Laparoscopic Splenectomy: Conventional Versus Robotic Approach

Abstract

Background:

Laparoscopic splenectomy is accepted as a safe approach in the surgical treatment of blood disorders worldwide. Compared with the laparotomic technique, it is associated with a lower risk of intraoperative bleeding, less postoperative pain, and faster discharge times. The advent of robotic surgery (RS) has changed the concept of minimally invasive surgery because, in addition to allowing a three-dimensional view, it permits greater freedom of movement and higher levels of accuracy than laparoscopic surgery (LS). The aim of this study was to comparatively evaluate whether RS presents advantages over LS in spleen surgery.

Methods:

In two Surgical Units with experience in laparoscopic splenectomy, over a 7-year period, two groups of 45 patients underwent LS and RS. The two groups were well matched for demographic characteristics, indications, and spleen size.

Results:

No statistically significant differences were found regarding intraoperative blood loss, conversion rate to laparotomy, food intake, drain removal, postoperative complications, and median time to discharge. On the contrary, statistically increased differences were observed in median operative time and costs. In both groups, the transfusion and mortality rate was 0%. At the 6-month follow-up no surgical complications were observed.

Conclusions:

Although RS offers a three-dimensional view, greater freedom of movement, and higher levels of accuracy, it is associated with longer operative times and higher costs. It can consequently be concluded that with the intrinsic limits of the study design used, at the current time, RS does not have any significant advantage over LS in splenectomy.

Introduction

Worldwide splenectomy is considered the standard surgical treatment for benign blood disorders and plays an important role in the diagnosis, staging, and treatment of a great many malignant lymphoproliferative disorders. Since 1991 when it was performed for the first time by Delaitre and Maignien,¹ laparoscopic splenectomy has gained increasing acceptance. The advantages of a minimally invasive approach, the good exposure of the surgical field and the results, which are comparable to those of the laparotomic procedure in terms of safety and efficacy, are widely recognized.^2–6

Many retrospective studies have shown that laparoscopic splenectomy can generally be performed with less surgical trauma and intraoperative blood loss, less postoperative pain, shorter hospital stays, and faster functional recovery than the open procedure.^7,8

However, the laparoscopic approach requires a well-trained surgeon with expertise in minimally invasive techniques and who is able to establish a correct approach to the hilar vessels, an awkward procedure due to the rich blood supply and severe complications involved, with uncontrolled intraoperative bleeding being considered the main cause of conversion and postoperative hemoperitoneum the most frequent cause of re-operation.⁹

The advent of robotic surgery systems has radically changed the concept of minimally invasive surgery. Specifically, it has improved vision in the surgical field, thanks to a three-dimensional view, and allows better movement accuracy than the laparoscopic technique, thanks to the six degrees of freedom provided by the robotic instrument tips.^10–14

Several published studies have evaluated the feasibility and safety of various robotic procedures in both general and specialized surgery such as radical prostatectomy.¹⁵ Nevertheless, very few trials have comparatively analyzed the clinical and economic results of robotic and conventional laparoscopic procedures, especially in the field of general surgery.

The aim of this study was to retrospectively evaluate the potential advantages and disadvantages of adopting the robotic approach versus conventional laparoscopic techniques in splenic surgery.

Materials and Methods

Patient data

The study caseload was comprised of 90 patients, all of whom had blood disorders, undergoing splenectomy over a 7-year period—from February 2002 to February 2009—in two different centers with experience in minimally invasive and spleen surgery:

Forty-five patients underwent laparoscopic splenectomy at the Department of Surgery of Modena University Hospital, using the conventional approach (group 1, G1).

Forty-five patients underwent robotic splenectomy at San Matteo degli Infermi Hospital in Spoleto, using the Da Vinci System (group 2, G2).

The first 15 cases of both the laparoscopic and robotic splenectomy groups were excluded from the study population, as they were considered part of the learning curve (in both groups >90% of the procedures were performed by the same surgeon). All trauma patients and those with massive splenomegaly or concomitant conditions considered to be contraindications to laparoscopy were also excluded. The series considered represent 41% and 37.5% of the splenectomies performed in the laparoscopic and robotics center, respectively, during the same period.

The two patient cohorts were well matched for demographic data, preoperative diagnosis, and median spleen diameter.

In G1, 24 patients were male and 21 female (m:f ratio=1.14:1) with a median age of 45.9 years (range: 15–81 years), whereas in G2, 28 patients were male and 17 female (m:f ratio=1.64:1) with a median age of 41 years (range: 14–66 years).

All patients had preoperative abdominal ultrasonography and computed tomography scans and a platelet count >70.000/μL.

The median diameter of the spleen was 15 cm (range 11–19 cm) in G1 and 13 cm (range 10–16 cm) in G2. (Table 1)

Table 1.

