Surg Endosc (2002) 16: 965 911

DOI:

10.

1007is00464-001-901 1-z

Springer-Verlag New York Inc

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Laparoscopic splenectomy for hematological diseases

P. Torelli,r D. Cavaliere,l M. Casaccia,l F. Panaro,l P. Grondona,' E. Rossi,2 G. Santini,2 M. Truini,3

\1. Gobbi.{ A. Bacigalupo.s L,. \'alentel

I Department of General Surgery and Transplant Surgery, University ol Genoa, San Martino Hospital, Largo R. Benzi 10, Genoa i6100, ltaly 2 Department of Hematology I, University of Genoa. San Martino Hospital, Largo R. Benzi 10, Genoa 16100, Italy 3 Pathological Anatomy Service, University olGenoa, San Martino Hospital, Largo R. Benzi 10. Genoa 16100. Italy a Department olHematology, University of Genoa. San Martino Hospital, Largo R. Benzi 10, Genoa 16100, Italy 5 Second Hematology Unit. San Martino Hospital, Largo R. Benzi 10, Genoa 16100, Italy
Received: 25 January 2001iAccepted

in fnal form:

15 Augusr 2001/Online

publication: 28 February 2002

Abstract
Background.' We reviewed retrospectively the records of all patients who underwent laparoscopic splenectomy (LS) at our institution for a wide range of hematological disorders. We compared our experience to those reported in the literature and analyzed various aspects of the treatment that are still under discussion and in need

Key words: Laparoscopic surgery

Non-HodgIdiopathic thrombocytopenic purpura kin's iymphoma Myeloflbrosis Hemolytic

anemia

Splenectomy

of confirmation, such as the treatment of malignant blood diseases, the indication in case ol splenomegaly,

In

and the adequacy of the detection of accessory spleens. Methods: Between June 1997 and June 2001, we performed 43 LS. The patients were classifled into three

groups according to clinical diagnosis: idiopathic thrombocytopenic purpura (ITP) (.n - 23), hemolytic anemia (HA) (n : 5), and hematological malignancy (HM) (rz - 15). Statistical analyses were done to com-

pare the three groups. Results: LS was completed in 41 patients, with a conversion rate of 57o. Splenomegaly was present in 3l7o of

all patients (737o of HM). Mean operative time was 128 min. The incidence of accessory spleens was 207o. A concomitant laparoscopic procedure was done in three
cases (cholecystectomy). Postoperative complications occurred in eight patients (187o). Duration of surgery, length of hospital stay, transfusions rate. and some demographics features, such as age and spleen weight and length, were significantly different in each group. No deaths were attributed to the procedure. Conclusions; The statistical analysis of our series shows management
diseases.

that, the laparoscopic approach reliable even in the ol malignant and nonmalignant blood

Cotespondence lo. P. Torelli

1991 Delaitre and Maignien [7] attempted the first laparoscopic splenectomy. Since then, the laparoscopic approach to splenectomy has gained wide acceptance and has been shown by several groups to be technically successful, safle, and effective 11,2,3,4,6,9,11, 14, 15, 30, 40, 42,441. Several factors, such as the potential for rapid and potentially severe hemorrhage and the difficult nature of the operative dissection, may dissuade the inexperienced surgeon [10, 12, 42]from performing this advanced laparoscopic procedure. However, the reduction in wound-related morbidity and rapid postoperative recovery associated wrlh a minimally invasive approach represent considerdble beneflts and have been universally reported [5, 8, 18, 34,42]. At the same time, concerns have been raised about the role oflaparoscopy in splenic malignancies, the removal of large spleens, and the detection of all accessory splenic tissue. In the absence of data lrom a large, randomized, controlled trial comparing open and laparoscopic splenectomy, case-control studies provide the only means of acquiring helpful information to assess the role of this new operation. The purpose of this study was to perform retrospectively evaluation of the outcomes of the LS performed at our institution over a period of 4 years and to compare our results with those reported in the literature. We analyzed various aspects of the treatment that are still under discussion and in need of confirmation, such as the treatment of malignant blood diseases, the indication in cases of splenomegaly, and the adequacy ol the detection of accessory spleen.

