How I approach hereditary hemolytic anemia and splenectomy.

Hereditary hemolytic anemias (HHA) are a heterogeneous group of anemias associated with decreased red cell survival. While there can be clinical benefit of splenectomy in many cases, splenectomy is not appropriate for all types of HHA. Additionally, there are significant risks during and following splenectomy including surgical risks, postsplenectomy sepsis, and thrombotic complications. This review discusses the diagnostic approach to HHA as well as the role of splenectomy in the management. Surgical approaches and outcomes for total and partial splenectomy are discussed.

Splenic trauma, the way forward in reducing splenectomy: our 15-year experience.

INTRODUCTION: The aim of this study was to study radiological assessment, management and outcome of traumatic splenic injury over 15 years in a UK district general hospital. METHOD: A retrospective database was established including all splenic injury cases from June 2002 to June 2017 by searching the clinical electronic database. We searched the radiological database for computed tomography reported phrases 'spleen injury', 'laceration', 'haematoma', 'trauma'. We interrogated theatre records for operations coded as splenectomy and cross-referenced this with pathology. Records were reviewed for demographics, vital observations, documentation of American Association for the Surgery of Trauma (AAST) grading of splenic injury, subsequent management and outcomes. RESULTS: There were 126 patients identified with traumatic splenic injury, with male to female ratio three to one. Operative management was undertaken in 54/126 (43%) patients and selective non-operative management in the remaining. Splenic artery embolisation was undertaken in 5/126 (4%) and 2/126 underwent splenorrhaphy. Computed tomography was undertaken in 109/126 (87%) patients and AAST grading was reported in 18 (17%) patients. AAST grade reporting did not improve significantly when comparing the first 7.5 years with the latter (2/30, 7%; 16/79, 20%), respectively; p = 0.09). Selective non-operative management increased significantly over the studied period (14/34, 42%; 58/93, 62%; p = 0.04). The overall hospital mortality was 10.3%. DISCUSSION AND CONCLUSION: AAST grade reporting of splenic injury has remained sub-optimal over 15 years. Despite progression towards selective non-operative management, operative intervention remained unacceptably high, with splenectomy being the main therapeutic modality. Standardisation through an integrated multidisciplinary diagnostic and management pathway offers the optimal strategy to reduce trauma-induced splenectomy.

Laparoscopic near-total splenectomy: a single-center experience of a standardized procedure.

Background: Near-total splenectomy (NTS) represents an innovative and effective surgery technique for spleen disease, reducing the risk of severe infections and thromboembolic events after total splenectomy. The authors reported a laparoscopic near-total splenectomy (LNTS) surgical experience following the optimal results of the open approach, describing a standardized and effective minimally invasive technique with the purpose of preserving a minimal residual spleen.Material and methods: From November 2006 to September 2016, 15 patients with splenic and hematologic disease underwent LNTS, according to a laparoscopic procedure developed by the authors. The end criterion was to conserve a remanent spleen of 10-15 cm3 in size.Results: Patient age ranged between 18 and 59 years. Mean operative time was 70 ± 20 min. Mean hospital stay was 3.46 (range 3-7) days. One complication occurred during the surgery for a lesion of the inferior polar artery with need of a total splenectomy. No conversion to open surgery was necessary.Conclusions: LNTS is a safe and effective technique for the management of splenic and hematologic disease with a low intra- and post-operative complication rate, and it can minimize the late sequelae of secondary splenectomy. However, it requires further studies with more cases to evaluate its role.

Laparoscopic splenectomy is emerging 'gold standard' treatment even for massive spleens.

