ORIGINAL ARTICLE Complications of Laparoscopic Splenectomy Eduardo M. Targarona, MD, PhD; Juan Jose´ Espert, MD; Ernest Bombuy, MD; Oscar Vidal, MD; Gemma Cerda´n, MD; Vicente Artigas, MD, PhD; Manuel Trı´as, MD, PhD Hypothesis: Analysis of the type and characteristics of Results: One hundred thirteen laparoscopic splenectomies complications after laparoscopic splenectomy may per- were completed (conversion rate, 7.4%). Twenty patients mit the identification of clinical factors with predictive (18%) developed 23 complications. All were Clavien type value for the development of complications. I or II, without mortality. One complication was intraop- erative (diaphragmatic perforation), and 22 were postop- Design: Univariate and multivariate analysis of factors erative: 6 pulmonary (26%), 3 fever (13%), 8 hemorrhagic related to complications in a prospective series of lapa- (35%) (5 episodes of postoperative bleeding and 3 abdomi- roscopic splenectomies. nal wall hematomas), and 6 others (26%). Ten (43%) of the 23 were technically related. Univariate analysis showed Setting: A large tertiary referral university–teaching gen- that complications were only related to age (mean±SD, eral hospital. 55±15 vs 39±17 years; P,.008) or transfusion (50% vs 11%; P,.001). Multivariate analysis showed that the learn- Patients: One hundred twenty-two nonselected con- ing curve (P,.005; 95% confidence interval, 2.46), age secutive patients, in whom laparoscopic splenectomy was (P,.001; 95% confidence interval, 1.04), spleen weight attempted between February 1993 and July 1999. (P,.009; 95% confidence interval, 1.00), and malignant neoplasmdiagnosis(P,.007;95%confidenceinterval,3.82) Intervention: Laparoscopic splenectomy. were independent predictors of complications. Main Outcome Measures: Immediate complica- Conclusions: Laparoscopic splenectomy is feasible, and tions classified according to the Clavien score. Univari- the incidence of severe complications is reduced. How- ate and multivariate analyses were performed of compli- ever, a high proportion of these complications are tech- cations related to age, sex, body mass index, and nique related. Laparoscopic splenectomy requires great malignant nature of the hematologic disease; preopera- technical care but offers major clinical advantages, even tive hematocrit and platelet count; operative time; in less favorable situations, such as in patients with sple- operative position; need of accessory incision; transfu- nomegaly or with malignant neoplasms. sion status; learning curve; and existence of comorbid diseases. Arch Surg. 2000;135:1137-1140 APAROSCOPIC splenectomy RESULTS (LS) has become increas- ingly popular in recent years.1-3 However, it entails One hundred thirteen LSs were com- technical difficulties due to the pleted (conversion, 9 [7.4%] of 122); the Lspleen’s vascular anatomic features and its clinical details are as follows: frail texture. In addition, the specific fea- Clinical Outcome Value* tures of hematologic diseases (low platelet Operative time, min 153 ± 59 (60-240) count, splenomegaly, or systemic disease Transfusion, % 18 [lymphoma]) may increase postoperative Morbidity, % 18 From the Services of General morbidity. The best evaluation of a new pro- Hospital stay, d 4 ± 2 (2-14) and Digestive Surgery, Hospital cedure is via an analysis of its complica- Spleen weight, g 493 ± 588 (60-3200) Accessory spleen, % 12 de Sant Pau, Autonomous tions and the advantages it offers; in the case University of Barcelona Accessory incision, % 36 (Drs Targarona, Cerda´n, of LS, an important argument in its favor is the reduction of the morbidity rate. Thus, *Data are given as mean±SD (range) unless other- Artigas, and Trı´as), and wise indicated. Hospital Clinic (Drs Espert, this study analyzes the type and character- Bombuy, and Vidal), istics of complications related to LS in a con- No conversions were related to Barcelona, Spain. secutive series of 122 patients. intraoperative complications. Twenty (REPRINTED) ARCH SURG/ VOL 135, OCT 2000 WWW.ARCHSURG.COM 1137 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Table 2. Clavien Classification for Surgical Complications* PATIENTS AND METHODS Clavien Type Description I Mild complications that do not affect the Between February 1993 and July 1999, 122 patients patient’s recovery in the hospital with a wide range of splenic disorders (Table 1) re- IIa Potentially life-threatening quiring splenectomy were approached about under- complications without sequel that going laparoscopy. Clinical data, technical details, and require noninvasive therapy immediate outcome were recorded prospectively. All IIb Potentially life-threatening patients received a preoperative pneumococcal