966

Table

1.

Patient demographics

ITP

HA
5

HM
15

No. of patients
Age (yr) Mean
Range Gender

23

42*21
1

25+20
655
2

57+14
27 77

6-11

Male
Female

123 11 26.5
20.645.3

i0
5

BMI
Mean
Range

24.\t
23.1 24.5

23.9

20.5 34.2 2.2 J. 0.7

l4 Fig. 1. Anterior approach: operating room setup and port positioning

ASA score
Mean
Range

2+0.1 13
307o
69Vo

2+0.8
1-3

Preoperative therapy Gammaglobulin Steroids (>6 mon) Chemotherapy

Splenomegalyu Massive splenomegalb

21
3

73Vo

4
7

lTP, idiopathic thrombocytopenic purpura; HA, hemolytic anemia; HM, hematological malignancy; BMI, body mass index; ASA,
American Society of Anesthesiologists

">500gor16cm br 1000 g or 20 cm

Materials and Methods

Between June 1997 and June 2001. a total of46 patients with different splenic disorders were referred to us for LS. Among these patients we have considered only those affected by hematological pathologies and have thus excluded two cases ol splenic traumatic injury and one case

Fig.2. Lateral approach: operating room setup and port positionrng.

of angioma. The remaining 43 patients comprise the subject of this

report. Twenty-eight patients were treated lor benign diseases; the other 15 had malignant splemc disorders. Patient demographics are shown in Table 1. We conducted a retrospective review ol the clinical and perioperative data of all patients. Patients were classified into the following three groups according to their clinical diagnosis: idiopathic thrombocytopenic purpura (ITP); Qz : 23), hemolytic anaemia (HA), @ : 5), hematological malignancy (HM), @ : 15). Data chosen lor analysis included age, gender, American Society of Anesthesiologists (ASA) score, body mass index (BMl), spleen weight and length, number of
converted patients, estimated blood loss and perioperative translusion, operating time, morbidity, mortality, and postoperative hospital stay. Statistical analyses were done with the Student's I test lor unpaited means to compare differences among the three groups. A p value of 0.05 was considered significant. We also selected papers from Medline that reported the results of the laparoscopic management of various hematological diseases. We searched from 1995 to today. The choice of the papers was made based on whether they had reported a large series in an important scientific review, whether they were well cited, and whether they had analyzed various aspects of the treatment. We compared our data to those reported in the selected literature. The indications for LS are shown in Table 2.

before operation [23]. Techniques for the colleotion of intraoperative blood loss were adopted lor all patients.

Anterior approach
At the beginning of our experience. we adopted the anterior approach. Nowadays, we choose this exposure only in cases where a concomitant surgical procedure is needed. The operating table is placed in a marked anti-Trendelemburg position and tilted to the right [5, 9, 28, 35]. The operating rom setup and port positioning lor the anterior approach to LS are shown in Fig. 1. The intervention starts with a careful peritoneal examination to detect any accessory spleens. The splenocolic ligament is dissected, with possible clipping of lower pola/ vessels. The technique allows good access to the connections between the posterior face of the spleen and the retroperitoneum. The hilum s freed lrom the peritoneum, if possible using an ultrasound dissector. The splenic artery and vein, if easily identifled, are bound, and both are sectioned by repeated application of a vascular endostapler. If the splenopancreatic ligament is too short and there is a risk ofinternal bleeding, we prefer to divide the short gastric vessels. Subsequently, the hilum elements are easily mobilized. Finally, the splenic connections to the retroperitoneum and the pancreatic tail are dissected until the spleen is totally freed.