Patients' Demographic Data

	Group 1	Group 2	P value
Male:female	24:21	28:17
Median age	45.9 years	41 years	ns
Preop platelets	>70.000	>70.000	ns
Median spleen diameter	15 cm	13 cm	ns
No. of patients	45	45	ns

ns, not significant.

The two patient cohorts were also well matched as regard their American Society of Anesthesiologists score (Table 2), and all of them received perioperative antibiotic and deep venous thrombosis prophylaxis with intravenous cephalosporin and subcutaneous low-molecular-weight heparin injection, respectively.

Table 2.

Preoperative American Society of Anesthesiologists Score

	Group 1	Group 2	P value
ASA I	4	6	ns
ASA II	26	27	ns
ASA III	14	11	ns
ASA IV	1	1	ns
No. of patients	45	45	ns

ASA, American Society of Anesthesiologists.

Finally, a multivalent vaccine (against encapsulated organisms) was administered to all patients about 2 weeks before surgery.

The preoperative diagnosis and indications for surgical treatment were similar in the two groups: benign blood disorders were observed in 24 cases in G1 and 22 cases in G2, whereas malignancies were identified in 21 patients in G1 and 23 in G2 (Table 3).

Table 3.

Preoperative Diagnosis

			Group 1	Group 2	P value
Malignancies	21	5 chronic lymphatic leukemia	23	6 chronic lymphatic leukemia	ns
		2 Hodgkin's disease		4 Hodgkin's disease
		13 non-Hodgkin lymphoma		12 non-Hodgkin lymphoma
		1 hairy-cell leukemia		1 hairy-cell leukemia
Benign diseases	24	1 thrombotic thrombocytopenic purpura	22	2 thrombotic thrombocytopenic purpura	ns
		4 spherocytosis		3 spherocytosis
		16 idiopathic thrombocytopenic purpura		14 idiopathic thrombocytopenic purpura
		3 cystic lesion		3 cystic lesion
Total	45		45		ns

Within 2 weeks after surgery, all patients had an abdominal ultrasonography to evaluate the presence of fluid in the left subphrenic space and a color Doppler examination of the splenic portal and mesenteric blood vessel to rule out the presence of thrombi.

Surgical procedure

All patients were placed in an incomplete lateral right decubitus position with an anti-Trendelenbourg inclination of about 30°. The laparoscopic rack in G1, which was replaced by a patient-side cart with robotic arms in G2, was positioned on the left side of the operating table.

A 12 mm Hg pneumoperitoneum was created using an open technique and by inserting a periumbilical 15 mm trocar in G1, and by introducing a Veress needle in the same point in G2 (the needle was then replaced with a 15 mm trocar). A 30° laparoscope was used in all cases. In the group of patients undergoing conventional laparoscopic splenectomies (G1), three more trocars were positioned in 38 cases, two additional surgical trocars were positioned in 3 patients, and four additional trocars in 4 cases. In the patients undergoing robotic splenectomy, three additional trocars were used in all cases.

A lateral approach was used in all procedures. In both groups, at the start of the procedure the abdominal cavity was examined to detect any accessory spleens, which were identified and removed in 4 G1 patients of which three were localized in the great omentum and one in the gastrocolic ligament. The first step consisted in the dissection of the inferior splenic pole and ligature of the lower polar vessels, followed by the dissection and ligature of the short gastric vessels. The second step was to approach the splenic pedicle next to the hilum; the ligature of hilar vessels was performed as far as possible from the pancreatic tail.

This part of the procedure is more precise using the robotics technique, thanks to the fine accurate movements the surgeon can perform at the console. The splenorenal ligaments were divided up to the splenodiaphragmal attachments. In G1 the splenic ligaments were dissected using a radiofrequency vessel sealing system in 34 cases (75.5%), monopolar electrocautery in 8 cases (17.8%), and ultrasonic dissection blade in 3 cases (6.7%). In the same group the hilum and the short gastric vessels were divided using a radiofrequency vessel sealing system in 34 cases (75.5%), with an endovascular stapler in 9 (20%), and using endoclips in 2 cases (4.5%).

In the robotic group splenic ligament dissection was performed using an ultrasonic device in all cases, and the hilar and short gastric vessels were dissected using an endovascular stapler in all cases.

The surgical pieces were removed, laparoscopically, through an enlarged median supra or subumbilical incision using an endobag, and a drainage was placed in all cases in both groups (Table 4) to improve early detection of any postoperative complications such as hemoperitoneum and pancreatic fistula. In all cases the drain was removed within 48 hours, to avoid the risk of postoperative infections.

Table 4.

