Concomitant Laparoscopic Splenectomy and Cholecystectomy: A Systematic Review of the Literature

Abstract

Background:

Concomitant laparoscopic splenectomy and cholecystectomy (CLSC) is performed for concurrent pathologies of the spleen and gallbladder. This systematic review aimed to evaluate the available evidence on its indications, operative technique, and outcomes.

Materials and Methods:

The PubMed and Cochrane bibliographical databases were searched from the beginning of time (last search: December 6, 2019) for studies reporting on CLSC. The National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool was utilized for the evaluation of eligible articles.

Results:

Eight studies met inclusion criteria and concerned collectively 108 patients (53 males and 55 females) with a mean age of 27.02 ± 20.48 years (mean, SD). The most common surgery indications were hereditary spherocytosis (38.9%) and sickle cell disease or β-thalassemia (32.4%). Laparoscopic cholecystectomy preceded splenectomy in the majority of cases (75%). A five-trocar approach was most frequently (89.8%) utilized. The mean operation duration was 170.18 ± 53.07 minutes (mean, SD). Resected spleen weight was 601.82 ± 386.02 g (mean, SD) and had a length of 18.74 ± 5.3 cm (mean, SD). The conversion rate was 2.7%, while 20.4% of included cases experienced postoperative complications. Most frequent ones included pulmonary infection (6.5%) and portal/splenic vein thrombosis (4.6%). No postoperative death was recorded. Mean hospitalization period was 5.43 ± 3.18 days (mean, SD).

Conclusions:

CLSC is a safe and feasible operation for simultaneous diseases of the spleen and gallbladder that require elective procedures. High-quality clinical trials are essential to further elucidate clinical evidence and standardize operative technique.

Introduction

Concomitant laparoscopic splenectomy and cholecystectomy (CLSC) was introduced in 1994 by Trias and Targarona¹ for the synchronous surgical management of coexisting pathologies of spleen and gallbladder. Despite advancements in laparoscopic surgery, no consensus has been reached regarding the technique and operative parameters of this procedure.^2,3

Minimally invasive surgery is considered the gold standard for both spleen and gallbladder diseases.³ Laparoscopic splenectomy (LS) was first reported in 1991 by Delaitre and Maignien⁴ and currently is routinely implemented for spleen elective surgical procedures, especially concerning hematological disorders.^5–7 On the contrary, laparoscopic cholecystectomy (LC), since its introduction in 1985,⁸ is widely adopted as the optimal treatment approach for symptomatic cholelithiasis and cholecystitis.⁹

Hematological diseases, such as hereditary spherocytosis, thalassemia, sickle cell disease, and idiopathic thrombocytopenic purpura, are often associated with symptomatic cholelithiasis, thus requiring frequently both splenectomy and cholecystectomy.^10–12 They usually concern patients in childhood or early adulthood, and so, an improved cosmetic result is necessary and the wide abdominal incision of a conventional open approach should be avoided.^13,14 In addition to minimal damage to the abdominal wall, CLSC is also reported to lead to less postoperative pain and faster recovery.¹⁵

The objective of this study was to systematically review available literature regarding CLSC and to evaluate its indications, surgical technique, and outcomes.

Materials and Methods

Protocol and search strategy

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and in line with the protocol agreed by all authors.¹⁶ Two investigators (I.K., E.K.) independently searched PubMed and Cochrane bibliographical databases (last search: December 6, 2019) using the following MeSH terms: “laparoscopic,” “cholecystectomy,” “splenectomy.” The title-abstract screening was performed using the Abstrackr tool.¹⁷ A third investigator (D.S.) was consulted to settle any disagreements.

Inclusion and exclusion criteria

English-language literature published from the beginning of time that concerned concomitant LC and LS were included in this systematic review. Studies published in a language other than English, reviews, experimental studies, case reports and small case series with <5 patients, studies not presenting separate data for concomitant LC and LS, editorials, and letters to the editor were excluded from the present study.

Data extraction of eligible studies

A predefined data collection form was utilized for data extraction of all included studies. The number of patients, age, sex and surgical indication were recorded. Surgical technique characteristics (patient's position, trocar number and sites, part of operation performed first, structure mobilization, hilar vessel ligation, spleen removal method, and drains) were also collected. Furthermore, we gathered data concerning operation duration, intraoperative blood loss, need for transfusion, resected spleen weight and diameter, and conversion rate, where applicable. Data regarding the length of hospitalization, 30-day postoperative complications, and death rate were recorded.

