Medical University No. 36, Sanhao Street Heping District Shenyang City, Liaoning Province, 110004 China E-mail: [email protected]
Single-Incision Laparoscopic Splenectomy with Conventional Instruments: Preliminary Experience in Consecutive Patients and Comparison to Standard Multiple-Incision Laparoscopic Splenectomy Ying Fan, MD, PhD, Shuo-Dong Wu, MD, PhD, Jing Kong, MD, PhD, and Weng Chao, MS
Abstract
Aim: To study the feasibility and efficiency of transumbilical single-incision laparoscopic surgery splenectomy (SILS-Sp) using conventional instruments in consecutive patients and to compare outcomes of the procedure with those of standard multiple-incision laparoscopic splenectomy (MLS). Patients and Methods: A retrospective review was conducted to evaluate all SILS-Sp procedures performed by a single surgeon between March 2010 and January 2013. Additionally, patients who underwent MLS by other surgeons in the same surgical group during the same period were evaluated to serve as a control group. Demographic data, operative parameters, and postoperative outcomes were assessed. Results: Thirteen patients underwent successful SILS-Sp during the study period without conversion to an open procedure or requiring additional ports. The median operative time was 165 minutes. There was 7.7% morbidity and no mortality in the study group. Median length of stay was 8.8 days. Additionally, 12 patients who underwent MLS were evaluated for comparison. No significant differences were identified in the preoperative patient characteristics between the two groups. For MLS, the median operative time was 158 minutes. There was 8.3% morbidity and no mortality in the group. Median length of stay was 8.3 days. SILS-Sp using conventional instruments was associated with reduced postoperative pain scores, but this did not reach statistical significance. The operative time, conversion rate, and length of stay were equivalent. The mortality, morbidity, and cost were also similar in the two groups. The umbilical incision of the single-incision group can be easily hidden in the umbilical fold with ideal cosmetic result. Conclusions: SILS-Sp is feasible and efficient in an unselected patient population in the hands of an experienced laparoscopic surgeon. The single-incision technique is comparable to standard laparoscopic splenectomy in terms of operative time and perioperative outcomes. Ideal cosmetic effect may be its potential advantage.
Introduction
hodes et al.1 reported the index case of laparoscopic splenectomy in 1995. Thereafter, this procedure has been widely adapted in clinical practice.2–8 It is now believed that the overall complication rate is higher after open splenectomy compared with laparoscopic splenectomy and that the latter can primarily be attempted in all patients.9 However, its benefits are not as dramatic as expected. One refinement of laparoscopic surgery has recently led to the development of natural orifice translumenal endoscopic
R
surgery (NOTES; American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]). However, despite the outstanding benefit of scarlessness, NOTES has raised the question of whether the risk of visceral injury is justifiable to improve cosmesis. In addition, NOTES lacks reproducibility because the procedure needs highly elaborate equipment still being developed. Another refinement, single-incision laparoscopic surgery (SILS), has advantages over NOTES in that existing laparoscopic instruments can be used and that relatively minor adjustments
Department of the Second General Surgery, Sheng Jing Hospital of China Medical University, Shenyang City, Liaoning Province, China.
799
800
FAN ET AL.
from the conventional multiport laparoscopic technique are needed. Thus far, it has been used for various abdominal procedures, including cholecystectomy,10 appendectomy,11 colectomy,12 and thyroidectomy,13 and recently this technique has been applied to splenic surgery.14 Because of limited numbers of studies reporting SILS splenectomy (SILS-Sp), its clinical significance remains to be elucidated. The purpose of this study is to study the feasibility and efficiency of SILS-Sp using conventional instruments in consecutive patients and to compare outcomes of the procedure with those of standard multiple-incision laparoscopic splenectomy (MLS).
FIG. 1.
Placement of the trocars.
Patients and Methods Patient selection and data collection
Thirteen consecutive patients, including 1 case of splenic aneurysm with intense adhesion with pancreatic tail, 1 case of traumatic rupture of the spleen, 1 case of idiopathic thrombocytopenia purpura, 1 case of congenital hemolytic anemia with gallstones, 2 cases of symptomatic splenic hemangioma, 2 cases of splenic cyst, and 5 cases of portal hypertension, who presented to a single senior surgeon (S.-D.W) between March 2010 and January 2013 with an indication for splenectomy underwent SILS-Sp after signing an informed consent form. Concurrent distal pancreatectomy, cholecystectomy, and pericardial devascularization were also performed in indicated cases. In addition, 12 patients, including 1 case of traumatic rupture of the spleen, 1 case of splenic aneurysm with intense adhesion with pancreatic tail, 3 cases of idiopathic thrombocytopenia purpura, 1 case of congenital hemolytic anemia with gallstones, 1 case of splenic hemangioma, 1 case of splenic cyst, and 4 cases of portal hypertension, who underwent MLS performed by other senior surgeons in the same surgical group from March 2010 to January 2013 were evaluated to serve as a control group. Patients were retrospectively identified by searching an electronic database. Medical records regarding characteristics of patients and operative outcomes were reviewed to collect relevant data. Postoperative pain was strictly assessed by using a same visual analog scale in the two groups.15 Complications were graded according to the modified Clavien–Dindo classification scheme of surgical complications.16 This study was approved by the Institutional Review Board at the Shengjing Hospital of China Medical University (Shenyang, China).
