The usefulness of modified splenic hilum hanging maneuver in laparoscopic splenectomy, especially for patients with huge spleen: a case-control study with propensity score matching



Although Laparoscopic splenectomy (LS) have been proven to the standard operation for removal of spleen, the rate of conversion to open surgery is still higher than those of other laparoscopic surgeries, especially for huge spleen. In order to reduce the rate of conversion to open surgery, we had developed LS using modified splenic hilum hanging (MSHH) maneuver: the splenic pedicle was transected en bloc using a surgical stapler after hanging splenic hilum with an atraumatic penrose drain tube.


Between January 2005 and December 2019, we retrospectively assessed 94 patients who underwent LS. MSHH maneuver was performed in 37 patients (39.4%). We compared the intra- and postoperative outcomes between patients with or without MSHH maneuver. To adjust for differences in preoperative characteristics and blood examination, propensity score matching was used at a 1:1 ratio, resulting in a comparison of 29 patients per group. Predictive factors of conversion from LS to open surgery were elucidated using the uni- and multi-variate analyses.


After the propensity score matching, blood loss (268 ml vs. 50 ml), the rate of conversion to open surgery (27.6% vs. 0%), and postoperative hospital stays (15 days vs. 10 days) were significantly decreased in patients with MSHH maneuver, respectively. Among 94 patients, 19 patients (20.2%) underwent conversion to open surgery. In multivariate analysis, spleen volume (SV) and LS without MSHH maneuver were independent predictive factors of conversion to open surgery, respectively. Additionally, cut-off value of SV for conversion to open surgery was 802 ml (sensitivity: 0.684, specificity: 0.827, p < 0.001).


LS using MSHH maneuver seems to be useful surgical technique to improve intraoperative outcomes and reduce the rate of conversion from LS to open surgery resulting in shorten postoperative hospital stay.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. 1.

    Delaitre B, Maignien B (1991) Splenectomy by the laparoscopic approach. Report of a case. Presse Med 20:2263

    CAS  PubMed  Google Scholar 

  2. 2.

    Matharoo GS, Afthinos JN, Gibbs KE (2014) Trends in splenec- tomy: where does laparoscopy stand. JSLS 18(e2014):00239

    Google Scholar 

  3. 3.

    Poulin E, Thibault C, Mamazza J, Girotti M, Côté G, Renaud A (1993) Laparoscopicsplenectomy: clinical experience and the role of preoperative splenic artery embolization. Surg Laparosc Endosc 3:445–450

    CAS  PubMed  Google Scholar 

  4. 4.

    Van Der Veken E, Laureys M, Rodesch G, Steyaert H (2016) Perioperative spleen embolization as a useful tool in laparoscopic splenectomy for simple and massive splenomegaly in children: a prospective study. Surg Endosc 30:4962–4967

    Article  Google Scholar 

  5. 5.

    Gelmini R, Romano F, Quaranta N, Caprotti R, Tazzioli G, Colombo G, Saviano M, Uggeri F (2006) Sutureless and stapleless laparoscopic splenectomy using radiofrequency: LigaSure device. Surg Endosc 20:991–994

    CAS  Article  Google Scholar 

  6. 6.

    Schaarschmidt K, Kolberg-Schwerdt A, Lempe M, Saxena A (2002) Ultrasonic shear coagulation of main hilar vessels: a 4-year experience of 23 pediatric laparoscopic splenectomies without staples. J Pediatr Surg 37:614–616

    Article  Google Scholar 

  7. 7.

    Misawa T, Yoshida K, Iida T, Sakamoto T, Gocho T, Hirohara S, Wakiyama S, Ishida Y, Yanaga K (2009) Minimizing intraoperative bleeding using a vessel-sealing system and splenic hilum hanging maneuver in laparoscopic splenectomy. J Hepatobiliary Pancreat Surg 16:786–791

    Article  Google Scholar 

  8. 8.

    Belghiti J, Guevara OA, Noun R, Saldinger PF, Kianmanesh R (2001) Liver hanging maneuver: a safe approach to right hepatectomy without liver mobilization. J Am Coll Surg 193:109–111

    CAS  Article  Google Scholar 

  9. 9.

    Mizuno S, Isaji S, Tanemura A, Kishiwada M, Murata Y, Azumi Y, Kuriyama N, Usui M, Sakurai H, Tabata M (2014) Anterior approach to the superior mesenteric artery by using nerve plexus hanging maneuver for borderline resectable pancreatic head carcinoma. J Gastrointest Surg 18:1209–1215

    Article  Google Scholar 

  10. 10.

    Kuroki T, Tajima Y, Kitasato A, Adachi T, Kanematsu T (2010) Pancreas-hanging maneuver in laparoscopic pancreaticoduodenectomy: a new technique for the safe resection of the pancreas head. Surg Endosc 24:1781–1783

    Article  Google Scholar 

  11. 11.

    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  Google Scholar 

  12. 12.

    Bassi C, Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M (2017) The 2016 update of the International study group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years After. Surgery 161:584–591

    Article  Google Scholar 

  13. 13.