Statistical analysis

Collected data were tabulated and analyzed using StataCorp 2015 (Stata Statistical Software: Release 14. College Station, TX: StataCorp LP). Continuous variables are presented as mean ± standard deviation, whereas categorical ones are summarized as valid percentages or frequencies. Pooled means and variances were calculated using aovsum STATA command. Formulas proposed by Hozo et al.¹⁸ were utilized for the estimation of mean and variance of variables, where only median, range, and sample size were reported.

Quality assessment

Two researchers (I.K., E.K.) working independently evaluated the eligible studies using the quality assessment tool for case series studies developed by the National Heart, Lung, and Blood Institute (NHLBI) and Research Triangle Institute International.¹⁹ The quality score ranges from 1 to 9; with 1–3 indicating poor quality, 4–6 fair quality, and 7–9 good quality. In the category assessing whether the follow-up period was long enough, the cutoff value was a priori set at 12 months following surgery.

Results

Literature search and eligible studies' characteristics

The literature search generated 253 studies. Eight studies met our inclusion criteria and were included in this systematic review.^{2,3,6,20–24} The detailed trial flow is shown in Figure 1. Eligible studies were published from 1999 to 2016 and 75% of them were published after 2007. Most studies originated from Italy (three studies, 37.5%), while one study came from each of the following countries: China, Japan, Greece, Saudi Arabia, and Turkey. Mean NHLBI quality assessment score was 7.13 ± 0.64 (mean, SD); 7 good-quality studies and 1 fair-quality study.

FIG. 1.

Trial flow diagram of this systematic review.

Patient characteristics

Included studies reported collectively on 108 patients, 53 males (49.1%) and 55 females (50.9%) with a mean age of 27.02 ± 20.48 years (mean, SD). The most frequent indications for operation were hereditary spherocytosis (38.9%) and sickle cell disease or β-thalassemia (32.4%). Other causes included liver cirrhosis complicated by hypersplenism and cholelithiasis (17.6%), idiopathic thrombocytopenic purpura (7.4%), autoimmune hemolytic anemia (1.9%), and 2 cases of combined cholelithiasis with splenic artery aneurysm (1.9%).

Surgical technique

In 75% of the studies, LC preceded LS, while in the remaining ones LS was performed first. In the majority of cases, the patient's initial position was right lateral or semilateral with left flank elevated at 30°–45°, while the operative table was tilted during surgery for the completion of both operative parts. Table 1 shows patient's position during each part of the operation for each included study. In the majority of cases (89.8%), a five-trocar approach was implemented, while a three-trocar and four-trocar approach was utilized at 5.6% and 4.6% of cases, respectively. Mobilization of the structures was performed using bipolar diathermy or ultrasonic scalpel, while hilar vessels were ligated utilizing the endostapler or electropolar sealing device. Detailed technical characteristics of eligible studies are presented in Table 2. In 96.2% of the available cases, the spleen was fragmented and a retrieval bag was used, while in 3.7% of cases, the spleen was removed intact. A drain was placed at the left subphrenic area in all the available cases, while a drain at the subhepatic space was utilized in 18.3% of available cases.

Table 1.

Patients' Position During Each Operative Part of Eligible Studies

Study (author, year)	Patients (N)	Initial position	Position change for first operation	First operation	Position change for second operation	Second operation
Ozemir, 2016	6	Right lateral with left flank elevated 45°	Table titled right	LS	Table titled left	LC
Vecchio, 2014	12	Right lateral with left flank elevated 30°	Table tilted left	LC	Table tilted right	LS
Wang, 2014	17	Supine	Table tilted left	LC	Right semilateral with left flank elevated 45°–60°	LS
Wang, 2014	17	Supine	Table tilted left	LC	Table tilted to anti-Trendelenburg	LS
Nobili, 2011	30	Right lateral with left flank elevated 30°–45°	Table tilted left	LC	Table tilted right	LS
Pal, 2010	21	Supine	N/A	LC	Table tilted left by 30° and anti-Trendelenburg	LS
Sasaki, 2010	9	Right lateral position	N/A	LS	Supine	LC
Leandros, 2006	6	French position	N/A	LC	Table tilted right by 30°–45° and anti-Trendelenburg	LS
Caprotti, 1999	7	French position	N/A	LC	N/A	LS

LC, laparoscopic cholecystectomy; LS, laparoscopic splenectomy; N/A, not applicable.