vac- complications without sequel that require interventional therapy cine, and antibiotic prophylaxis was initiated intra- III Complications with residual disability operatively. Laparoscopic splenectomies were per- IV Death formed through an anterior or lateral approach, using 4 techniques previously described. Immediate com- *Data from Clavien et al.5 plications were prospectively recorded and classi- fied according to the Clavien score (Table 2).5 Uni- variate and multivariate analyses were performed of complications related to age, sex, body mass index Table 3. Postoperative Complications After Successful (calculated as weight in kilograms divided by the Laparoscopic Splenectomy square of height in meters), and malignant nature of the hematologic disease; preoperative hematocrit and Complications* Clavien Type Technique Related platelet count; operative time; operative position; need Hemorrhagic of an accessory incision; transfusion status; learning Abdominal wall hematoma (3) I Yes curve; and the existence of comorbid diseases. The Subdiaphragmatic hematoma IIa Yes 2 x test was used for comparison of the 2 propor- Hemoperitoneum (3) IIb Yes tions, and the t test was used to compare differences Hemopneumothorax IIb Yes between the 2 series. Multivariate analysis and a model Lung of logistic regression with backward and forward Atelectasis IIa No analysis were used. Pneumonia (2) IIa No Upper airway infection (2) I No Fever and lung tuberculosis II No Septic Wound sepsis I Yes Catheter sepsis II No Table 1. Hematologic Diagnosis in 122 Cases of Attempted Urinary infection I No Laparoscopic Splenectomy* Others Sweet syndrome II No Gout attack I No Hematologic Diagnosis No. of Cases Hypophyseal insufficiency II No Autoimmune low platelet counts 52 Postoperative ileus (2) I No ITP 46 Diaphragmatic perforation II Yes Evans syndrome 3 ITP and systemic lupus erythematosus 2 *Numbers in parentheses indicate the number of cases. ITP and myelodysplastic syndrome 1 HIV related 8 Low platelet counts 5 patients (18%) in the successful LS group developed 23 Hypersplenism 1 complications. All of them were Clavien type I or II, and Splenomegaly and suspicion of malignant neoplasm 2 there was no mortality. Complications and their type are Autoimmune hemolytic anemia 9 described in Table 3. Of the 23 complications, 10 (43%) Spherocytosis 14 Malignant neoplasm 29 were technically related to the procedure, 8 (35%) were Non-Hodgkin lymphoma 15 hemorrhagic complications, 6 (26%) were pulmonary Myelofibrosis 3 complications, 3 (13%) were infectious complications, Chronic lymphocytic leukemia 3 and 6 (26%) were other types of complications. Com- Chronic myeloid leukemia 1 plications were not related to the diagnosis of a malig- Hairy cell lymphoma 4 nant neoplasm (malignant vs benign, 37% vs 21%), spleen Others 3 weight (patients with complications vs those without com- Others 10 Splenomegaly 2 plications, 717±504 vs 474±628 g), or operative time (pa- Splenic tumor tients with complications vs those without complica- Hydatidic cyst 1 tions, 172±75 vs 147±54 minutes; P,.06) (data are given Hamartoma 1 as mean±SD unless otherwise indicated). However, pa- Cyst 1 tients with complications were significantly older and re- Angioma 3 quired more blood (53% vs 13%; P,.001); complica- Splenic trauma 1 Thrombotic thrombocytopenic purpura 1 tions had a direct impact on postoperative stay (mean±SD, 9±5 vs 3±1 days; P,.001) (Table 4). *ITP indicates idiopathic thrombocytopenic purpura; HIV, human Logistic regression analysis indicated that factors with immunodeficiency virus. predictive power for morbidity were age, spleen weight, (REPRINTED) ARCH SURG/ VOL 135, OCT 2000 WWW.ARCHSURG.COM 1138 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 malignant nature of the disease, and procedures per- formed early in our experience (learning curve) (Table 5). Table 4. Results of Univariate Analysis of Clinical Factors The reasons for the 9 conversions were as follows: Related to Complications After Laparoscopic Splenectomy diffuse oozing (n=2), spleen size (n=6), and adhesions Patients Patients (n=1). The characteristics of the 9 patients are as follows: With Without Characteristic Value Complications Complications Age, mean±SD 55±20 Clinical Factor (n = 20) (n = 93) P Male-female ratio 5:4 Sex, M/F 9/11 25/68 ..18 Body mass index, mean±SD 24±3 Age, mean ± SD, y 55 ± 15 39 ± 17 ,.001 Spleen weight, mean±SD (range), g 1843±1323 (200-3500) Body mass index, 25.0 ± 5.0 25.0 ± 4.5 ..99 Maligant-benign disease ratio 4:5 mean ± SD* Complications, No. (%) 2 (22%) Preoperative hematocrit 0.37 ± 0.05 0.35 ± 0.07 ,.22 Transfusions 7 Preoperative platelet count, 111 ± 114 104 ± 93 ,.78 Postoperative