ABSTRACT
Resumen: Introducción: si bien la esplenectomía laparoscópica en esplenomegalias masivas y supramasivas constituye un desafío técnico, su realización es factible y segura en centros con equipos con experiencia en cirugía laparoscópica. Objetivo: presentar el primer caso de esplenectomía laparoscópica en esplenomegalia masiva realizada en Uruguay. Caso clínico: se trata de una paciente de 70 años portadora de una pancitopenia periférica, esplenomegalia masiva y diagnóstico realizado por punción de médula ósea de neoplasia linfoproliferativa tipo B de bajo grado, a quien se le indicó la esplenectomía con fines diagnósticos y terapéuticos. La paciente se operó en decúbito lateral derecho a 15 grados, los trócares se colocaron bajo visión directa adaptados al tamaño del bazo que se extendía desde el diafragma hasta el estrecho superior de la pelvis. Se realizó la esplenectomía en un tiempo de 220 minutos, extrayéndose la pieza íntegra y sin haberla colocado en bolsa a través de un hemi Pfannenstiel, protegiendo la pared con un retractor de heridas quirúrgicas. No presentó complicaciones, fue dada de alta a las 48 horas. El hemograma realizado a las 24 horas demostró un aumento de las cifras de todas las series celulares y el informe anatomopatológico diagnosticó un linfoma no Hodgkin de zona marginal. Discusión: la esplenectomía laparoscópica en esplenomegalias masivas requiere de un mayor tiempo quirúrgico, aunque las pérdidas sanguíneas y la estadía hospitalaria son menores en comparación a los procedimientos convencionales, presentando una morbilidad similar. En la experiencia inicial de los equipos quirúrgicos se reporta un porcentaje de conversiones y reingresos cercanos al 30%.
Abstract: Introduction: despite the fact that laparoscopic splenectomy for massive and supramassive splenomegaly constitutes a technical challenge, it is a feasible and safe procedure in the context of institutions with experienced teams in laparoscopic surgery. Objective: to present the first case of laparoscopic splenectomy for massive splenomegaly in Uruguay. Clinical case: the study presents the case of a 70-year-old patient carrier of peripheral pancytopenia, massive splenomegaly and a diagnosis of type B lymphoproliferative neoplasm based on bone marrow aspiration and biopsy, who underwent diagnostic and therapeutic splenectomy. The patient was operated in supine position with a 15-degree tilt, the trocars were placed under direct view, adapted to the size of the spleen which went from the diaphragm until the superior pelvic outlet. Splenectomy was performed in 220 minutes, the entire piece was removed through a hemi Pfannenstiel incision, without placing it in a bag, the wall being protected with a surgical wound retractor. There were no complications and the patient was discharged from hospital 48 hours. The blood count performed after 24 hours evidenced increase in all cell series and the pathology report confirmed diagnosis of marginal zone non- Hodgkin lymphoma. Discussion: laparoscoppic splenectomy in massive splenomegaly requires of a greater surgical time, although blood loss and hospital star are lower when compared to conventional procedures and evidence similar morbility. The initial experience of surgical teams reports 30% of conversions and readmissions.
Resumo: Introdução: embora a esplenectomia laparoscópica em esplenomegalias massivas e supremassivas seja um desafio técnico, sua realização é viável e segura em centros com equipes com experiência em cirurgia laparoscópica. Objetivo: apresentar o primeiro caso de esplenectomia laparoscópica em esplenomegalia maciça realizada no Uruguai. Caso clínico: paciente de 70 anos com pancitopenia periférica, esplenomegalia maciça e diagnóstico feito por punção de medula óssea de neoplasia linfoproliferativa tipo B de baixo grau, com indicação de esplenectomia para fins diagnósticos e terapêuticos. A paciente foi operada em decúbito lateral direito a 15 graus, os trocartes foram colocados sob visão direta adaptados ao tamanho do baço que se estendia do diafragma ao estreito superior da pelve. A esplenectomia foi realizada em um tempo de 220 minutos, retirando-se toda a peça e sem colocá-la em bolsa por meio de uma hemi Pfannenstiel, protegendo a parede com afastador de ferida operatória. Sem apresentar complicações a paciente teve alta após 48 horas. O hemograma realizado 24 horas depois da cirurgia mostrou um aumento no número de todas as séries de células e o laudo anatomopatológico diagnosticou linfoma não Hodgkin de zona marginal. Discussão: a esplenectomia laparoscópica nas esplenomegalias maciças requer um tempo cirúrgico maior, embora as perdas sanguíneas e a permanência hospitalar sejam menores em comparação aos procedimentos convencionais, apresentando morbidade semelhante. Na experiência inicial das equipes cirúrgicas, é relatado um percentual de conversões e readmissões próximo a 30%.