Table 2.

Detailed Technical Characteristics of Each Study

Study (author, year)	Trocars (N)	Trocar placement	Mobilization/dissection	Hilar vessel ligation
Ozemir, 2016	3	1.Umbilical	Ultrasonic/bipolar	Electropolar sealing device
		2. Umbilical (left side)
		3. Umbilical (upper side)
Vecchio, 2014	5	1. Epigastric	Ultrasonic	Endostapler
		2. Left hypochondrium
		3. Left abdomen at transverse umbilical line
		4. Left subcostal
		5. Right subcostal
Wang, 2014	5	1. Umbilical	Bipolar/ultrasonic	Endostapler
		2. Epigastric
		3. Right subcostal
		4. Left hypochondrium
		5. Left subcostal
Nobili, 2011	5 (25 pts) 4 (5 pts)	1. Umbilical	Bipolar/ultrasonic	Electropolar sealing device/endostapler
		2. Epigastric
		3. Right hypochondrium
		4. Left hypochondrium
		5. Left subcostal
		or
		1. Umbilical
		2. Epigastric
		3. Left hypochondrium
		4. Left subcostal
Pal, 2010	5	1. Umbilical	Bipolar	Electropolar sealing device/endostapler
		2. Epigastric
		3. Right hypochondrium
		4. Right subcostal
		5. Left subcostal
Sasaki, 2010	5	1. Umbilical	N/A	Endostapler
		2. Epigastric
		3. Right hypochondrium
		4. Left hypochondrium
		5. Left subcostal
Leandros, 2006	5	1. Umbilical	Bipolar	Endostapler
		2. Epigastric
		3. Right hypochondrium
		4. Right hypochondrium
		5. Left hypochondrium
Caprotti, 1999	5	1. Subxiphoid	N/A	Endostapler
		2. Umbilical (left side)
		3. Umbilical (right side)
		4. Right subcostal
		5. Left subcostal

N/A, not applicable.

Surgery outcomes

The mean duration of the operation was 170.18 ± 53.07 minutes (mean, SD). Resected spleen weighted 601.82 ± 386.02 g (mean, SD) and had a length of 18.74 ± 5.3 cm (mean, SD). An accessory spleen was found in 9 cases (8.3%). Mean blood loss was 118.68 ± 125.95 mL (mean, SD), and in 5 cases (4.6%) a transfusion was needed. In 3 cases (2.7%), a conversion to open surgery was decided due to excessive splenomegaly, lack of anatomical structure recognition, and bleeding from the splenic hilar vessels.^2,20,23 In total, 22 patients (20.4%) experienced postoperative complications, with pulmonary infection (6.5%), portal/splenic vein thrombosis (4.6%), and postoperative bleeding (3.7%) being the most frequently encountered ones. Detailed postoperative complications of each included study are shown in Table 3. No postoperative death was reported. The mean hospitalization period was 5.43 ± 3.18 days (mean, SD).

Table 3.

Detailed Postoperative Complications per Eligible Study

Study (Author, year)	Total patients with complications N (%)	Pulmonary infection/atelectasis N (%)	Subcutaneous hematoma N (%)	Nonspecified minor complications N (%)	Splenic fossa collection N (%)	Pleural effusion N (%)	Portal-splenic vein thrombosis N (%)	Postoperative bleeding N (%)	Pancreatic leakage N (%)
Ozemir, 2016	1 (16.7%)	N/A	1 (16.7%)	N/A	N/A	N/A	N/A	N/A	N/A
Vecchio, 2014	0 (0%)	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Wang, 2014	8 (47.1%)	1 (5.9%)	N/A	N/A	1 (5.9%)	1 (5.9%)	2 (11.8%)	1 (5.9%)	2 (11.8%)
Pal, 2010	0 (0%)	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Nobili, 2011	5 (16.7%)	N/A	N/A	2 (6.7%)	N/A	N/A	N/A	3 (10.0%)	N/A
Leandros, 2006	6 (100%)	6 (100%)	N/A	N/A	N/A	N/A	1 (16.7%)	N/A	N/A
Sasaki, 2010	2 (22.2%)	N/A	N/A	N/A	N/A	N/A	2 (22.2%)	N/A	N/A
Caprotti, 1999	0 (0%)	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Total	22 (20.4%)	7 (6.5%)	1 (0.9%)	2 (1.9%)	1 (0.9%)	1 (0.9%)	5 (4.6%)	4 (3.7%)	2 (1.9%)

