A Comparison of Single-Incision Versus Multiport Laparoscopic Splenectomy in Children

Abstract

Background:

Although single-incision endoscopic splenectomy (SIES-Sp) has been shown to be feasible and safe, few have compared the SIES-Sp with multiport laparoscopic splenectomy (MPLS). The purpose of this study was to compare the two techniques in children undergoing total splenectomy.

Materials and Methods:

We reviewed all children (age <18 years) who underwent minimally invasive total splenectomy at a single tertiary referral center from January 1, 2000 to January 1, 2019. The primary outcome was complication rate 30 days after discharge defined by maximum Clavien–Dindo score. Secondary outcomes included conversion, operative time, hospital length of stay, postoperative pain scores, and readmission within 30 days of discharge. SIES-Sp and MPLS were compared using univariate analysis.

Results:

Of 48 children undergoing laparoscopic total splenectomy, 60% (n = 29) were SIES-Sp and 40% (n = 19) were MPLS. Subjects were 48% female (n = 23). Common diagnoses were idiopathic thrombocytopenic purpura (33% [n = 16]), hereditary spherocytosis (29% [n = 14]), and other congenital hemolytic anemias (23% [n = 11]). There were no differences in age, gender, or diagnosis between groups (all P > .05). One in three cases involved additional procedures. Spleens were smaller in both greatest dimension (13.0 cm versus 16.4 cm) and weight (156.5 g versus 240.0 g) in SIES-Sp compared with MPLS patients (both P < .05). Readmission and reoperation rates were similar (both P > .05). Complications occurred in 7% (n = 2) of SIES-Sp and in 11% (n = 2) of MPLS patients (P > .99). Severe complications included: cardiac arrest in 1 SIES-Sp patient and bleeding requiring reoperation in 1 MPLS patient.

Conclusion:

SIES-Sp is a safe alternative to the traditional MPLS for children. Additional procedures do not preclude a less invasive approach, but larger spleens may present a challenge.

Introduction

Splenectomy is a common operation performed electively on children with benign and malignant hematologic conditions. Before the late 1990s, splenectomy was largely performed in an open manner, and the literature has often compared the laparoscopic approach with the traditional open technique.^1,2 Recent multicenter evidence suggests laparoscopic surgery has become the standard approach for pediatric splenectomy with shorter hospital stays and no differences in morbidity when compared with open approaches.³

Since the advent of laparoscopy, surgery has aimed to be less invasive while maintaining safety and efficacy. Although the benefits of laparoscopic splenectomy (LS) are clear,³ evidence regarding single-incision endoscopic splenectomy (SIES-Sp) is less robust. The first single-incision endoscopic surgery (SIES) to remove the appendix was reported in 1998.⁴ In the intervening years, pediatric surgeons expanded this technique to more anatomic locations and complex procedures, including splenectomy.^5,6 SIES-Sp has been reported as feasible and safe,^6,7 even in the contexts of surgical training⁸; however, literature on SIES-Sp performed on children are mainly consecutive case series that discuss factors related to need for conversion and surgical outcomes.^5,8 Two studies have compared outcomes between SIES-Sp and multiport laparoscopic splenectomy (MPLS), finding no major differences in complications but a trend toward shorter length of stay.^9,10 The overall number of SIES-Sp cases in these analyses was small, leaving us to question whether additional benefits might come from the less invasive approach. We reviewed our institutional experience with LS and aimed to compare SIES-Sp and MPLS among children undergoing total splenectomy.

Materials and Methods

This study was reviewed and approved by the Mayo Clinic Institutional Review Board before performing any data extraction or analysis.

Population and study setting

We reviewed all children (age <18 years) who underwent total splenectomy at Mayo Clinic from January 1, 2000 to January 1, 2019. All cases were reviewed to determine planned operative approach: open, MPLS, or SIES-Sp. Patients who underwent planned open splenectomy were excluded.

Data and exposure status

Patient demographics, perioperative clinical and surgical variables, complications, and readmissions were retrospectively abstracted. Exposure status was defined as LS for which SIES-Sp was the intended operative approach.

Primary and secondary outcomes

The primary outcome was complication rate 30 days after discharge. Complications were graded according to Clavien–Dindo classification¹¹ with the highest Clavien–Dindo score reported. Secondary outcomes included conversion to more invasive approach, operative time, hospital length of stay, postoperative pain scores, and readmission within 30 days of discharge.