INTRODUCTION: Since its first description by Delaitre and Maignien in 1991, laparoscopic splenectomy (LS) has evolved as treatment of choice for mild-to-moderately-enlarged spleens and for benign haematological disorders. LS is a challenge if massive spleens or malignant conditions necessitate treatment, but we report our method and its feasibility in this study. METHODS: We undertook a retrospective study of prospectively collected data of all elective splenectomies carried out in our firm of upper gastrointestinal surgeons from June 2003 to June 2012. Only patients opting for elective LS were included in this study. RESULTS: From June 2003 to June 2012, elective splenectomy was carried out in 80 patients. Sixty-seven patients underwent LS and 13 underwent open splenectomy (OS). In the LS group, there were 38 males and 29 females. Age ranged from 6 years to 82 years. Spleen size in the LS group ranged from ≤11 cm to 27.6 cm. Twelve patients had a spleen size of >20 cm. Weight ranged from 35 g to 2,400 g. Eighteen patients had a spleen weight of 600-1,600 g and eight had a spleen weight >1,600 g. Operating times were available for 56 patients. Mean operating time for massive spleens was 129.73 min. There was no conversion to OS. There were no major complications. CONCLUSIONS: With improved laparoscopic expertise and advancing technology, LS is safe and feasible even for massive spleens and splenic malignancies. It is the emerging 'gold standard' for all elective splenectomies and has very few contraindications.

Recommendations for gross examination and sampling of surgical specimens of the spleen.

This review examines handling and processing of spleen biopsies and splenectomy specimens with the aim of providing the pathologist with guidance in optimizing examination and diagnosis of splenic disorders. It also offers recommendations as to relevant reporting factors in gross examination, which may guide diagnostic workup. The role of splenic needle biopsies is discussed. The International Spleen Consortium is a group dedicated to promoting education and research on the anatomy, physiology, and pathology of the spleen. In keeping with these goals, we have undertaken to provide guidelines for gross examination, sectioning, and sampling of spleen tissue to optimize diagnosis (Burke). The pathology of the spleen may be complicated in routine practice due to a number of factors. Among these are lack of familiarity with lesions, complex histopathology, mimicry within several types of lesions, and overall rarity. To optimize diagnosis, appropriate handling and processing of splenic tissue are crucial. The importance of complete and accurate clinical history cannot be overstated. In many cases, significant clinical history such as previous lymphoproliferative disorders, hematologic disorders, trauma, etc, can provide important information to guide the evaluation of spleen specimens. Clinical information helps plan for appropriate processing of the spleen specimen. The pathologist should encourage surgical colleagues, who typically provide the specimens, to include as much clinical information as possible.

Laparoscopic Splenectomy with Technical Standardization and Selection Criteria for Standard or Hand-Assisted Approach in 390 Patients with Liver Cirrhosis and Portal Hypertension.

BACKGROUND: Laparoscopic splenectomy (LS) is still challenging in patients with liver cirrhosis and portal hypertension. This study was designed to establish safe and less invasive LS in patients with liver cirrhosis and portal hypertension. STUDY DESIGN: We analyzed 390 patients with liver cirrhosis and portal hypertension, who underwent LS between 1993 and 2013. Patients were divided into 3 time periods; early (1993 to 2004, n = 106); middle (2005 to 2008, n = 159); and late (2008 to 2013, n = 125). During the middle time period, standardized technique for LS and selection criteria for hand-assisted LS were adopted. Patients with spleen volume ≥ 1,000 mL by CT volumetry, large perisplenic collateral vessels, and/or Child-Pugh score ≥ 9, underwent hand-assisted LS. During the late time period, the selection criteria were refined and patients with spleen volume ≥ 600 mL underwent hand-assisted LS. RESULTS: Conversion to open splenectomy decreased (10.4% in the early time period, 1.9% in the middle time period, and 3.2% in the late time period, p = 0.004), median blood loss decreased (300g, 87g, and 98g, respectively, p < 0.001), and the success rate of pure LS tended to improve (87.2%, 89.5%, and 98.0%, respectively, p = 0.110). Mortality was 0% in each time period, Clavien-Dindo grade IIIb or more complications tended to decrease (5.7%, 2.5%, and 0.8%, respectively, p = 0.081), and technique-related complications decreased significantly (10.4%, 3.8%, and 2.4%, respectively, p = 0.014). CONCLUSIONS: Laparoscopic splenectomy is now a safe and less invasive approach, even in patients with liver cirrhosis and portal hypertension, because of its technical standardization with the refined selection criteria for pure or hand-assisted LS.