    Austin PC (2009) Some methods of propensity-score matching had superior performance to others: results of an empirical investigation and Monte Carlo simulations. Biom J 51:171–184

    Article  Google Scholar 

  14. 14.

    Habermalz B, Sauerland S, Decker G, Delaitre B, Gigot JF, Leandros E, Lechner K, Rhodes M, Silecchia G, Szold A, Targarona E, Torelli P, Neugebauer E (2008) Laparoscopic splenectomy: the clinical practice guidelines of the European association for endoscopic surgery (EAES). Surg Endosc 22:821–848

    CAS  Article  Google Scholar 

  15. 15.

    Rehman S, Hajibandeh S, Hajibandeh S (2019) A systematic review and meta-analysis of anterior versus lateral approach for laparoscopic splenectomy. Surg Laparosc Endosc Percutan Tech 29:233–241

    Article  Google Scholar 

  16. 16.

    Di Sandro S, Danieli M, Ferla F, Lauterio A, De Carlis R, Benuzzi L, Buscemi V, Pezzoli I, De Carlis L (2018) The current role of laparoscopic resection for HCC: a systematic review of past ten years. Transl Gastroenterol Hepatol 3:68

    Article  Google Scholar 

  17. 17.

    Simorov A, Shaligram A, Shostrom V, Boilesen E, Thompson J, Oleynikov D (2012) Laparoscopic colon resection trends in utilization and rate of conversion to open procedure: a national database review of academic medical centers. Ann Surg 256:462–468

    Article  Google Scholar 

  18. 18.

    Habermalz B, Sauerland S, Decker G, Delaitre B, GigotLean- drosLechnerRhodesSilecchiaSzoldTargaronaTorelliNeugebauer JFEKMGAEPE (2008) Laparoscopic splenectomy: the clinical practice guidelines of the European association for endoscopic surgery (EAES). Surg Endosc 22:821–848

    CAS  Article  Google Scholar 

  19. 19.

    Patel AG, Parker JE, Wallwork B, Kau KB, Donaldson N, Rhodes MR, O’Rourke N, Nathanson L, Fielding G (2003) Massive splenomegaly is associated with significant morbidity after laparoscopic splenectomy. Ann Surg 238:235–240

    PubMed  PubMed Central  Google Scholar 

  20. 20.

    Kawanaka H, Akahoshi T, Kinjo N, Harimoto N, Itoh S, Tsutsumi N, Matsumoto Y, Yoshizumi T, Shirabe K, Maehara Y (2015) Laparoscopic splenectomy with technical standardization and selection criteria for standard or hand-assisted approach in 390 patients with liver cirrhosis and portal hypertension. J Am Coll Surg 221:354–366

    Article  Google Scholar 

  21. 21.

    Wang X, Li Y, Crook N, Peng B, Niu T (2013) Laparoscopic splenectomy: a surgeon’s experience of 302 patients with analysis of postoperative complications. Surg Endosc 27:3564–3571

    Article  Google Scholar 

  22. 22.

    Casaccia M, Sormani MP, Palombo D, Dellepiane C, Ibatici A (2019) Laparoscopic splenectomy versus open splenectomy in massive and giant spleens: should we update the 2008 EAES guidelines? Surg Laparosc Endosc Percutan Tech 29:178–181

    Article  Google Scholar 

  23. 23.

    Rodriguez-Otero Luppi C, Targarona Soler EM, Balague Ponz C, Pantoja Millan JP, Turrado Rodriguez V, Pallares Segura JL, Bollo Rodriguez J, Trias Folch M (2017) Clinical, anatomical, and pathological grading score to predict technical difficulty in laparoscopic splenectomy for non-traumatic diseases. World J Surg 41:439–448

    Article  Google Scholar 

  24. 24.

    Liu P, Li Y, Ding HF, Dong DH, Zhang XF, Liu XM, Lv Y, Xiang JX (2020) A novel preoperative scoring system to predict technical difficulty in laparoscopic splenectomy for non-traumatic diseases. Surg Endosc.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


There was no funding to support this study.

Author information



Corresponding author

Correspondence to Naohisa Kuriyama.

Ethics declarations


Naohisa Kuriyama, Koki Maeda, Haruna Komatusbara, Toru Shinkai, Daisuke Noguchi, Kazuyuki Gyouten, Aoi Hayasaki, Takehiro Fujii, Yusuke Iizawa, Yasuhiro Murata, Akihiro Tanemura, Masashi Kishiwada, Hiroyuki Sakurai, and Shugo Mizuno have declared that no conflict of interest exists. We have no disclosures or financial support to report for this study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 764 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kuriyama, N., Maeda, K., Komatsubara, H. et al. The usefulness of modified splenic hilum hanging maneuver in laparoscopic splenectomy, especially for patients with huge spleen: a case-control study with propensity score matching. Surg Endosc (2021).

Download citation


  • Laparoscopic splenectomy
  • Splenic hilum hanging maneuver
  • Spleen volume
  • Conversion surgery
  • Propensity score matching