Improved outcome in laparoscopic splenectomy in children with benign hematological disease after standardization of techniques

  • Kin Wai Edwin ChanEmail author
  • Kim Hung Lee
  • Hei Yi Vicky Wong
Original Research



Laparoscopic splenectomy has gained popularity in the management of children with benign hematological disease who required splenectomy. We aim to report the outcome after standardization of techniques in laparoscopic splenectomy.

Materials and methods

A retrospective study was conducted in which all children with benign hematological disease underwent laparoscopic splenectomy in our institute from 2003 to 2017. The demographics and outcomes before (Group 1) and after (Group 2) standardization of techniques were compared. The laparoscopic techniques were standardized in Group 2. They all underwent multiport laparoscopic splenectomy and the splenic pedicles were divided by bipolar sealing device (LigaSure). In Group 1, splenectomy could be performed by single port or multiple ports approach. The splenic pedicles could be divided by endovascular stapler or LigaSure.


Group 1 included 14 children who underwent splenectomy from 2003 to 2010 and Group 2 included 9 children who were operated from 2011 to 2017. The demographics were comparable between the two groups. Group 2 was associated with lower complication (0 vs. 5, p = 0.043), shorter operative time in splenectomy (146 min vs. 173 min, p = 0.056) and shorter mean hospital stay (3.8 days vs. 7.1 days, p < 0.0001).


Superior outcomes including lower complication rates and shorter hospital stay were observed after standardization of surgical techniques in laparoscopic splenectomy in children using multiple ports and LigaSure.


Hematological Laparoscopy Splenectomy Standardization Techniques 


In children with benign hematological disease including chronic hemolytic anemia and chronic idiopathic thrombocytopenic purpura, splenectomy may be required if the medical treatment failed [1, 2]. Laparoscopic splenectomy has gained popularity and has become the treatment of choice in patients who required splenectomy in benign hematological condition [3, 4]. A systemic review and meta-analysis concluded that laparoscopic splenectomy is a feasible, safe, and effective surgical procedure in children [5]. Comparing with open splenectomy, laparoscopic splenectomy has the advantages of shorter hospital stay and less blood loss [5].

In the era of minimally invasive surgery, there have been evolutions of techniques in laparoscopic splenectomy. Conventional multiport laparoscopic splenectomy, single incision laparoscopic splenectomy, and robotic splenectomy had been reported [6, 7, 8]. In laparoscopic splenectomy, the use of various laparoscopic hemostatic devices had also been reported in the literatures [9, 10, 11, 12]. They included endovascular stapler (EndoGIA, Ethicon Endosurgery, Inc, Cincinnati, OH), Ultracision harmonic scalpel (United States Surgical Corp, Norwalk, CT, USA), and bipolar devices (LigaSure Vessel Sealing System Atlas, Valleylab, Tyco healthcare Group, Boulder, CO, USA). In this study, we aimed to review our experience in laparoscopic splenectomy in children with benign hematological disease over the past 14 years and the outcome after standardization of techniques.

Materials and methods


From January 2003 to December 2017, 24 children with benign hematological condition were referred from the Pediatric Hematological team to the Pediatric Surgical team for splenectomy. Laparoscopic splenectomy was the choice of approach in elective splenectomy in our institute. One patient underwent open splenectomy since massive splenomegaly was excluded from this study. A retrospective review was performed on the 23 children who underwent laparoscopic splenectomy. Demographics including the age, sex, underlying hematological disease, and weight of spleen were reviewed. Laparoscopic technique, the method of spleen dissection and vessel transection, intra-operative or 30-day post-operative complication, operative time, and the length of stay were reviewed. The outcome of laparoscopic splenectomy was compared before and after standardization of technique in 2011. The study was reviewed and approved by the Joint CUHK-NTEC Clinical Research Ethics Committee (CREC).

Operative techniques

In multiport laparoscopic splenectomy, three 5-mm ports were inserted over subumbilical region, right middle quadrant of the abdominal wall, and xiphisternum. If EndoGIA was used to divide the splenic pedicle, a 12-mm port was inserted at left middle quadrant of the abdominal wall. Otherwise, a 5-mm port was inserted instead. Electrocautery, Harmonic scalpel or LigaSure were the energy source in splenic dissection. The splenic pedicle was divided by EndoGIA or LigaSure.