Subject(s)
Humans , Female , Aged , Splenectomy , Splenomegaly/surgery , Laparoscopy , Lymphoma, Non-HodgkinABSTRACT
Laparoscopic splenectomy(LS) is superior to open splenectomy(OS) because of advantages of minimal invasion,such as small trauma,rapid recovery,and short hospitalizing time,widely used in the resection of normalsized or moderately enlarged spleens. With the wide application of LS,the indications have been extended to the excision of massive spleens. However,there is still a tremendous controversy about the upper limit of splenic size which can be in accord with a requirement of LS and selection of surgical indications. Taking the issues into account,the authors recommended that the splenomegaly should be divided into“four degrees”rather than“three degrees”used today widely in order to guide the selection of appropriate surgical methods.
ABSTRACT
Although the clinical benefit of laparoscopic splenectomy and devascularization (LSD) has been elaborated in many studies, its application in massive splenomegaly remains controversial. We conducted a retrospective research to assess the curative efficacy of LSD for massive splenomegaly due to portal hypertension. Forty-seven patients with massive splenomegaly due to portal hypertension were enrolled in this study, and divided into two groups. Twenty-one patients underwent open splenectomy and devascularization (OSD) from June 2010 to October 2012 (OSD group). From March 2013 to February 2015, LSD was performed on 26 patients (LSD group). Perioperative variables were analyzed. Compared to OSD, LSD was associated with less blood loss (241.9±110.0 mL vs. 319.0±139.5 mL, P<0.05), more rapid resumption of oral diet (2.46±0.95 days vs. 3.76±1.09 days, P<0.05), and shorter postoperative hospital stay (5.35±1.65 days vs. 7.24±1.55 days, P<0.05). It was concluded that for patients with massive splenomegaly due to portal hypertension, LSD is feasible and as safe as OSD.
Subject(s)
Adult , Female , Humans , Male , Middle Aged , Blood Loss, Surgical , Hypertension, Portal , Laparoscopy , Methods , Length of Stay , Splenectomy , Methods , Splenomegaly , General Surgery , Vascular Surgical Procedures , MethodsABSTRACT
Objective To study the impact of obesity on the perioperative outcomes of hand-assisted laparoscopic splenectomy combined with esophagogastric devascularization (LSED).Methods The clinical data of patients who underwent hand-assisted laparoscopic splenectomy combined with esophagogastric devascularization between Jan.2013 and Nov.2015 were retrospectively analyzed.The patients were classified as obese group A (BMI≥28 kg/m2) or non-obese group B (BMI ＜ 28 kg/m2).Group A was further divided into two subgroups:group A1 massive splenomegaly (diameter ＞ 20 cm) and A2 splenomegaly (diameter ≤20 cm).The conversion rates,operative complications,mortality,length of stay,operative time,and blood loss were analyzed and compared.Results One hundred and sixty patients who underwent hand-assisted LSED were included into this study.54 patients were in group A and 106 in group B.A significantly longer operative time was found in group A (291 min vs.261 min,P ＜ 0.05).The conversion rates,blood loss,length of hospital stay,overall morbidity rates,and mortality rates were similar in the two groups (P ＞0.05).The mean operative time was significantly longer in group A1 (336 min vs.270 min;P ＜0.01)although blood loss,conversion rates,and overall morbidity rates were higher in group A1.However,there were no significant differences (P ＞ 0.05).Conclusions Hand-assisted laparoscopic splenectomy combined with esophagogastric devascularization for obese patients was safe and feasible.However,for patients with massive splenomegaly,LSED should be performed with caution.