N/A, not applicable.

Discussion

CLSC is indicated for the surgical management of diseases that affect both the spleen and the gallbladder. It was originally recommended 25 years ago and several techniques have been proposed through the years.^3,25 To our knowledge, this is the most conclusive systematic review regarding CLSC, its indications, and the operative technique.

Several hematological diseases that lead to hemolytic anemia often affect both the spleen and the gallbladder. Benign disorders, such as hereditary spherocytosis, idiopathic thrombocytopenic purpura, and sickle cell disease, require splenectomy when conservative treatment fails, and a minimally invasive approach is the optimal alternative.⁵ Furthermore, the resulting catabolic breakdown of heme leads to increased unconjugated bilirubin and the development of black pigment gallstones.²⁶ LC is indicated in patients with symptomatic gallstones, while the role of prophylactic surgery of asymptomatic patients remains a controversial issue.¹⁰ About 8 of 10 of our included cases concerned such hematological disorders, with hereditary spherocytosis (38.9%) and sickle cell disease or β-thalassemia (32.4%) being the most frequent ones.

Liver cirrhosis complicated by portal hypertension results in hypersplenism and thus thrombocytopenia and leukopenia.²⁷ A splenectomy and devascularization or shunt surgery are essential for these patients to avoid the increased risk of variceal bleeding and bleeding tendency resulting from thrombocytopenia.²⁸ LS was contraindicated in such cases, but with recent advancements in minimally invasive procedures and instruments, LS is currently considered to be a feasible, safe, and effective procedure.^29,30 Furthermore, Child–Pugh A and B patients suffering from symptomatic gallstones can safely undergo LC without any significant consequence in morbidity and mortality, whereas Child–Pugh C patients necessitate a careful preoperative evaluation.^31–33 Wang et al. concluded that CLSC is a safe treatment approach for Child–Pugh A and B cirrhotic patients presenting with symptomatic gallstone disease and hypersplenism.²⁰

CLSC consists of two parts, LS and LC, performed consecutively. Wang et al. advocated that LC should be the initial one mainly due to its low conversion rate.²⁰ Our findings are in accordance with that, as 75% of the included studies performed LC first. Furthermore, the placement of the patient at a right lateral position with the left side elevated at 30°–45° is preferable and, during the operation, the table is tilted to set the patient at the optimal position for each part of the operation.^2,3,6,23 The right lateral position gives an advantage for the excision of mildly enlarged spleens since it offers a better view of the splenic hilum and vessels.^34,35

Most authors agree that a five-trocar approach is favorable for a better view of the operating field and improved recognition and exposure of the implicated anatomical structures.^2,20–24 As far as the retrieval of the specimens is concerned, the gallbladder is typically extracted through the umbilical port, while the spleen can be placed in an endobag, fragmented, and then removed through the largest port.²³ In the case of advanced splenomegaly, a port incision can be extended and spleen removed through it.³ Mobilization of the structures can be performed using bipolar diathermy or ultrasonic scalpel, while hilar vessels can be dissected with the endostapler or electropolar sealing device, on the condition that the pancreatic tail has been previously isolated.^6,36 A drain at the left subphrenic area is essential at least for the 1st postoperative day.^2,20

Operative time, as it was expected, is significantly prolonged compared with the one of each individual operation.^5,37 As far as the spleen size is concerned, a laparoscopic approach is safe and comparable with that of a normal-sized spleen for a weight of <2000 g.³⁵ Mean blood loss and the need for transfusion rate of CLSC were comparable with those of LS.²⁰ The conversion rate of about 3% is considered to be mainly affected by LS rather than the LC part and is related to excessive splenomegaly, intraoperative bleeding, and difficult recognition of the anatomical structures.^2,20,23 The mean hospitalization period was similar to the one of LS.⁵