Intraoperative Data

		Group 1	Group 2
Pneumoperitoneum	Verress needle	/	45
	Open laparoscopy	45	/
No. of trocars	3	3	/
	4	38	45
	5	4	/
Dissection	Monopolar coagulation	8	/
	Radiofrequency vessel sealing system	34	/
	Ultrasound coagulation	3	45
Hilar section	Radiofrequency vessel sealing system	34	/
	Linear stapler	9	45
	Clip	2	/
Minilaparotomy	Subumbilical	36	/
	Supraumbilical	9	45

Operating theater and staff costs were assessed by the hospital accounts department and calculated according to the median operating time for each group. Expenses for disposable instrumentation were also added in both cases. Both centers involved in the study are public hospital and operating theater and staff costs and instrumentation fees are similar in all public hospitals across Italy.

The Mann–Whitney U-test and Fisher test were used for statistical analysis and a p-value of <.05 was considered significant.

Results

The two groups of patients in this series were well matched with regard to demographic data, preoperative management, and postoperative care.

The median operative time was statistically significantly different (P value <.05): 125 minutes in G1 and 153 minutes in G2 (including the time required to set up the robot, which more or less corresponds to the difference in the mean operating time between the two groups). Despite excluding the first 15 cases in both cohorts, the mean operative time decreases over time in both the robotic and the laparoscopic groups. In the case of the robotics group, this reduction was primarily due to the surgeon's greater confidence, rather than a shorter setup time, as the surgeons operating on these patients gained experience also by performing other procedure as Nissen-Rossetti fundoplicatio.

The conversion rate was similar for the two groups of patients. In both groups conversion—which was to the laparotomic procedure in all cases—was due to intraoperative bleeding, and occurred in 5 patients (11.1%) in G1 and 4 cases (8.9%) in G2. In all cases, which were limited to the early years of this study, the bleeding was not massive and the decision to convert was taken as a precautionary measure. The bleeding was caused by technical errors in two cases in G1 and two cases in G2 (hemorrhage during splenic vessels dissection). Oozing lymphadenopathy was the cause of the hemorrhage in the remaining three patients in G1 and in two cases of G2. Large population studies in literature report a conversion rate of between 0% and 12%.^9,16

Both the mortality rate and the transfusion rate were 0%.

In line with the data available in literature,⁹ in this study, food intake started between the first and fourth postoperative day (median 2.5 in G1 and 2.7 in G2), and the median hospital stay was 5.3 days in G1 and 5.1 days in G2.

Total procedure costs were considerably higher in the robotic group (2590 US$ in G1 versus 6930 US$ in G2), with a statistically significant difference of P value <.05 (Table 5).

Table 5.

Postoperative Data

	Group 1	Group 2	P value
Median operative time (minutes)	125	153	<.05
Drainage (no. of patients)	45	45	ns
Conversion rate	5	4	ns
Trasfusion rate	0	0	ns
Median postoperative stay (days)	5.3	5.1	ns
Postoperative food intake (days)	2.5	2.7	ns
Median costs (US$)	2590	6930	<.05

The postoperative morbidity rate, which was identical for the two groups, was of 11.1% (5 patients).

In G1 the postoperative complications consisted of hemoperitoneum in 4 patients (in 3 cases patients were treated laparoscopically, whereas in the remaining case the laparotomic approach was preferred), and pleural effusion in 1 patient who received medical treatment.

In G2 the postoperative complications consisted of hemoperitoneum in just 1 case, treated with the laparotomic approach and pleural effusion in 4 patients, all of whom were asymptomatic (Table 6).

Table 6.

Postoperative Complications

	Group 1	Group 2	P value
Pleural effusion	1	4	ns
Hemoperitoneum	4	1	ns
Total	5	5	ns

All 5 cases of postoperative hemoperitoneum were recognized just a few hours after surgery, thanks to the blood content of the drain, and in all cases the bleeding was caused by a diffuse oozing from the retroperitoneum.

Six months after splenectomy all patients were in good health with no signs of late complications.

Discussion

Laparoscopic splenectomy is a safe, effective, and advanced minimally invasive procedure.

At the current time, it can be considered a well-accepted approach for the differential diagnosis and the staging of lymphoproliferative diseases, for re-staging after chemotherapy or radiotherapy in abdominal lymphoma, as well as when diseases recurrence is suspected, for the treatment of cystic or solid splenic lesions, and for the surgical treatment of blood disorders.

In laparoscopic splenectomy, the golden rules for optimal surgical treatment are, first, a gentle dissection to avoid incidental hemorrhages or parenchymal rupture due to traction on the spleen and cellular dissemination; second, accurate hemostasis and transection of the hilar vessels—which are fundamental to reducing the conversion rate due to hemorrhage; and, finally, the identification and removal of accessory spleens that can cause the failure of the surgical procedure.

A successful laparoscopic procedure determines a low complication rate, and the semilateral right decubitus position associated with a lateral approach to the splenic hilum has reduced the risks of intraoperative bleeding, which is the most important reason for conversion to the laparotomic approach.⁹

Although the operative time is longer than for the traditional surgery,^3,17 laparoscopy obtained a considerable reduction in hospital stay and postoperative pain along with a reduced use of painkillers and a faster return to a full social life after hospital discharge.