Surgical technique

Lateral approach
Perioperative management
All patients received pre- and postoperative medical therapy consisting ol the following measures: (a) antibiotic prophylaxis, initiated during surgery (sulbactam/
ampicillin 3 g iv), (b) respiratory physiokinesitherapy [22], (c) injection of local anesthetics into the wound before the incisions [22], (d) Mobilization a few hours after surgery, (e) early refeeding with essential elements, (f) administration of pneumococcal vaccines at >1 week

At

present, we routinely use this operating approach. The patient lies in lateral right decubitus with a lateral flexion ofthe spine to allow lor the best exposure ofthe splenic area [11, 16, 36, 38,41]. The operating room setup and port positioning for the lateral approach to LS are shown in Figure 2. The first step is to identify any accessory spleen by a meticulous intraabdominal exploration. After this, the splenic flexure of the colon is dissected away from the splenic lower pole. The next step sonsists of the freeing of the splenophrenic and splenorenal

967

Table

2. Indications for laparoscopic

splenectomy

First author freference]

Decker [6] Park [26]

N". LS attempted
35

N". ITP
12 (34)

(7o)

N'. HA
3 (e) 21 (13) 22 (21) l0 (20)
0

(7o)

N'. HM
13 (37)

(7o)

N". Other
7 (20) (15) 12 (t2) 4 (8) 2 (7) e (12) 2 (e) 3 (8)

(7o)

203

t2e (64)
67 (6s) 31 (62) 1e (70) 37 (s0) 1 r (s0)

Katkhouda [21] Gigot [14]

Emmermann [9] Targarona [37]

r03
50

Poulin [27]
Flowers

Donini [8] Total

[0]

27 74 22 39

13 (18)

16 (8) 2 (2) 5 (10) 6 (22) l 5 (20)

l1

7 (32)
7 (18)

44
+o 643

Present series

22 (s6) 24 (55) 23 (s0)

375 (58)

2 (:e) 7 (18)
r

NA
s (10)'
e4
(1 5)

3 (30)

NA
3 (6)" 80 (12)

15 (12)b e1 (1 s)

LS, laparoscopic splenectomy; ITP, idiopathic thrombocytopenic purpura; HA, hemolytic anemia; Spherocytosis (n : 4), hereditary hemolytic anemia (r : 1) : l) b Myelofibrosis (r : 3), non-Hodgkin's lymphoma (ll : l0), hairy-cel1 leukemia (,

HM, hematological malignancy

"

Table

3. Results of laparoscopic

splenectomy by diagnosis and statistical analysis Spleen Spleen

Patrent (r)

weight (g)

length (cm) 12.9

Estimated blood loss (ml)

369 184 538
n.s.

Operating time (min) 122

Morbdit1
4 (\1)

i%1

Hospital stay (d) 4.8

ITP

23

30

129

+
+

t.9
3.5

245
116

30

(8s 600) HA HM
l-test for unpared means (P)

560 t7 ITP vs HA ITP vs HM

(e
839

r5)

(100 1000)

406

17.6

+
+

(78

170)

(2
(4

r
10)

1.9 1.3

173+5
(170 r80) 128 +24

5.2

+
).

(s95 l80o)
1207 <0.05 <0.05
n.s-

(10 i8)
< 0.05

(20 800)
340

(20)

6)

(16s 3000)

20.1 + 4.8 (10 23)

6.8
3 (20)
n. s.

4.2

(100 1200)

(90

16s) < 0.05

(3
n. s.

1e)

<0.05
n.s.

HA vs HM
standard deviation (range)

<0.05 <0.05

n.s. < 0.05

n.s. n.s.

n.s. n.s-

ITP, idiopathic thrombcytopenic purpura; HA, hemolytic anemia, HM, hemolytic malignancy; n.s., not significant values given as mean +

attachments, thus permitting the spleen to be moved medially so as to expose the posterior aspect of the splenic vessels. Alter sectioning of the short gastric vessels, we proceed to the dissection ol the pedicle, which has become thinner due to the posterior mobilization. Finally, the splenic pedicle comprising the main artery and vein is dissected by repeated application of an endostapler. The spleen is thus totally freed.