Approximately 1 of 5 patients experienced minor or major postoperative complications, whereas no postoperative death was recorded. Portal/splenic vein thrombosis is a severe complication, after LS, that could lead to devastating consequences. The longer operative time of CLSC and the consequent longer exposure to pneumoperitoneum could be a potential risk factor for its occurrence, as it reduces the blood flow in the portal system.² A routine postoperative screening is advocated by some researchers for the prompt diagnosis and treatment of this clinical entity.³⁸

In conclusion, CLSC is a safe and feasible operation for diseases that affect both the spleen and the gallbladder, while its complications and conversion rate are comparable with the ones of each operation. Further high-quality clinical trials are necessary to strengthen available evidence and lead to a standardization of the operative technique.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

References

Trias

, Targarona

. Laparoscopic treatment of hereditary spherocytosis (splenectomy plus cholecystectomy). J Laparoendosc Surg, 1994; 4:71–73.

Vecchio

, Intagliata

, Marchese

, et al. Laparoscopic splenectomy coupled with laparoscopic cholecystectomy. J Soc Laparoendosc Surg, 2014; 18:252–257.

Ozemir

, Bayraktar

, et al. Single-site multiport combined splenectomy and cholecystectomy with conventional laparoscopic instruments: Case series and review of literature. Int J Surg Case Rep, 2016; 19:41–46.

Delaitre

, Maignien

. Splenectomy by the laparoscopic approach. Report of a case. Presse Med, 1991; 20:2263.

Moris

, Dimitriou

, Griniatsos

. Laparoscopic splenectomy for benign hematological disorders in adults: A systematic review. In Vivo, 2017; 31:291–302.

Sasaki

, Nitta

, Otuska

, et al. Concomitant laparoscopic splenectomy and cholecystectomy. Surg Laparosc Endosc Percutan Tech, 2010; 20:66–68.

Rosen

, Brody

, Walsh

, et al. Outcome of laparoscopic splenectomy based on hematologic indication. Surg Endosc, 2002; 16:272–279.

Miyasaka

, Nakamura

, Wakabayashi

. Pioneers in laparoscopic hepato-biliary-pancreatic surgery. J Hepatobiliary Pancreat Sci, 2018; 25:109–111.

Wakabayashi

, Iwashita

, Hibi

, et al. Tokyo Guidelines 2018: Surgical management of acute cholecystitis: Safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci, 2018; 25:73–86.

10.

Shah

, Taborda

, Chawla

. Acute and chronic hepatobiliary manifestations of sickle cell disease: A review. World J Gastrointest Pathophysiol, 2017; 8:108–116.

11.

Gallagher

PG.

Abnormalities of the erythrocyte membrane. Pediatr Clin North Am, 2013; 60:1349–1362.

12.

Neunert

, Cooper

. Evidence-based management of immune thrombocytopenia: ASH guideline update. Hematology Am Soc Hematol Educ Program, 2018; 2018:568–575.

13.

Patton

, Moss

, Haith

Jr , et al. Concomitant laparoscopic cholecystectomy and splenectomy for surgical management of hereditary spherocytosis. Am Surg, 1997; 63:536–539.

14.

Choi

, Han

, Yoon

, et al. Laparoscopic splenectomy plus cholecystectomy for treating hereditary spherocytosis combined with cholelithiasis in siblings. Minim Invasive Ther Allied Technol, 2007; 16:317–318.

15.

Tam

, Lee

, Chan

, et al. Technical report on the initial cases of single-incision laparoscopic combined cholecystectomy and splenectomy in children, using conventional instruments. Surg Innov, 2010; 17:264–268.

16.

Liberati

, Altman

, Tetzlaff

, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. PLoS Med, 2009; 6:e1000100.

17.

Wallace

, Small

, Brodley

, et al., Deploying an interactive machine learning system in an evidence-based practice center: Abstrackr, in Proceedings of the 2nd ACM SIGHIT International Health Informatics Symposium. 2012, ACM: Miami, Florida, USA. p. 819–824.

18.