Statistical analysis

Patients who underwent SIES-Sp were compared with those undergoing traditional MPLS. Pain scores were averaged over hospital stay and expressed as a group mean with standard deviation with comparisons made using Student's t-test. All other continuous variables were reported as medians and analyzed using the two-tailed Wilcoxon rank-sum test, whereas categorical variables were analyzed through the Pearson χ² test or Fisher's exact test. Statistical significance was set as P < .05. Data management and analysis utilized STATA 15.1 (College Station, TX, USA).

Results

Demographics and surgical approach

Over the study period 99 elective total splenectomies were performed. Forty-eight patients underwent planned LS with 60% (n = 29) using a single-incision and 40% (n = 19) using a multiport approach. Median age at operation was 10 [interquartile range; IQR: 5, 13], and 48% (n = 23) children were female. Median weight (in kg) was 35.8 [IQR: 19.3, 57.1] with a median BMI-for-age-and-gender percentile of 72.9 [IQR: 47.6, 90.1]. Underlying pathologies were idiopathic thrombocytopenic purpura (ITP) in 33% (n = 16), hereditary spherocytosis in 30% (n = 14), other congenital hemolytic anemias in 23% (n = 11), splenic cyst in 4% (n = 2), autoimmune lymphoproliferative disorder in 2% (n = 1), immunodeficiency in 2% (n = 1), thrombotic thrombocytopenic purpura in 2% (n = 1), wandering spleen with axial volvulus in 2% (n = 1), and littoral cell angioma in 2% (n = 1).

Perioperative details

Perioperative details between SIES-Sp and MPLS are reported in Table 1. One in three SIES-Sp (n = 9) and MPLS (n = 6) cases involved additional procedures (P = .74), including cholecystectomy (n = 10), accessory spleen removal (n = 2) colectomy (n = 1), inguinal hernia repair (n = 1), and kidney biopsy (n = 1). Pfannenstiel removal of the spleen occurred due to spleen size in 3 and broken EndoCatch™ bag in 2. Spleens were smaller in both greatest dimension (13.0 cm versus 16.4 cm, P = .031) and weight (156.5 g versus 240.0 g, P = .031) in SIES-Sp compared with MPLS patients. In the one conversion from SIES to MPLS, insertion of a second trocar was necessary to retract a large liver.

Table 1.

Comparison of Perioperative Details Between Single-Incision and Multiport Laparoscopic Splenectomies

Factor	Level	Single-incision	Multiport	P
N		29	19
Operative time (minutes), median [IQR]		247 [225, 266]	270 [196, 331]	.64
Additional procedures, n (%)		9 (31)	6 (32)	.76
Blood loss (mL), median [IQR]		62.5 [25, 137.5]	75 [25, 150]	.87
Hilar vessel management, n (%)	Staple	25 (89)	16 (84)	.40
	Energy device	3 (11)	2 (11)
	Suture ligation	0 (0)	1 (5)
Conversion, n (%)	Pfannenstiel removal of spleen	1 (3)	4 (21)	.10
	Elongation of incision	0 (0)	1 (5)
	SIES to MPL	1 (3)	(0)
	Laparoscopic to open	3 (10)	3 (16)
Average pain score, mean (SD)^a		3.3 (1.6)	2.7 (1.6)	.22
Postoperative transfusion requirement, n (%)		1 (4)	2 (11)	.55

Four patients were missing values for pain score.

IQR, interquartile range; MPL, multiport laparoscopic; SD, standard deviation; SIES, single-incision endoscopic surgery.

Postoperative outcomes

Complications occurred in 7% (n = 2) of SIES-Sp and in 11% (n = 2) of MPLS patients (P > .99) with similar patterns of maximum Clavien–Dindo grades, Table 2. Median hospital length of stay, readmission, and reoperation were similar (all P > .05). Minor complications included dehydration (n = 1 MPLS) and postoperative pneumonia requiring readmission (n = 1 SIES-Sp). The most severe complications were cardiac arrest upon induction of anesthesia with return of spontaneous rhythm before surgery in 1 SIES-Sp patient and bleeding from the staple line requiring reoperation in 1 MPLS patient. Two patients died from causes attributable to their medical illness.

Table 2.

