[Laparoscopic splenectomy: value of the posterior approach]

Intraoperative bleeding is the main complication and main cause of conversion to open surgery during laparoscopic splenectomy (LS). We present the advantages of the posterior approach to splenic vessels.

We have performed a total of 52 LS using several approaches. In the last 24 patients, we used a posterior approach to the splenic vessels with the patient in full lateral position. Only three ports were used. The major part of the dissection was performed from behind, thus allowing safer vascular control. The division of short gastric vessels and lower pole vessels was performed using US. The main vascular pedicle was stapled. The spleen was removed through a Pfannenstiel incision. The patients were 11 males and 13 females with a mean age of 38 years (17-71 years). Sixteen had immune thrombocytopenic purpura (ITP), 2 had HIV infection related purpura 3 had haemolytic anemia and 2 had spherocytosis.

There was no conversion to laparotomy. The average splenic weight was 372 g (162-1420 g). In all but one patient, the intraoperative blood loss was less than 60 cc and was nil in 7 patients. The average operative time was 126 min (70-220), including the time required for change of position and Pfannenstiel incision. There was no mortality. All but one patient had an uneventful postoperative course. The HIV infected patient developed severe postoperative pancreatitis. In those an patients with uncomplicated course, the average postoperative stay was 4.1 days (2-8 days).

The lateral position with a posterior approach to splenic vessels allows for a safe vascular control. This is illustrated by the average intraoperative bleeding of this series which is much lower than that observed in our previous experience and in other published series.