[Comparison of laparoscopic and open splenectomy]. / Laparoscopos és nyitott splenectomia összehasonlítása.

INTRODUCTION: Conventional operative techniques are gradually being replaced by minimally invasive surgical methods in the surgery of the spleen. We summarized our 10-year-experience after the introduction of laparoscopic splenectomy at the University of Szeged, Department of Surgery, comparing open and minimally invasive techniques. MATERIAL AND METHOD: Between 1st January 2002 and 1st December 2011 we performed 141 splenectomies of which 17 were acute operations. Of the 124 elective procedures 54 were laparoscopic and 70 open operations. In 40 cases (open procedures) splenectomy was part of multivisceral surgery which were excluded from the analysis. In this retrospective analysis a comparison of laparoscopic and open elective technique was carried out. RESULTS: Average operating time of laparoscopic procedures was slightly longer than that of open technique (133 vs. 122 minutes, p = 0.074). After the learning period, duration of laparoscopic procedures became shorter (first five years: 147 min., second five years: 118 min, p = 0.003), larger spleens were removed (220 vs. 450 grams, p = 0.063) and conversion rate became lower. In cases of laparoscopic procedures fewer reoperations needed to be performed (1.5% vs. 6%, p = 0.718), bowel motility recovered earlier (2 vs. 3 days, p = 0.002) and hospital stay was shorter (5 vs. 8 days, p ≤ 0.001). CONCLUSION: Our study proves that laparoscopic splenectomy is a safe method with many advantages. Our results correlate with data of international publications.

Is expertise in pediatric surgery necessary to perform laparoscopic splenectomy in children? An experience from a department of general surgery.

Splenectomy is frequently required in children for various hematologic pathologic findings. Because of progress in minimally invasive techniques, laparoscopic splenectomy (LS) has become feasible. The objective of this report is to present a monocentric experience and to evaluate the efficacy of and complications observed after laparoscopic splenic procedures in a department of general surgery. 57 consecutive LSs have been performed in a pediatric population between January 2000 and October 2010. There were 33 females and 24 males with a median age of 12 years (range 4-17). Indications were: hereditary spherocytosis 38 cases, idiopathic thrombocytopenic purpura 10, sickle cell disease (SCD) 6, thrombocytopenic thrombotic purpura 2 and non-hodgkin lymphoma 1 case. Patients were operated on using right semilateral position, employing Atlas Ligasure vessel sealing system in 49 cases (86%) and Harmonic Scalpel + EndoGIA in 8. In 24 patients (42.1%), a cholecystectomy was associated. Two patients required conversion to open splenectomy (3.5%). In three cases, a minilaparotomy was performed for spleen removal (5.2%). Accessory spleens were identified in three patients (5.2%). Complications (8.8%) included bleeding (two), abdominal collection (one) and pleural effusion (two). There was no mortality. Average operative time was 128 min (range 80-220). Average length of stay was 3 days (range 2-7). Mean blood loss was 80 ml (range 30-500) with a transfusion rate of 1.7% (one patient). Laparoscopic spleen surgery is safe, reliable and effective in the pediatric population with hematologic disorders and is associated with minimal morbidity, zero mortality, and a short length of stay. Ligasure vessel sealing system shortened operative time and blood loss. On the basis of the results, we consider laparoscopic approach the gold standard for the treatment of these patients even in a department of general surgery.

Laparoscopic splenectomy: a personal series of 140 consecutive cases.