On the other hand, the introduction of the Da Vinci Robotic System has made it possible to accomplish amazing objectives in mini-invasive surgery. This system offers many advantages over conventional laparoscopy, such as a three-dimensional view of the surgical field, the finer and more accurate movements that the surgeon can performed using the console, and surgical instruments with six degrees of freedom enabling 360° movements, which are superior even to those of the surgeon's hand in open procedure.^18,19 Moreover, these innovations have allowed the “robotic” surgeon to see and work inside the closed abdomen and safely conduct surgical procedures, such as some very complex splenectomies, which would otherwise have been likely candidates for laparotomic conversion. Finally, the training required to use the Da Vinci Robotic System is straightforward with a short “learning curve.”²⁰

Despite these ***factors in favor of robotic surgery, the study in questions did not shown that this technique has brought any clear advantages to minimally invasive splenic surgery. More specifically, the higher costs and longer operating times prevent robotic surgery from being considered the new gold standard for splenectomy. It is also important to note that although they can be used up to 10 times, the cost of the instruments required is so high, which makes the robotic system more expensive than conventional laparoscopy. In our study the analytical evaluation and comparison of the specific costs of the two procedures, which also consider their different median operative times, show the costs of the robotic procedure and traditional laparoscopy as being 6939 US$ and 2590 US$, respectively. These findings are consistent with previous study on robotic splenectomy.^10,21

Further, in contrast to conventional laparoscopic surgery, another obstacle to the robotic approach's being considered as the gold standard in spleen surgery is the lack of different dedicated robotic instruments.¹⁹ The key element in laparoscopic splenectomy is hilar vessel transection, which is usually performed using an endovascular stapler or a radiofrequency device, neither of which is available in robotic surgery. For this reason the crucial step of the procedure is not performed by the surgeon at the console, rather by the second surgeon at the operating table using a conventional laparoscopic stapler or a radiofrequency device through the traditional laparoscopic trocar.

Another drawback of the robotic system is its rigidity, which means that it is only possible to change the table position during the operation only by disconnecting the robotic arms, which would result in a considerable loss of time.²¹

Therefore, one of the prerequisites for the acceptance of the robotic approach as the gold-standard treatment in spleen surgery is the introduction of new instruments such as robotic staplers and radiofrequency devices. An additional robotic arm with a dedicated washing–suction system would be an interesting evolution that would simplify robotic procedures. In due time, the next generation of robotic instrument could provide some tangible advantages as equipment improves.

It therefore seems likely that the future implementation of improved instruments and robotic systems could lead to shorter operating time and, consequently, lower procedure costs, although the lack of competition between manufactures has negative effects on reducing costs and permitting a broader use of robotics.¹⁹

At the current time, the number of surgical procedures using the robotic approach is limited to radical prostatectomy and gastroesophageal junction, rectal, major pancreatic, and liver surgery.^{10,11,13,19,22,23}

Although conventional laparoscopic and robotic splenectomy did not show statistically significant differences in terms of conversion rate, food intake, drain removal, postoperative complications, and median hospital stay, the two approaches were found to be statistically significantly different as regard median operating time and overall procedure costs. At this point and with limit imposed by the study design used (all of the robotic and all of the laparoscopic cases were performed at two different hospitals by different surgeons), the robotic technique would seem to give similar clinical outcomes, but is associated with higher mean costs and longer operating times than the laparoscopic procedure.

These results find agreement in the few reports and meta-analysis that compare robotic splenectomy to the conventional laparoscopic approach to splenectomy.^10,12,21

Finally, in the light of the above findings, we can conclude that robotic surgery, at the present state of the art, is unlikely to prove advantageous for the patient in procedures such as splenectomy, where there is no reconstructive phase, and therefore no need for suturing, which is where robotics makes a difference. This said, we believe that performing robotic splenectomies is an important step toward adequate training in robotics that allows surgeon to obtain the experience they need to perform more complex procedures, with a reconstructive phase, such as a Whipple procedure. Therefore, at the present time, conventional laparoscopic splenectomy is to be considered the technique of choice in the surgical treatment of blood disorders without prejudice to the fact that robotics represents a real challenge for the future that necessitates large randomized studies to be correctly evaluated.

Footnotes

Disclosure Statement

No competing financial interests exist.

Partially presented as oral communication at 19th SLS annual meeting and Endo Expo 2010 (New York, September 2010).

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Laparoscopic Splenectomy: Conventional Versus Robotic Approach—A Comparative Study

Abstract

Abstract

Background:

Methods:

Results:

Conclusions:

Introduction

Materials and Methods

Patient data

Surgical procedure

Results

Discussion

Footnotes

Disclosure Statement

References