three ports were placed within the umbilical incision in an inverted equilateral triangular configuration, 1 cm apart, with the camera placed at the apex (Fig. 1). A 30 10-mm rigid laparoscope (Stryker Endoscopy, San Jose, CA) was used throughout the procedures. A grasper was inserted through the 5-mm trocar, while a Harmonic scalpel (Ethicon EndoSurgery) or LigaSure (Covidien, Mansfield, MA) is inserted through the 12-mm trocar for dissection. For the majority of the cases, once access was obtained, the intraabdominal procedure was virtually the same as for multiport laparoscopy. The first step was to free the inferior pole of the spleen with the dissection of the splenocolic ligament. Second, the gastrosplenic ligament was opened by the Harmonic scalpel, and the lesser sac was explored to expose the splenic hilum. Then, splenorenal and splenophrenic ligaments were also freed. A dissector was used to elevate the lower pole of the spleen, and the splenic pedicle was stapled by a 60-mm endoscopic stapler with a white cartridge (Fig. 2). For the patient with a splenic aneurysm, the lesion was closely attached to the major blood vessels of the spleen and pancreatic tail, making it impossible to preserve the spleen and pancreatic tail. After the spleen was initially freed from its surrounding ligaments, in the order of gastrocolic, gastrosplenic, splenorenal, and splenophrenic ligaments, and the tail of the pancreas was freed from the lower and posterior pancreas, the whole mass, including the tail of the pancreas, the aneurysm, and the normal-sized spleen, were dissected together by a 60-mm endoscopic stapler with a blue cartridge with a single bite at the pancreatic tail. For the patient with
Surgical technique
SILS-Sp procedures were performed with the patient under general anesthesia and in the supine position with legs parted and the left shoulder raised 15–20. The viewing monitor was placed above the patient’s left shoulder, with the surgeon standing between the patient’s legs and the camera operator on the patient’s right side. Pneumoperitoneum was established by using the closed Veress needle technique through the umbilicus. After insufflation of CO2 and maintaining the pressure at 13 mm Hg, a 3-cm periumbilical incision was made, preserving the fascial layer for trocar access. Conventional trocars were used, including a 5-mm and a 10-mm standard trocar and an unbladed trocar (ENDOPATH Xcel B12LT; Ethicon Endo-Surgery, Inc., Blue Ash, OH). The
FIG. 2. The splenic pedicle was dissected using an endoscopic stapler.
COMPARISON STUDY BETWEEN SILS-SP AND MLS
801
traumatic rupture of the spleen, in order to control the bleeding first, the splenic artery was ligated first as we have described in the literature.17 For patients with gallstones or portal hypertension, concurrent cholecystectomy or pericardial devascularization was also performed as we have reported in the literature.18 For all cases, a specimen bag was finally inserted through the 12-mm trocar, and the spleen was placed in it to be removed piecemeal from the abdominal cavity. Statistical analysis
Continuous data are presented as the mean – standard deviation, median, and range. Categorical variables are expressed as numbers and percentages for the group from which they were derived. Continuous variables were compared between the single-incision and standard laparoscopic splenectomy groups using an unpaired-sample Student’s t test and the Mann–Whitney test. Results were considered statistically significant for P < .05. Results
Patient characteristics of both groups are listed in Table 1. All preoperative patient characteristics of the SILS-Sp group were compared with those of the patients who underwent MLS, and there were no statistically significant differences between the groups (Table 1). Operative data are given in Table 2. In the SILS-Sp group, all operations were successfully completed with a single incision without conversion to open procedures or placement of additional ports. The median operative time (SILS-Sp,