INTRODUCTION: Laparoscopic splenectomy has emerged as a safe and effective treatment for a variety of haematological conditions. The objective was to review the results from a large personal series from the perspective of outcomes according to operative time, conversion to open operation, complications and mortality. The application of laparoscopic splenectomy to cases of splenomegaly without hand assistance is examined. PATIENTS AND METHODS: A retrospective review of 140 patients undergoing laparoscopic splenectomy at a single university hospital by one surgeon during 1994-2006. Case notes were reviewed and data collected on operative time, conversion to open procedure, morbidity and mortality. Particular reference was made towards the results of cases of splenomegaly. RESULTS: In total 140 laparoscopic splenectomies were performed with a complication rate of 15% and no mortality. The median operative time was 100 min and conversion to open procedure was necessary in 2.1%. Conversion for cases of splenomegaly was only 5.7%. The median hospital stay was 3 days. CONCLUSIONS: Laparoscopic splenectomy is a safe procedure with acceptable morbidity. A laparoscopic approach for splenomegaly is feasible.

Reaching proficiency in laparoscopic splenectomy.

AIM: To investigate the proficiency level reached in laparoscopic splenectomy using the learning curve method. METHODS: All patients in need of splenectomy for benign causes in whom laparoscopic splenectomy was attempted by a single surgeon during a time period of 6 years were included in the study (n = 33). Besides demographics, operation-related variables and the response to surgery were recorded. The patients were allocated to groups of five, ranked according to the date of the operation. Operation duration, complications, postoperative length of stay, conversion to laparotomy and splenic weight were then compared between these groups. RESULTS: There was a significant difference regarding operation times between the groups (P = 0.001). An improvement was observed after the first 5 cases. The learning curve was flat up to the 25th case. Following the 25th case the operation times decreased still further. There was no difference between the groups regarding the other parameters. CONCLUSION: Unlike the widely accepted "L" shape, the learning curve for laparoscopic splenectomy is a horizontal lazy "S" with two distinct slopes. Privileges may be granted after the first 5 cases. However proficiency seems to require 25 cases.

Technical standardization of laparoscopic splenectomy harmonized with hand-assisted laparoscopic surgery for patients with liver cirrhosis and hypersplenism.

BACKGROUND/PURPOSE: The aims of this study were to standardize the techniques of laparoscopic splenectomy (LS) to improve safety in liver cirrhosis patients with portal hypertension. METHODS: From 1993 to 2008, 265 cirrhotic patients underwent LS. Child-Pugh class was A in 112 patients, B in 124, and C in 29. Since January 2005, we have adopted the standardized LS including the following three points: hand-assisted laparoscopic surgery (HALS) should be performed in patients with splenomegaly (> or =1,000 mL), perisplenic collateral vessels, or Child-Pugh score 9 or more; complete division and sufficient elevation of the upper pole of the spleen should be performed before the splenic hilar division; and when surgeons feel the division of the upper pole of the spleen is too difficult, conversion to HALS should be performed. RESULTS: There were no deaths related to LS in this study. After the standardization, conversion to open surgery significantly reduced from 11 (10.3%) of 106 to 3 (1.9%) of 159 patients (P < 0.05). The average operation time and blood loss significantly reduced from 259 to 234 min (P < 0.01) and from 506 to 171 g (P < 0.01), respectively. CONCLUSIONS: With the technical standardization, LS becomes a feasible and safe approach in the setting of liver cirrhosis and portal hypertension.

Late postoperative follow-up of patients undergoing subtotal splenectomy.