Extraction ol the specimen

The organ's size permitting (normal, mild, or moderate enlargement), the specimen is introduced into an endobag. Alter internal fragmentation. it is removed via the umbilical or subcostal port lurthest to the left. A service mini-laparotomy (6-1()-cm) is perlormed in a lelt subcostal position in cases where the spleen is large and whenever pzrthologic examination of the surgical specimen is re<luired to document the hematological disease (i.e., splenic tumor). We consider this procedure to be similar to a complete laparoscopic splenectomy Finally, one drain is positioned in the left hypochondrium and another is positioned in the pelvis in cases ol large intraperitoneal blood loss.

gammaglobulin infusion (a00 mg/kg for 5 days), and 16 had been undergoing cortisone treatment for >6 months. The average weight of the spleen was 301 + 129 g. Twenty-six totally laparoscopic splenectomies were performed. Conversion was necessary in two patients to control massive, intractable bleeding lrom the splenic hilum. The average intraoperative blood loss was 369 * 245 mL Three patients required postoperative transfusion. Five accessory spleens were detected in four patients. The average operative time was 122 + 30 min. Posloperal.ire complications'occurred in lour patients (l7Vo). In one case, bleeding from a short gastric vessel necessitated a laparotomy a few hours after surgery; two

Results

The statistical results for our 43 cases, as broken down into three diagnoses, are shown in Table 3.

ITP group
The mean age of the 23 patients with ITP was 42 + 21 years. Six patients received preoperative therapy with

patients developed pneumonia, which was treated medically; and, one patient had progressive anemia requiring blood transfusion. The average hospital stay was 4.8 + 1.9 days. A positive postoperative therapeutic response to splenectomy was seen in 20 of 23 patients (86.5Vo1. All 20 patients had a normal platelet count (> 100.000 mmr) at discharge. The other three patients required postoperative corticosteroid therapy for 3 months. The average preoperative platelet count was 49,500/mm3 (range, 13,000-177,000); and the average postoperative platelet count was 205,000/mm' (tarrge, 74,000 705,000). The average ratio of postoperative to preoperative platelet count was 4 (range, 0.7 30). The average improvement of platelet count at discharge was 127,000/mm3. Long-term follow-up (22 months on

968

average) was obtained in 20 ol 23 patients (86.57a). There was one early recurrence, 1 month alter surgery, as a consequence ofundetected accessory spleens. These was found and removed laparoscopically with a good, lasting response. ln four patients (20Vo),late recurrence (at 10, 18, 21, and 33 months after surgery) needed a medical therapy with low-dose cortisone.

for all but two patients (14Eo). One perioperative death occurred in a young patient with nonHodgkin's lymphoma who was in severe generai conditions (ASA IV) complicated by a secondary blast crisis. Two other deaths occurred at 3 and 25 months after surgery due to progression of disease (non-Hodgkin's lymphoma and myelofibrosis). Seven patients were diswas obtained

HA group
The average age of the flve patients with HA (four cases of spherocytosis and one case of hereditary anemia) was 25 + 20 years; two ol these patients were children (aged 6 and 8 years, respectively). In all cases, splenomegaly was present. Three patients also had gallstones; in these
cases, the patient was placed in supine position, a splenectomy was performed first, and then a concomi-

at an average follow-up of 22 months. One patient affected by myelofibrosis developed a clinical recurrence afler 26 months olfollow-up and is still alive at 32 months. In two uses, follow-up was too short (0 2 months) for the results to be meaningful.
ease-free Discussion

A comparison of our analysis to reports in the literature

showed no substantial differences (Table 4) [6,

tant cholecystectomy was done by the introduction of one other port in the right side. Average spleen weight was 560 + 406 g. No conversions were necessary. Average blood loss was 184 + 116 ml. One accessory spleen was detected and retrieved. The average duration of surgery was 173 .l 5 min. Postoperative complications occurred in one patient, who had a pleural effusion with fever. Average hospital stay was 5.2 * 1.3 days. A signiflcant improvement (257o) in hematocrit level was seen in all patients at discharge. These patients had an
average preoperative hematocrit level