Hozo

, Djulbegovic

, Hozo

. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol, 2005; 5:13.

19.

National

Heart

, Lung, and Blood Institute (NHLBI). Quality assessment tool for case series studies. 2019. Available at: www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools (accessed November 10, 2019).

20.

Wang

M-J

, Li

J-L

, Zhou

, et al. Consecutive laparoscopic gallbladder and spleen resections in cirrhotic patients. World J Gastroenterol, 2014; 20:546–554.

21.

Caprotti

, Franciosi

, Romano

, et al. Combined laparoscopic splenectomy and cholecystectomy for the treatment of hereditary spherocytosis: Is it safe and effective?. Surg Laparosc Endosc Percutan Tech, 1999; 9:203–206.

22.

Leandros

, Alexakis

, Albanopoulos

, et al. Hand-assisted laparoscopic surgery with a Pfannenstiel incision in beta-thalassemia patients: Initial experience. World J Surg, 2006; 30:1216–1220.

23.

Nobili

, Romano

, Ciravegna

, et al. Consecutive concomitant laparoscopic splenectomy and cholecystectomy: An Italian experience of 30 patients and proposition of a technique. J Laparoendosc Adv Surg Tech A, 2011; 21:313–317.

24.

Pal

. Modified port placement and pedicle first approach for laparoscopic concomitant cholecystectomy and splenectomy in children. J Indian Assoc Pediatr Surg, 2010; 15:93–95.

25.

Trias

, Targarona

, Balague

. Laparoscopic splenectomy: An evolving technique. A comparison between anterior and lateral approaches. Surg Endosc, 1996; 10:389–392.

26.

Ebert

, Nagar

, Hagspiel

. Gastrointestinal and hepatic complications of sickle cell disease. Clin Gastroenterol Hepatol, 2010; 8:483–489; quiz e70.

27.

Peck-Radosavljevic

. Hypersplenism. Eur J Gastroenterol Hepatol, 2001; 13:317–323.

28.

Hama

, Takifuji

, Uchiyama

, et al. Laparoscopic splenectomy is a safe and effective procedure for patients with splenomegaly due to portal hypertension. J Hepatobiliary Pancreat Surg, 2008; 15:304–309.

29.

Zhan

X-L

, Ji

, Wang

Y-D

. Laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension. World J Gastroenterol, 2014; 20:5794–5800.

30.

Zhu

, Wang

, Ye

, et al. Laparoscopic versus open splenectomy for hypersplenism secondary to liver cirrhosis. Surg Laparosc Endosc Percutan Tech, 2009; 19:258–262.

31.

Quillin

, 3rd, Burns

, Pineda

, et al. Laparoscopic cholecystectomy in the cirrhotic patient: Predictors of outcome. Surgery, 2013; 153:634–640.

32.

Hamad

, Thabet

, Badawy

, et al. Laparoscopic versus open cholecystectomy in patients with liver cirrhosis: A prospective, randomized study. J Laparoendosc Adv Surg Tech A, 2010; 20:405–409.

33.

Curro

, Iapichino

, Melita

, et al. Laparoscopic cholecystectomy in Child-Pugh class C cirrhotic patients. JSLS, 2005; 9:311–315.

34.

Tan

, Zheng

C-X

, Wu

Z-M

, et al. Laparoscopic splenectomy: The latest technical evaluation. World J Gastroenterol, 2003; 9:1086–1089.

35.

Terrosu

, Baccarani

, Bresadola

, et al. The impact of splenic weight on laparoscopic splenectomy for splenomegaly. Surg Endosc, 2002; 16:103–107.

36.

Vecchio

, Marchese

, Swehli

, et al. Splenic hilum management during laparoscopic splenectomy. J Laparoendosc Adv Surg Tech A, 2011; 21:717–720.

37.

Zhou

M-W

, Gu

X-D

, Xiang

J-B

, et al. Comparison of clinical safety and outcomes of early versus delayed laparoscopic cholecystectomy for acute cholecystitis: A meta-analysis. ScientificWorldJournal, 2014; 2014:274516–16.

38.

Romano

, Caprotti

, Conti

, et al. Thrombosis of the splenoportal axis after splenectomy. Langenbeck's Arch Surg, 2006; 391:483–488.