PURPOSE: Over the past 21 years, we have performed more than 200 subtotal splenectomies, in which the upper splenic pole vascularized only by the gastrosplenic pole vascularized only by the gastrosplenic vessels is preserved, to treat different pathologic conditions. A meticulous follow-up of the postoperative results of this procedure is of fundamental importance. METHODS: All patients undergoing subtotal splenectomy were invited to be reviewed. A total of 86 patients who had undergone surgery 1 to 20 years ago were gathered; the surgical procedure was performed for one of the following conditions: portal hypertension due to schistosomiasis (n = 43), trauma (n = 31), Gaucher's disease (n = 4), myeloid hepatosplenomegaly due to myelofibrosis (n = 3), splenomegalic retarded growth and sexual development (n = 2), severe pain due to splenic ischemia (n = 2) and pancreatic cystadenoma (n = 1). Patients underwent a hematologic exam, an immunologic assessment, abdominal ultrasonography, computed tomography, scintigraphy and endoscopy. RESULTS: Increased white blood cell count and platelets were the only hematological abnormalities. No immunologic deficit was found. Esophageal varices were still present in patients who underwent surgery because of portal hypertension although without rebleeding. The ultrasound, tomography and scintigraphy exams confirmed the presence of functional splenic remnants without significant size alteration. CONCLUSIONS: Subtotal splenectomy seems to be a safe procedure that can be useful in treating conditions involving the spleen. The functions of the splenic remnants are preserved during long periods of time.

Late postoperative follow-up of patients undergoing subtotal splenectomy

OBJETIVO: Durante 21 anos, realizamos mais de 200 esplenectomias subtotais para tratar diferentes condições patológicas. É fundamental conhecer os resultados pós-operatórios desse procedimento. MÉTODO: Todos os pacientes submetidos a esplenectomia subtotal foram convidados para serem submetidos a revisão. Pudemos reunir 86 pacientes operados em um período de um a vinte anos por hipertensão porta esquistossomática com sangramento prévio pelas varizes (n = 43), trauma (n = 31), doença de Gaucher (n = 4), hepatoesplenomegalia mielóide devido a mielofibrose (n = 3), retardo de desenvolvimento somático e sexual esplenomegálico (n = 2), dor intensa por isquemia esplênica (n = 2) e cistoadenoma corpocaudal pancreático (n = 1). Os pacientes foram submetidos a exame hematológico, avaliação imunológica, ultra-som, tomografia computadorizada, cintilografia e endoscopia digestiva alta. RESULTADOS: Aumento do número de leucócitos e plaquetas foram a única alteração hematológica encontrada. Não foram constatados distúrbios imunológicos. Varizes esofágicas ainda estavam presentes em pacientes operados de hipertensão porta, porém sem ressangramento. O ultra-som, a tomografia computadorizada e a cintilografia confirmaram a presença do remanescente esplênico funcionante, sem mudanças em seu tamanho.CONCLUSÃO: A esplenectomia subtotal parece ser um procedimento seguro e pode seu útil para tratar condições nas quais o baço estiver envolvido.

[Clinical Practice Guidelines 2004. Standards, Options and Recommendations for the management of patient with adenocarcinoma of the stomach: radiotherapy (therapeutic evaluation)]. / Recommandations pour la pratique clinique. Standards, Options et Recommandations 2004 pour la prise en charge des patients atteints d'adénocarcinomes de l'estomac, cancers du cardia, autres types histologiques exclus (évaluation des thérapeutiques).

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centers (FNCLCC), the 20 French regional cancer centers, and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. OBJECTIVES: To elaborate clinical practice guidelines for patients with stomach adenocarcinoma. These recommendations cover the diagnosis, treatment and follow-up of these tumors. METHODS: The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. The Standards, Options and Recommendations are thus based on the best available evidence and expert agreement. RESULTS: This guidelines presents the synthesis of the data concerning the evaluation of the therapeutic ones. The main questions concern the type of gastrectomy to realize (Total Gastrectomy or gastrectomy subtotal), the extent of the lymphadenectomy (D2, D3 versus D1, D3, D2 versus D4) and the role of postoperative chemotherapy and adjuvant concomitant chemoradiotherapy.

Laparoscopic versus open splenectomy in the management of hematologic diseases.