14.21,26,27,371. It must be emphasized that

10, 13, this

comparison is based on the average data ofeach author, which include splenectomies with different indications and evolutions. For this reason, we chose to do a statistical analysis based on each patient's perioperative data as divided into three subgroups of pathologies. In our series, the dimension and weights of the spleens are higher due to the fact that we treated a larger number ol malignant spleens (32Ea). As a matter of fact, we treated 16 patients with splenomegaly and >10 of these patients suffered lrom massive splenomegaly. Regarding the term "splenomegaly," there is no universally agreed-on deflnition in the literature. Some authors deflne splenomegaly by weight 16, 72, 19, 25, 4ll; however, there are differences between one author and the next. Others define splenomegaly according to the longitudinal diameter [6, 9, 10, 27,28,33]. In our opinion, the longitudinal diameter, as measured by simple ultrasonogram is the easiest and simplest index of splenomegaly. Hovrever, the factor that is most important to determine to establish the feasibility of LS is the relation between the size of the spleen and the abdomen's volume. This relation gives the expectation of the intraabdominal working room: if it does not allow adequate space, it will be more diffcult to expose and mobilize the spleen. The conversion rat for our series (5%) is well within line with the average rate repofted by other authors [6, 8, 9, 10, 13, 14,21,26,27, 421. However, the two conversions in our series occurred in the ITP group, in contrast with what can be deduced from the international literature. These conversions were probably related to the high BMI of the patients in this group (average, 26.4), which was greater than that of the other subgroups. It has often been demonstrated that this parameter increases the technical difficulty in laparoscopic procedures [29]. Long-term cortisone treatment in 697o of the ITP patients may also have been a contributing factor. Moreover, both conversions occurred in our first 15 patients, whereas there were no conversions among in the following 28 cases. Thus, we think the conversions could also be related to the relative inexperience of the surgeon, the lack of modern instrumentation, and the routine use of the anterior
access.

24.5 35.2) and

of 29.4Vo (range, a postoperative hematocrit level of 38.6%

(range. 32 44). Over an average period of 21 months, all patients were followed up. There were no cases of late postoperative complication or recurrence.

HM group
The average age of the 15 patients with malignant pathologies was 57 .E 14 years. Eleven patients had previously received chemotherapy. This subgroup of patients tended to have large spleens; infact, the average spleen weight was 1207 + 839 g. In 1l patients, splenomegaly was present; and in seven cases, the spleen
weighed 1,000 g (massive splenomegaly). None

patients required conversion

to open technique. The

of

the

spleen was morcellated and retrieved using an endobag cases. A subcostal mini-laparotomy was performed in 11 patients to allow removal of the entire organ. In four patients, an accessory spleen was found and retrieved. Average blood loss was 538 + 340 m1.

in four

Five patients required a perioperative transfusion ol

homologous blood. The average operating time was 128 ). 24 min. Postoperative complications included: one pleural effusion, one progressive anemia (due to disease progression), and one pancreatitis (evaluated as an increase in amylase of > 400 U/ml and clinical symptoms) associated with ileus. There were no complications due to infection in spite of the fact that most of these patients had received either long-term cortisone therapy and/or chemotherapy. Average hospital stay was 6.8 t 4.2 days. No differences in postoperative recovery were noted among the patients who required the service laparotomy. Long-term follow-up (19 months on average)

