Brody F J, Chekan E G, Pappas T N, Eubanks W S
Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
Surg Endosc. 1999 Aug;13(8):789-91. doi: 10.1007/s004649901100.
Since 1994, 27 patients at our institution have undergone laparoscopic splenectomy for immune thrombocytopenic purpura (ITP). Laparoscopic splenectomy was completed in 22 of these patients. We sought to identify factors that precluded successful laparoscopic splenectomy in the remaining 5 patients.
Retrospective review of 27 patients with ITP undergoing laparoscopic splenectomy was performed at Duke University Medical Center from August, 1994 to September, 1997.
Laparoscopic splenectomy was performed in 16 women and 11 men with a mean age of 47.2 years. Five (18%) of these procedures were converted to open splenectomy. There was no significant difference in age, ASA score, gender, weight, height, or splenic size between the converted and laparoscopic groups. However, preoperative and postoperative platelet counts were significantly higher in the laparoscopic group than in the converted group (p < 0.001). Operative times also were significantly longer for the laparoscopic group than for the converted group (p < 0.001). Adherent adjacent structures, associated comorbidities, and technical errors prohibited laparoscopic completion in five patients. Technical errors with subsequent bleeding required conversion in two patients. A thickened greater omentum blanketing the splenic capsule and a densely adherent pancreatic tail extending well into the splenic hilum prevented laparoscopic completion in two patients. Increased peak airway pressures greater than 60 mmHg after pneumoperitoneum necessitated conversion in the remaining patient, who had a previous history of pulmonary insufficiency. Regardless of surgical approach, all patients achieved a therapeutic response after splenectomy. Splenectomies completed laparoscopically resulted in a significantly shorter length of hospital stay (p < 0.01).
Densely adherent adjacent structures, technical errors, and cardiopulmonary instability may preclude successful completion of laparoscopic splenectomies. Thorough preoperative evaluation with an emphasis on the cardiopulmonary system may elicit a cohort of individuals with ITP who are unlikely to undergo laparoscopic splenectomy successfully. This cohort also may include individuals with preoperative platelet counts less than 35,000 mm(-3).
自1994年以来，我院有27例患者因免疫性血小板减少性紫癜（ITP）接受了腹腔镜脾切除术。其中22例患者成功完成了腹腔镜脾切除术。我们试图找出导致其余5例患者腹腔镜脾切除术未能成功的因素。
对1994年8月至1997年9月在杜克大学医学中心接受腹腔镜脾切除术的27例ITP患者进行回顾性研究。
16例女性和11例男性接受了腹腔镜脾切除术，平均年龄47.2岁。其中5例（18%）手术转为开腹脾切除术。中转组和腹腔镜组在年龄、美国麻醉医师协会（ASA）评分、性别、体重、身高或脾脏大小方面无显著差异。然而，腹腔镜组术前和术后血小板计数显著高于中转组（p<0.001）。腹腔镜组手术时间也显著长于中转组（p<0.001）。粘连的相邻结构、合并症和技术失误导致5例患者无法完成腹腔镜手术。技术失误及随后的出血导致2例患者中转手术。增厚的大网膜覆盖脾包膜以及紧密粘连且延伸至脾门的胰尾导致2例患者无法完成腹腔镜手术。气腹后气道峰值压力超过60 mmHg，使得其余1例有肺功能不全病史的患者中转手术。无论采用何种手术方式，所有患者脾切除术后均获得了治疗反应。腹腔镜完成的脾切除术住院时间显著缩短（p<0.01）。
紧密粘连的相邻结构、技术失误和心肺不稳定可能妨碍腹腔镜脾切除术的成功完成。全面的术前评估，重点关注心肺系统，可能找出一组不太可能成功接受腹腔镜脾切除术的ITP患者。这组患者可能还包括术前血小板计数低于35,000/mm³的个体。