165.38 – 41.51 minutes; MLS, 158.50 – 40.66 minutes; P = .68) and median estimated blood loss (SILS-Sp, 143.8 5 – 56.94 mL; MLS, 139.17 – 48.33 mL; P = .827) did not significantly differ between the two groups. Six patients (46.2%) in the SILS-Sp group and 5 (41.7%) in the MLS group required intraoperative transfusion of blood supplements (including platelet transfusions); these rates were similar. The median length of stay was 8.8 days for the SILSSp group and 8.3 days for the MLS group. There was no mortality in either group. The complication rate in the SILSSp group was 7.7%, with 1 patient who developed a postoperative splenic bed bleeding and was re-operated on laparoscopically (Grade 3), and 8.3% in the MLS group, with 1 patient who developed a postoperative deep vein thrombosis (Grade 2). The complication rates were similar in both groups. The media cost for the SILS-Sp group was 36,800 Chinese yuan (roughly equivalent to $5993 U.S.) versus 37,400 Chinese yuan (roughly equivalent to $6091 U.S.) for the MLS group, which did not significantly differ between the two groups (P = .911). SILS-Sp using conventional instruments was associated with reduced postoperative pain scores, but this did not reach statistical significance (3.2 – 0.2 versus 3.6 – 0.9 for postoperative Day 1 [P > .05]; 1.8 – 0.1 versus 2.0 – 0.45 for postoperative Day 2 [P > .05]) (Table 3). There were no incisional hernias in the SILS-Sp group during the average 2 years of follow-up. Discussion
This series demonstrates SILS-Sp using conventional instruments to be feasible in 13 consecutive unselected patients
Table 1. Characteristics of Patients Who Underwent Single-Incision and Standard Laparoscopic Splenectomy SILS-Sp (n = 13) Gender [n (%)] Male Female Diagnosis [n (%)] Splenic aneurysm Traumatic rupture of the spleen ITP Congenital hemolytic anemia with gallstones Splenic hemangioma Splenic cyst Portal hypertension ASA grade [n (%)] 1 2 3 4 Prior abdominal surgery [n (%)] Surgical procedure [n (%)] Splenectomy + distal pancreatectomy + cholecystectomy + pericardial devascularization Age (years) [mean – SD (range)] Body mass index (kg/m2) [mean – SD (range)] ASA [mean – SD (range)]
MLS (n = 12)
P .91
10 (76.92) 3 (23.08)
9 (75) 3 (25) .712
1 1 1 1 2 2 5
(7.7) (7.7) (7.7) (7.7) (15.4) (15.4) (38.4)
1 1 3 1 1 1 4
(8.3) (8.3) (25) (8.3) (8.3) (8.3) (33.3)
4 5 4 0 0
(30.8) (38.4) (30.8) (0) (0)
4 4 4 0 0
(33.3) (33.3) (33.3) (0) (0)
.189
> .9 6 1 1 5 42.15 – 14.62 23.38 – 2.49 2 – 0.82
(46.2) (7.7) (7.7) (38.4) (17–73) (18.6–26.6) (1–3)
6 1 1 4 41.67 – 14.08 23.29 – 2.69 2 – 0.85
(50) (8.3) (8.3) (33.4) (23–74) (19.1–27.8) (1–3)
.933 .929 > .9
ASA, American Society of Anesthesiologists; ITP, idiopathic thrombocytopenia purpura; MLS, multiple-incision laparoscopic splenectomy; SD, standard deviation; SILS-Sp, single-incision laparoscopic surgery splenectomy.
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Table 2. Operative Outcomes for Single-Incision and Standard Laparoscopic Splenectomy SILS-Sp (n = 13) Operative time (minutes) (mean – SD) 165.38 – 41.51 Estimated blood loss (mL) (mean – SD) 143.85 – 56.94 Blood transfusion [n (%)] 6 (46.2) Conversion to open surgery [n (%)] 0 (0) Weight of spleen (g) (mean – SD) 808 – 152 Intake of liquid diet (days) (mean – SD) 2.3 – 0.7 Mortality [n (%)] 0 (0) Morbidity [n (%)] 1 (7.7) Complications (Clavien–Dindo classification) [n (%)] Grade 1 0 (0) Grade 2 0 (0) Grade 3 1 (7.7) Grade 4 0 (0) Grade 5 0 (0) Hospital stay (days) (mean – SD) 8.8 – 1.2 Cost (U.S. dollars) (mean – SD) 5993 – 570
MLS (n = 12) 158.50 – 40.66 139.17 – 48.33 5 (41.7) 0 (0) 825 – 142 2.6 – 0.9 0 (0) 1 (8.3) 0 (0) 1 (8.3) 0 (0) 0 (0) 0 (0) 8.3 – 1.4 6091 – 407
P .68 .827 .821 .846 > .9
.921 .911
MLS, multiple-incision laparoscopic splenectomy; SD, standard deviation; SILS-Sp, single-incision laparoscopic surgery splenectomy.
