Refining the selection criteria for laparoscopic versus open splenectomy for splenomegaly

Background: Although laparoscopic splenectomy is considered the procedure of choice for patients with normal-sized spleens, the benefits are less clear in the presence of splenomegaly, which represents a heterogeneous patient population with a variety of underlying diseases. The aim of this study was to compare the outcomes of laparoscopic (LS) and open splenectomy (OS) for spleens between 15 and 25 cm in length in order to identify strategies for patient selection for the laparoscopic approach. Study Design: The medical records of concurrent patients undergoing splenectomy for splenomegaly (>15 cm in the long axis) from 2000 to 2005 were reviewed at two hospitals. At one hospital, LS was performed unless the spleen was >25 cm in length, while the other hospital used OS exclusively. Demographic, intraoperative, and postoperative variables were compared for patients potentially eligible for LS. Data are expressed as median (interquartile range) and were analyzed by using nonparametric tests. A value P < 0.05 was considered statistically significant. Results: Sixty-five laparoscopic and 25 open splenectomies were performed at the two hospitals, of which 34 were for splenomegaly. Five open cases involved spleens >25 cm and were excluded, leaving 18 LS (13 hand assisted) and 11 OS for further analysis. The groups were similar in comorbidity score, spleen length, hematologic diagnosis, and intraoperative blood loss. The open group was younger, included more females, and had a shorter operative time. Time to oral intake (1 vs. 2 days; P = 0.04) and length of hospital stay (3 vs. 6 days; P = 0.01) were shorter in the LS group. Postoperative complications occurred in 7 (39%) LS and 6 (55%) OS patients (P = 0.47); these were major in 3 LS patients and 1 OS patient (P = 1.0). All 3 major complications after LS occurred in the 3 patients with myelofibrosis and involved a conversion or reoperation by laparotomy for bleeding. Conclusions: Laparoscopic splenectomy confers benefit for most patients with splenomegaly between 15 and 25 cm, as it is associated with faster time to oral intake and a shorter hospital stay. Major morbidity after laparoscopic splenectomy was mostly related to surgery for myelofibrosis. These patients did not derive any benefit from the laparoscopic approach due to bleeding complications, requiring a conversion or relaparotomy.