Over the past 3 years, in fact, several factors have contributed to our growing confidence with this technique, thus reducing the conversion rate. Heavy bleeding, which can now be n-ranaged laparoscopically, was once a cause for conversion. Other improvements include the use of technical devices such as the ultrasonic dissector [16] and the use of radiofrequency instruments, which facilitate the dissection in many phases, from the section of the short gastric vessels to the lreeing of the lateral splenic attachments. In addition, the shift from the supine to the fully lateral position of the patients has greatly influenced the outcome to the procedure. ln fact,
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our dissection technique has changed from the exclusive use of the anterior approach to the splenic hilum to a combined posterior anterior approach. As a result, the freeing of the splenophrenic and splenorenal attachments permits the spleen to move medially. exposing the posterior aspect of the splenic vessels. Then, the section of the gastrospler-ric iigament and short gastric vessels performed at the front of the spleen, results in a thinner pedicie that is easier to transect. In terms of average intraoperative blood loss and number of perioperative transfusions, the results in our series were higher than the international rate [6, 8, 9, I 3, 21, 26, 27). The larger number ol malignant spleens and pancytopenic patients could explain this fact. In fact, through statistical analysis of the three subgroups, it was deduced that a direct correlation existed between the intraoperative blood loss and the need for transfusion;

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HA and higher in cases of malignant disease. Intraoperative blood tranfusion was done in 13 patients (307o) at the discretion of
they were lower in cases of the anesthesiologist. Eight patients (18%) also received homologous blood translusions (mean, 2.4 U) in the perioperative period. Concerning the indication for LS in cases with malignant spleens, even in the presence of massive spleno-

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bidity and postoperative mortality. Moreover,

patients are often subjected to adjuvant chemo- and radiotherapy, which can be done within a shorter time from the intervention; LS allows the most favorable therapeutic program to be instituted. In service laparotomy cases, the postsurgical course could be superimposed on the complete laparoscopic splenectomies. Meanwhiies methods for the accurate identiflcation accessory spleens are still under debate. Gigot et a1. [13] reported that 20 months after surgery, 507o of patients
presented with residual disease either caused by an unrecognized accessory spleen or related to organ fragments implanted in the peritoneal cavity after the intraoperative procedure. Other authors [17, 31, 34,35, 35, 42) have reported an incidence of <207o. The detec-

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tion of accessory spleens among our patients was equivalent to the rate reported in the literature [6, 15,21, 24,26,28, 431and similar to the rate of accessory spleens found during open surgery [32]. It is of critical importance to spend a few minutes at the start of the operation and at the last moment before removing the trocars to make a thorough peritoneal search. Good knowledge

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970

of the most common sites for accessory spleens (hilum, retroperitoneum, greater omentum, and mesentery) is indispensible. The overall visualization obtained by video laparoscopy is excellent. The only case of early relapse caused by the nondetection of an accessory spleen occurred in an obese patient. Many techniques have been used to detect accessory or residual splenic tissue including: preoperative technetium 99m or indium 111 scanning, computed tomography (CT), and laparoscopic ultrasonography [13, 21]. The routine use of preoperative scintigraphy seems to us superfluous and not cost-effective, since these exams are not only expensive but also lack ol sensitivity and speciflcity. However, they could be helpful in obese patients. In the future, the use of the laparoscopic echographic probe will surely be expanded. Currently they require specially qualifled operators, long training, and capital resources that not all hospitals can afford. The operative times in our series were shorter than those reported by other authors, possibly due to the absence ol organ fragmentation in our frequent cases of malignancy. This phase can take an extra 15 40 min to
fragment the spleen inside the endobag if a morcellator device is not available. in particular, the average operating time for the ITP and HM patients was equivalent and signiflcatively less than that for the HA patients. But the difference of 50 min in our HA patients was justified by an additional cholecystectomy performed in three cases (spherocytosis) and by the need to fragment the larger spleens before retrieval. Although ITP spleens

difficuit but feasible, safe, and effective. The morbidity and mortality rates are remarkably low. We can affirm that laparoscopic splenectomy now represents the gold standard in the treatment of ITP and that it can be successfully adopted for other pathologies, such as hemolytic anemia and malignant splenic
disorders.