with no conversions to open splenectomy or placement of additional ports. Unlike previous reports, our series demonstrates that SILS-Sp can be applied to a diverse patient population, including patients in emergency condition (traumatic rupture of the spleen), who require concurrent operations (distal pancreatectomy, cholecystectomy, or pericardial devascularization), have medical comorbidities (American Society of Anesthesiologists up to grade 3), and have severe thrombocytopenia (preoperative platelet count as low as 35 · 109/L in 1 patient with portal hypertension). Although these examples represented the extremes in our population, these types of patients are seen in everyday practice. We also demonstrated that SILS-Sp is efficient, although our mean operative time of 165 minutes is slightly longer than the times published for MLS19,20 or SILS-Sp.21,22 It should be noted that some complicated concurrent operations have been successfully performed by the surgical team. To ensure efficiency, we think accumulation of SILS experience for a period of time is essential in the beginning for splenic surgeons without extensive SILS experience, or they could team up with a SILS expert for initial operations. We began to perform SILS in 2009, and with the experiences gradually accumulating, 10 months later, we attempted the first SILSSp. In addition, what we still want to highlight is that the average body mass index of the patients in our study is only 23.38 kg/m2, although our consecutive patient study does not specifically restrict this. This may be related to eating habits in China. For patients with a high body mass index, careful consideration should be given before attempting SILS-Sp, as
Table 3. Comparison of Postoperative Pain Scores
Postoperative Day 1 Postoperative Day 2
SILS-Sp (n = 13)
MLS (n = 12)
P
3.20 – 0.20 1.80 – 0.10
3.60 – 0.90 2.00 – 0.45
> .05 > .05
Data are mean – standard deviation values. MLS, multiple-incision laparoscopic splenectomy; SILS-Sp, single-incision laparoscopic surgery splenectomy.
a high body mass index would increase the difficulty and risks of SILS, as well as the wound complication rate.23 So, this approach may not be very applicable in patients with a high body mass index, in whom the transumbilical approach would not be feasible. In this series we compared the initial experience of a single surgeon performing SILS-Sp with other senior surgeons’ experience in the same surgical group. All surgeons are highly experienced laparoscopic surgeons and routinely perform MLS. There were no differences in preoperative patient characteristics between the two groups. SILS-Sp using conventional instruments was associated with reduced postoperative pain scores, but this did not reach statistical significance. The operative time, conversion rate, and length of stay were equivalent. The mortality, morbidity, and cost were also similar in the two groups. Studies comparing postoperative median pain score between SILS-Sp and MLS are still limited with controversial results. A recent meta-analysis that pooled randomized trials comparing single-incision laparoscopic cholecystectomy and multiple-incision laparoscopic cholecystectomy found no difference in short-term postoperative pain intensity.24 We think, in our study, that improvements in pain and analgesia theoretically associated with the reduction of port sites may be offset by a larger incision, more torque through a single site, and greater peritoneum tension. With any new technology, associated cost needs to be considered. Unlike other reports of SILS-Sp requiring purchase of proprietary access devices and additional pieces of equipment, we used conventional instruments during the procedure, which did not increase the economic burden of the patients. Significantly improved cosmesis is an obvious advantage of the procedure. Indeed, when performed through the umbilicus, the procedure is virtually scarless (the umbilicus is a natural scar of the abdomen surface). Overall, our series demonstrates that SILS-Sp is at least equivalent to MLS. Of course, limitations exist in this study. This is a retrospective study with a small number of patients, and only a single surgeon’s experience with a small group of colleagues
COMPARISON STUDY BETWEEN SILS-SP AND MLS
was compared. Lack of representativeness of the general surgeon population is its main limitation. Nevertheless, the study does demonstrate that the procedure is feasible in treating consecutive patients meeting indications for splenectomy in the hands of experienced laparoscopic surgeons. With the gradual accumulation of surgeons’ experience with SILS, it could be attempted in suitable cases where patients have strong concerns about cosmetic appearance; perhaps in the future, improvements in laparoscopic instruments will also render SILS more straightforward. Conclusions
It is our opinion that SILS-Sp is feasible and efficient in an unselected patient population in the hands of an experienced laparoscopic surgeon. The single-incision technique is comparable to standard laparoscopic splenectomy in terms of operative time and perioperative outcomes. Ideal cosmetic effect may be its potential advantage. Disclosure Statement
No competing financial interests exist. References
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Address correspondence to: Shuo-Dong Wu, MD, PhD Department of the Second General Surgery Sheng Jing Hospital of China Medical University No. 36, Sanhao Street Heping District Shenyang City, Liaoning Province, 110004 China E-mail: [email protected]