UNLABELLED: Splenectomy is the best available treatment for severe forms of hereditary spherocytosis, idiopathic thrombocytopenic purpura, and other hematologic conditions when these prove refractory to conservative management. It has been employed for many decades with low mortality and favorable remission rates. The use of laparoscopic splenectomy in recent years has been rapidly and even enthusiastically adopted in this field. However, the exact role of laparoscopic versus open surgery for hematologic diseases is still debated. In this study of 58 adult patients, laparoscopic procedures were compared with conventional splenectomies for similar indications. METHODS: All patients were operated on within an 8-year period. Subjects underwent similar procedures under the supervision of the same surgical school and were compared regarding age, gender, body mass index, and diagnosis. Laparoscopically managed cases (Group I, n = 30) were prospectively followed according to a written protocol, whereas the same investigation was retrospectively done with regard to traditional laparotomy (Group II, n = 28). Methods included general and demographic findings, duration and technical steps of operation, blood loss, weight of spleen, need for conversion (in minimally invasive subjects), intraoperative and postoperative complications, time until realimentation, postoperative hospitalization, mortality, and late follow-up including recurrence rate. RESULTS: Idiopathic thrombocytopenic purpura was the surgical indication in over 50% of the patients in both groups, but familial spherocytosis, thalassemia, myelodysplasia, and lymphomas were also represented in this series. Laparoscopic procedures took more time to perform (P = 0.004), and postoperative hospitalization was 2 days shorter, but this difference was not statistically significant. Postoperative hematocrit and volume of blood transfusions was equivalent, although the laparoscopic cases had a somewhat lower preoperative hematocrit (NS) and displayed better recovery for this measurement (P = 0.03). More patients in Group I were able to accept oral food on the first day than subjects undergoing conventional operations (P < 0.05). Relatively few conversions were necessary during the minimally invasive surgeries (13.3%), and postoperative early and late complications as well as recurrences occurred in similar proportions. Also, the mean weight of the spleen was not statistically different between the groups, although there was a marked numerical tendency toward larger masses in conventional procedures. No spleen in Group I exceeded 2.0 kg, whereas in Group II values up to 4.0 kg occurred, and the mean weight was 50% higher in the latter group. CONCLUSIONS: 1) Minimally invasive splenectomy was essentially comparable to open surgery with regard to safety, efficacy, and late results; 2) Advantages concerning shorter postoperative hospitalization could not be shown, despite earlier food intake and a non-significant tendency toward earlier discharge; 3) This new modality should be considered an option in cases of hematologic conditions whenever the spleen is not hugely enlarged.

[Laparoscopic splenectomy, is it the gold standard?]. / Esplenectomía laparoscópica, es la técnica ideal?

BACKGROUND: At the beginning of the last decade, different groups of workers developed almost simultaneously the laparoscopic splenectomy technique. From then on, and based on the accumulated experience done in the field, this technique has become the preferred approach. OBJECTIVES: to analyze the results obtained with laparoscopic splenectomy on 29 patients with various pathologies. LOCATION: General Surgery Service Number 2, Prof. Pablo Mirizzi, Clinic National Hospital. General Surgery Service, Sucre Clinic, Córdoba. DESIGN: prospective study. MATERIALS AND METHODS: Twenty-nine laparoscopic splenectomies were indicated in 22 cases of idiopatic thrombocytopenic purpura, 4 autoimmune hemolytic anemia, two spheroid and one segmental hypertension portal. A simultaneous prophylactic cholecistectomy was performed in cases of malign spheroid associated with cholelitiasis. Cases of incorrigible coagulopaty, ascitis and spleenomegaly, greater than 30 cm., were discarded. Antibiotic prophylaxis, bovine anti-pneumonic vaccine, drainage to the spleen cavity, precocious mobilization and liquid diet starting at 6 a.m. were systematically indicated. RESULTS: there was no mortality and a patient with spleenomegaly of 28 cm. was converted (3.4%). The average surgical time was 90 minutes. In 4 cases (13.7%) of patients with ITP, accessory spleens were found. No patient was transfused when bleeding was less than approximiately 100cm. The main surgical difficulty was the spleen mobilization at the level of the pedicle in the big spleens and the hemorrhaging in small volumes during the dissection. CONCLUSION: this technique offers a series of advantages that allow it to be considered as the new "gold standard" for splenectomy.