The improvement of technical devices such as the ultrasonic dissectors and the ability to perform coagulation by radiofrequency has made it easier to the access and dissects the splenic pedicle. Nevertheless, there are still some difficulties in exposing the upper pole for the dissection of the short gastric vessels and the splenophrenic ligaments due to the lack of instruments especially designed for the handing of large spleens. In our experience, the shift from a supine to a fuliy lateral

position of the patient improved the visibility of the organ and facilitated the dissection. However some questions still remain. There is no uniformity in the literature about which parameters should be used to define splenomegaly. Spleen diameter, as measured by ultrasound examination, is a reliable and reproducible measure and actually seems to be the most commonly used and helpful preoperative volumetric variable. Splenomegaly, even if massive, is no longer considered an absolute contraindication to the procedure but only a bump on the surgeon's learning curve. In fact, the only variable that seems to be correlated with certain failure of the technique is lack of
surgeon experience.

also, need to be fragmented, they are smaller. HM spleens are generally big, but they are wually (73Vo) extracted without fragmentation. Laparoscopic assisted removal of the entire spleen to via an accessory mimlaparotomy, however, did not affect the duration of surgery, rate of complications, or length of hospital
stay [8].
The immediate response rate in our series was 86.57o in patients with ITP. On long-term follow-up, four patients experienced recurrences, for a total failure rate of 20Vo.Thts high response rate was also noted in most of the other laparoscopic series and is similar to the results of open splenectomy. A complete response was obtained

The laparoscopic approach affords excellent overall

visualization of the abdominal cavity and permits the detection of accessory splenic tissue. A potential criticism concerns its accuracy in obese patients, but there are alternative methods for the detection ol accessory spleens that can be used in this subpopulation of
patients.

References
1. Baccarani U, Donini A, Terrosu G, Pasqualucci A, Bresadola F (1999) Laparoscopic splenectomy for haematological diseases: review of current concepts and opinions. Eur J Surg 165: 917
923

in all patients in the HA group, conlrming that

ectomy is potentially curative in this disease, even

splen-

if

the

number of patients treated by our group is very low. Concerning the HM group, and in accordance with other authors [6, 20, 33], our series demonstrates the feasibility and safety of LS even in the presence of
secondary hypersplenism and massive splenomegaly. Because conventional splenectomy for malignant conditions is associated with high morbidity, these patients are the ones who would likely derive the greatest benefit from a laparoscopic approach [20].

2. Baccarani U, Terrosu G, Donini A, Zaja F, Bresadola F, Baccarani M (1999) Splenectomy in hematology: current practice
and new perspectives. Haematologica 84: 431434

3. Basso N, Silecchia G, Perrotta N, De Leo A, Raparelli L, Elmore U, Fantini A, Clementi M (2000) Laparoscopia e malattie ematologiche: un nuovo gold standard? Osp Ital Chir 6: 106 112

4.

Bove T, Delvaux G, Van Eijkelenburg P, De Backer A, Willems G (1996) Laparoscopic assisted surgery ol the spleen: clinical expe-

rience in expanding indications. J Laparos Surg 6: 213 217

5. Caprotti R, Franciosi C, Romano F, Codecasa G, Musco F, Motta M. Uggeri F (1999) Combined laparoscopic splenectomy and cholecystectomy for treatment of hereditary spherocytosis: is it safe and effective? Surg Laparosc Endosc Percutan Tech 9:
203-206

Conclusions

6. Decker G, Millat B, Guillon F, Atger J, Linon M (1998) Laparoscopic splenectomy for benign and malignant hematologic diseases: 35 consecutive cases.

World J Surg 22: 62 68

The data reported here are similar to those reported in the literature and confirm that elective laparoscopic splenectomy for hematological diseases is technicaily

7. Delaitre B, Maignien B (1991) Splenectomy by the coelioscopic

approaoh: report of a case. Press Med 20: 2263

8. Donini

A.

Baccarani U, Terrosu G, Corno

V,

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