Postoperative Outcomes

Factor	Level	Single-incision	Multiport	P
N		29	19
Hospital length of stay, median [IQR]		2 [1, 3]	3 [1, 4]	.28
Complication, n (%)		2 (7)	2 (11)	>.99
Maximum Clavien–Dindo grade, n (%)	No complications	27 (93)	17 (89)	.52
	1	1 (3.5)	0 (0)
	2	0 (0)	1 (5.5)
	3	0 (0)	0 (0)
	4	1 (3.5)	0 (0)
Readmission, n (%)		1 (3)	2 (11)	.55
Reoperation, n (%)		0 (0)	1 (5)	.40

Discussion

Less invasive procedures with similar (or improved) outcomes continue to drive surgical practice and innovation. Although the benefits of LS over open surgery for children and adults are clear,^3,12 due to small numbers, the advantages of SIES-Sp over MPLS have been more difficult to define for pediatric patients. Our experience with SIES-Sp supports the assertions that the technique is safe with similar operative times and rates of conversion and complication when compared with the MPLS technique. Both SIES-Sp and MPLS accommodated concomitant procedures, with similar feasibility when comparing approaches. Patients with larger spleen size might be more appropriately managed with a MPLS technique, and selection of patients for SIES-Sp could bias the results of this study as well as previously published literature.

The feasibility of SIES-Sp in pediatric patients was first reported in 2009,^13,14 building upon the safety and successes of traditional MPLS.¹² Since that time, SIES-Sp has expanded in both adults and children. For children, SIES-Sp has been shown to be safe and feasible in a variety of settings and patient populations.^8,15 Complication rates after pediatric SIES-Sp have not been routinely reported, and Seims et al. reported no complications among “reduced port” LS.^6,8,9 Our postoperative complication rate for SIES-Sp is similar to reported rates of 6% for SIES-Sp¹⁰ and 12.4% for MPLS³ in children. Only two studies have directly compared SIES-Sp with MPLS.^9,10 Perger et al. compared 16 SIES-Sp with 14 traditional MPLS patients in 2013.¹⁰ Seims et al. compared 14 reduced port LSs with traditional MPLS in 2016.⁹ Similar to both studies, we did not find substantial differences in operative time, blood loss, conversion to more invasive procedures, or complications.

Along with a comparable safety profile, both SIES-Sp and MPLS accommodated additional procedures. Our surgeons completed broad range of concomitant procedures with varying difficulty without a more invasive multiport approach, including cholecystectomy and colectomy. Our study confirms the findings of Seims et al. who first reported that additional procedures and accessory spleens did not significantly influence the ability to perform SIES-Sp.⁶ Although the small numbers of splenectomies with concomitant procedures in this study precluded a subgroup analysis, a recent review of multicenter data from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) found that LS with concomitant cholecystectomy had similar rates of complications and readmissions to LS alone.³

Spleen size likely influences the selection and completion of SIES-Sp among children requiring total splenectomy. In adults, surgeons debate the use of laparoscopy for massive splenomegaly,¹⁶ but evidence seems to suggest that greater laparoscopic experience facilitates increasing use of LS for massive splenomegaly.¹⁷ Evidence also suggests that LS is emerging as the standard treatment for children requiring splenectomy, but the understanding of how splenic size influences the ability to perform SIES-Sp is limited. The umbilical incision is often enlarged for spleen removal; therefore, doing it at the start of the case and placing the SIES apparatus might be a very similar sized incision when compared with the multiport approach. In contrast to our findings, Perger et al. found no difference in spleen size between SIES-Sp and MPLS patients. We suspect the most likely reason for this is lack of statistical power, but bias in selection of patients for SIES-Sp makes this difficult to determine. Siems et al. actually found reduced port LS to have greater splenic volume than traditional MPLS, but their more liberal definition of “reduced port” LS makes it difficult to compare directly with our results and those of Perget et al.

Interpretation of this study's results must take its limitations into account. First, this is a retrospective study with a relatively small number of patients. Although we have presented one of the largest cohorts of SIES-Sp, our study may be underpowered to detect differences in outcomes. Selection bias no doubt affects the results, but this limitation is shared among most studies evaluating SIES-Sp.⁷ Second, we assumed a priori that the “near scarless” cosmetic result achieved through SIES-Sp was preferred over the small but more numerous scars after MPLS. Although we did not survey patients' satisfaction with cosmetic results, the use of SIES in other procedures would suggest patient satisfaction is superior for single-incision compared with multiport approaches.¹⁸ Finally, we did not collect information on long-term outcomes such as rates of incisional hernia or missed accessory spleens, in the case if ITP or other consumptive processes. Future study should examine the advantages of SIES-Sp versus MPLS using multicenter data or in a well-designed randomized controlled trial for improved power.

Conclusion

SIES-Sp is a safe alternative to the traditional MPLS for children. Additional procedures do not preclude a less invasive approach, but greater spleen sizes may present a challenge. Additional studies are needed to determine if there are long-term benefits of the SIES approach.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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