Esplenectomia laparoscopica, ¿es la técnica ideal? / Laparoscopic splenectomy, is it the gold standard?

Antecedentes: A comienzos de la década pasada, distintos grupos de trabajo desarrollaron casi simultáneamente la técnica de la esplenectomia laparoscópica. Desde entonces y en base a la experiencia acumulada, llegó a convertirse en la vía de abordaje de elección. Objetivos: analizar los resultados obtenidos con la esplenectomia laparoscópica en 29 pacientes con patologías diversas. Lugar de aplicación: Servicio de Cirugía General N° 2. Prof. Pablo Luis Mirizzi, Hospital Nacional de Clínicas. Servicio de Cirugía General Clínica Sucre, Córdoba. Diseño: estudio prospectivo. Material y método: veinte y nueve esplenectomías laparoscópicas fueron indicadas en 22 casos de Púrpura Trombocitopénica Idiopática, 4 anemias hemolíticas autoinmunes, 2 esferocitosis y uno por hipertensión portal segmentaria. En los casos de esferocitosis maligna asociados a colelitiasis se realizo simultáneamente colecistectomía profiláctica. Fueron descartados los casos con: coagulopatías incorregible, ascitis y esplenomegalias superiores a 30 cm. Se indicó sistemáticamente antibiótico profilaxis, vacuna anti-pneumocócica, drenaje al lecho esplénico, movilización precoz y dieta liquida a partir de las 6 hs. Resultados: no hubo mortalidad y un paciente con esplenomegalia de 28 cm. fue convertido (3,4%). El tiempo quirúrgico promedio fue de 90 minutos. En los pacientes con PTI se localizaron vasos accesorios en 4 casos (13,7%). Ningún paciente fue transfundido no superando el sangrado los 100 cm.' aproximadamente. La principal dificultad operatoria fue la movilización esplénica a nivel del pedículo en los grandes bazos y la hemorragia en pequeños volúmenes durante la disección. Conclusión: esta técnica ofrece una serie de ventajas que permiten situarla como el nuevo "gold standard" para la esplenectomia.

Background: At the beginning of the last decade, different groups of workers developed almost simultaneously the laparoscopic splenectomy technique. From then on, and based on the accumulated experience done in the field, this technique has become the preferred approach. Objetives: to analyze the results obtained with laparoscopic splenectomy on 29 patients with various pathologies. Location: General Surgery Service Number 2, Prof. Pablo Mirizzi, Clinic National Hospital. General Surgery Service, Sucre Clinic, Cordoba. Design: prospective study. Materials And Methods: Twenty-nine laparoscopic splenectomies were indicated in 22 cases of idiopatic thrombocytopenic purpura, 4 autoimmune hemolytic anemia, two spheroid and one segmental hypertension portal. A simultaneous prophylactic cholecistectomy was performed in cases of malign spheroid associated with cholelitiasis. Cases of incorrigible coagulopaty, ascitis and spleenomegaly, greater than 30 cm., were discarded. Antibiotic prophylaxis, bovine anti-pneumonic vaccine, drainage to the spleen cavity, precocious mobilization and liquid diet starting at 6 a.m. were systematically indicated. Results: there was no mortality and a patient with spleenomegaly of 28 cm. was converted (3.4%). The average surgical time was 90 minutes. In 4 cases (13.7%) of patients with ITP, accessory spleens were found. No patient was transfused when bleeding was less than approximiately 100cm. The main surgical difficulty was the spleen mobilization at the level of the pedicle in the big spleens and the hemorrhaging in small volumes during the dissection. Conclusion: this technique offers a series of advantages that allow it to be considered as the new "gold standard" for splenectomy.