ABSTRACT
Tumours of the spleen are as such rare. Of these rare tumours, haemangioma is the most commonly encountered benign tumour with fewer than 100 cases reported. It is either an incidental finding or presents as splenic enlargement or with complications. Preoperative investigations are often inconclusive and may not distinguish between haemangioma and metastases. We report a case of 40 years female with cavernous haemangioma of spleen presenting as massive splenomegaly. Splenic haemangioma presenting as massive splenomegaly is extremely rare and deserves a mention.
ABSTRACT
Splenomegaly is a common finding in a wide-spectrum of diseases. It is usually reported in myeloproliferative disorders, lymphoma, leukemia, visceral leishmaniasis, tropical malaria and extrahepatic (noncirrhotic) portal hypertension. We describe herein recently encountered one unusual case of massive splenomegaly in a patient of hepatic cirrhosis with portal hypertension. This case report highlights that cirrhotic portal hypertension may be added in the differential diagnosis of massive splenomegaly to facilitate timely diagnosis and treatment.
ABSTRACT
Massive splenomegaly is in the which the growth of the spleen has spread to other quadrants of the abdomen. It is produced by a limited number of pathologies, both benign and malignant. It is presented a case of a 62 year-old woman who is consulting for four years of progressive increase in her abdominal volume, associated to the feeling of abdominal fullness, dyspnea on moderate exertion and lower extremities edema. At the physical examination was observed massive splenomegaly and jaundice. The hemogram showed pancytopenia and a lymphocyte count of80 percent. The myelogram revealed marrow infiltration by lymphocytes of mature appearance. Flow cytometry of peripheral blood showed 70 percent of lymphocytes, which expressed B cells markers CD19, CD20, CD23and FMC7 in addition to Kappa light chain restriction, suggesting marginal splenic zone lymphoma. The bone marrow biopsy showed lymphoid small cells infiltrate with positive markers CD20, CD5,CD23 and negative cyclin D1 study. BCL-2 was also positive. It was considered unfit to receive chemotherapy and was treated with 4 cycles of rituximab, with significant decrease of splenic size.
Subject(s)
Humans , Female , Middle Aged , Splenomegaly/pathology , Lymphoma, B-Cell, Marginal Zone/pathology , Splenic Neoplasms/pathology , Antibodies, Monoclonal, Murine-Derived/therapeutic use , Antineoplastic Agents/therapeutic use , Splenomegaly/etiology , Lymphoma, B-Cell, Marginal Zone/complications , Lymphoma, B-Cell, Marginal Zone/drug therapy , Splenic Neoplasms/drug therapyABSTRACT
The spleen whose size reaches or exceeds third degree should be regarded as massive splenomegaly.Splenectomy for massive splenomegaly demands precise procedures.First,median incision on upper abdomen(or vertical rectus muscle splitting incision)and incision under left costal arch are preferred.Second,the spleen was freed and then 0.33 mg of epinephrine was injected via the splenic artery before splenic artery ligation.During the process,a cell saver helps to minimize blood loss and makes autoinfusion possible for patients with benign lesions.Third,preoperative administration of fibrinogen,platelet and essential styptieum combined with the cooperation between surgeons and anesthesi010gists are the key points of bloodless surgery which is important for the recovery of patients.Four common problems of splenectomy for massive splenomegaly should also be addressed,including operation discontinuance,perioperative hemorrhage,accessory injury and postoperative intractable fever.
ABSTRACT
Objective To explore the safety, feasibility, and techniques of hand-assisted laparoscopic splenectomy (HSLS) for massive splenomegaly. Methods Between January 2005 and December 2006, 40 patients with massive splenomegaly owning to portal hypertension were treated with HSLS or open splenectomy (OS). The two groups were comparable in age, sex, hepatic function by Child classification, and size of the spleen. Results No serious complications occurred in both the groups. Compared with the OS group, patients in the HALS group had more blood loss [ (312?61) ml vs (235?105) ml, t=2.583, P=0.014], longer operation time [(95?20) min vs (73?16) min, t=3.832, P=0.000], earlier recovery of intestinal function [(48?1) h vs (98?1) h, t=-153.093, P=0.000], and shorter postoperative hospital stay [(6?2) d vs (10?2) d, t=-6.124, P=0.000]. Conclusions HSLS is feasible and safe for patients with massive splenomegaly. Despite a longer operation time, the procedure is superior in postoperative recovery.