The technique, single incision laparoscopic splenectomy was described before [7]. In brief; the three 5-mm ports were inserted over the same fascial plan at the subumbilical region. Electrocautery and LigaSure (Fig. 1) were used as the energy source in splenic dissection. The splenic pedicle was divided by LigaSure.
Fig. 1

LigaSure was the only energy source in division of splenic pedicle after standardization of technique

In all patients, after splenic dissection and division of pedicle, the spleen was put inside a 15-mm endobag (Endocatch II, Autosuture, Tyco Healthcare, Connecticut USA). The spleen was then manually morcellated within the endobag through the umbilical wound (if Ligasure was used) (Fig. 2) or the 12-mm port wound (if EndoGIA was used) and then removed from the peritoneal cavity.
Fig. 2

The spleen was manually morcellated and removed via the umbilical wound

Standardization of techniques

In Group 1, from 2003 to 2010, there was no standardization of surgical technique. It included nine patients who underwent multiple ports laparoscopic splenectomy and five children underwent single port laparoscopic splenectomy. The methods of splenic dissection and pedicle control were not standardized in Group 1. In Group 2, from 2011 to 2017, nine patients underwent multiport laparoscopic splenectomy. Electric cautery and LigaSure were used in splenic dissection. LigaSure was the sole energy source used in division of splenic pedicles in Group 2.

Statistical analysis

Statistical analysis was accomplished using the SPSS program for Windows 21.0 (SPSS, Chicago, IL, USA). The Student’s t test was used to compare the continuous data. Chi-Square test was used to compare the categorical data. p < 0.05 was considered statistically significant.


Thirteen boys and ten girls were included in this study. The mean age at operation was 10.0 years (range 4–17 years). Thirteen children suffered from thalassemia, five children had hereditary spherocytosis, four children had chronic immune thrombocytopenia, and one child had chronic hemolytic anemia of unknown cause. Nine patients (39%) underwent concomitant cholecystectomy because of gallstone disease.

There was no difference in patient’s demographics between the two groups (Table 1). The overall mean operative time was statistically shorter in Group 2 (150 min vs. 259 min, p = 0.003) (Table 1). Seven patients in each group underwent laparoscopic splenectomy only. The mean operative time was shorter in Group 2 but did not reach statistical difference (Table 2). In patients who underwent concomitant cholecystectomy, the mean operative time in Group 2 was significantly shorter (Table 2).
Table 1

Patients’ characteristics and outcome between the two groups


Group 1 (n = 14)

Group 2 (n = 9)

p value

Age, mean (SD) (year)

10.7 ± 3.5

8.6 ± 4.2


Sex, male/female




Weight of spleen, mean(SD) (g)

423.3 ± 192.4

276.7 ± 173.4


Operative time, mean (SD) (min)

259.4 ± 109.1

150.3 ± 27.9


Complication (n)




Length of stay, mean (SD) (day)

7.1 ± 1.5

3.8 ± 1.1

< 0.001*

*p < 0.05 was considered statistically significant

Table 2

Operative time in subgroup analysis

Splenectomy only

Group 1 (n = 7)

Group 2 (n = 7)

p value

Operative time, mean (SD) (min)

172.9 ± 9.1

146.1 ± 29.6


Splenectomy + cholecystectomy

Group 1 (n = 7)

Group 2 (n = 2)


Operative time, mean (SD) (min)

345.9 ± 90.6

165.0 ± 21.2


*p < 0.05 was considered statistically significant

The overall complication rate was statistically higher in Group 1 (Table 1). In Group 1, one patient underwent single port surgery who required conversion to open approach because of bleeding during dissection of polar vessels. Two patients had a drop of hemoglobin to 5 g/dL post-operatively. EndoGIA was used in pedicle division in these two cases. Laparotomy was performed in the first patient on post-operative day 1 because of unstable hemodynamics. Intra-operatively, hemoperitoneum was present but no active source of bleeding was identified. The bleeding was thought to be from the splenic pedicle. The pedicle was further plicated with sutures. In the second patient, conservative treatment including close monitoring and blood transfusion was adopted. In addition, two patients had post-operative fever in Group 1. In Group 2, no intra-operative and 30-day post-operative complications were encountered. The mean length of stay was statistically shorter in Group 2 (3.8 days vs. 7.1 days, p < 0.0001).


Bleeding is one of the common complications during splenectomy [13, 14]. In addition, bleeding is one of the major indications for conversion to open procedure during laparoscopic splenectomy [12, 15]. Oosan et al. reported that 8% of patients required conversion to open surgery because of intra-operative bleeding [15]. With the evolution of laparoscopic instruments, different techniques had been reported in laparoscopic splenectomy for hemostasis and in pedicle control [9, 10, 11, 12]. In the early era, ligature and clips were used as the method of vascular control and were cost effective [16]. However, skeletonization of the pedicle is required and may result in bleeding. The application of endovascular stapler has then gained favor in pedicle control because it allows en bloc transection of the pedicle [11, 12, 17]. The proper positioning of the stapler is essential to avoid damaging of the adjacent organs including the pancreas and to ensure proper closure of the jaws of stapler [12]. In our study, we placed the 12-mm port at the left middle quadrant to allow a proper angulation of the staplers. Despite this adaptation, two patients had major bleeding in Group 1. Bleeding from the stapler line or incomplete transection was postulated to be the underlying reason for post-operative bleeding in study that used stapler to divide the splenic pedicle [12].

The introduction of Harmonic scalpel provided a stronger energy source in hemostasis than electrocautery. It has been used in division of smaller polar vessels and gastric vessels [10, 11, 12]. However, harmonic scalpel was rarely reported as a tool in pedicle division [18, 19]. It was often used in conjunction with endovascular stapler to complete the polar vessels transection [10, 11, 12].

The use of LigaSure has been increasing, reportedly, in laparoscopic splenectomy adult and children [20, 21]. It was reported that the use of LigaSure was associated with shorter operative time and decreased risk of bleeding [20, 21]. In addition, there is no need to exchange the instrument frequently because it allows cutting of the tissue together with hemostasis. We did found that LigaSure is a user friendly device in particular in splenectomy in children. It allows division of the vessel up to 7 mm and we could use LigaSure in splenic dissection and division of splenic pedicles. We did not encounter any major bleeding from the splenic pedicles after using LigaSure in multiport laparoscopic splenectomy. In studies comparing the use of LigaSure and endovascular stapler in the transection of splenic hilum, they concluded that the blood loss was less with the use of LigaSure [11, 12, 21].

With the evolution of minimally invasive surgery (MIS), single incision laparoscopic surgery (SILS) has become an alternative to conventional multiport laparoscopy [22]. The single incision at the umbilicus definitely provides better cosmesis when compared to multiport laparoscopic surgery. We have reported our experience in SILS in splenectomy using conventional laparoscopic instruments [7]. From our experience, SILS can be safely performed with excellent cosmesis. However, we did encounter difficulty in surgical ergonomics as a result of the close proximity of the laparoscope and the working instruments. In addition, SILS poses additional mental workload to surgeons when compared with multiport laparoscopic surgery [23, 24]. The longer operative time in patients in Group 1, in particular in patient who underwent concomitant laparoscopic cholecystectomy may reflect the learning curve and difficulty in single port surgery (Table 2).

With the development of technology and minimally invasive surgery, MIS has been reported as a new gold standard in a number of operations. However, we have demonstrated in patients with biliary atresia, laparoscopic Kasai was not associated with a better outcome [25]. Open Kasai was reintroduced and was associated with better early biliary drainage and native liver survival [26]. In laparoscopic splenectomy, we experienced the difficulty and apparently less favorable outcome in SILS. We decided to switch back to the multiport LS after the trial of SILS.

The hospital stay was significantly shortened after standardization of techniques. It can be attributed by the lower complication rate in Group 2. In Group 1, two patients had post-operative bleeding including one who required hemostasis by laparotomy. They had a prolonged stay in hospital for close monitoring for any re-bleeding. Two patients in Group 1 developed post-operative fever. They received prolonged courses of antibiotics and were discharged from hospital until fever settled.

The limitations of this study included retrospective data collection and small sample size. This truly reflected the rare incidence of hematological disease in our locality that required surgical intervention. In western population, hereditary spherocytosis and sickle cell’s disease were the leading cause of hematological condition in patients who required splenectomy, but the incidence of these two diseases was much rare in Asian [12].

In conclusion, laparoscopic splenectomy can be performed safely in children with benign hematological disease despite the small case volume. With improvement in technology and the hemostatic devices, the length of stay was significantly shorter with the current technique in laparoscopic splenectomy.




Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interest.


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© Springer Nature Singapore Pte Ltd 2019

Authors and Affiliations

  1. 1.Division of Paediatric Surgery and Paediatric Urology, Department of SurgeryThe Prince of Wales Hospital, The Chinese University of Hong KongHong KongChina

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