Laparoscopic splenectomy for solitary splenic tumors
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- Makrin, V., Avital, S., White, I. et al. Surg Endosc (2008) 22: 2009. doi:10.1007/s00464-008-0024-8
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Solitary splenic masses are a rare entity. There is a paucity of data in the literature on the evaluation and laparoscopic treatment for splenic masses. To further elucidate the evaluation and laparoscopic management of splenic masses we evaluated our own data.
Materials and methods
Data was collected retrospectively for all patients who underwent laparoscopic splenectomy (LS) in our institution for the diagnosis of a solid mass. Patients’ charts were reviewed. Complementary data was completed when needed by telephone interviews.
28 patients underwent LS for solid splenic masses between 1997 and 2006. Mean age was 54.3 years and 68% were women. Patients’ symptoms included abdominal pain (46.5%), anemia (32%), weight loss (21%), and palpable abdominal mass (21%). Fifty-three percent were asymptomatic at diagnosis. Preoperative patients’ imaging included computed tomography (92.8%), abdominal ultrasound (71.4%), and positron emission tomography (PET, 32%). Seven patients (25%) had a history of lymphoproliferative disease. The mass size as measured by computed tomography (CT) scan ranged from 4 to 11 cm. Three patients (10.7%) had multiple splenic lesions. Mean operative time was 125 min. Mean estimated blood loss was 200 ml. Five patients (17.9%) had massive splenomegaly. Conversion rate was 14.3%. In three patients (10.7%) the spleen was removed with additional organs’ tissue (stomach and pancreas). Two patients (7.1%) were reoperated. There was no postoperative mortality. Mean hospital stay was 4.7 days. Four patients (14.3%) were readmitted due to complications. Pathology revealed eight patients (28%) with benign tumors and the rest (71.4%) with malignant lymphoma.
Splenic solid tumor is a rare entity. Most of the cases were eventually diagnosed as malignant tumors. In our series, all malignant tumors were non-Hodgkin lymphoma. The most common benign lesion was inflammatory pseudotumor. This study has demonstrated the feasibility and safety of LS for diagnosis and treatment of both benign and malignant tumors of the spleen.
KeywordsLaparoscopic splenectomySpleenSplenic tumorTumor
Solid tumors of the spleen are relatively rare. The most common malignant tumor of the spleen is lymphoma . Other less common malignancies include primary splenic angiosarcoma, or metastases from nongastrointestinal malignancies [2–6].
Benign lesions are exceedingly rare and may include hemangiomas, angiomas [7–9] and inflammatory pseudotumors, a rare and poorly understood entity . It is important to emphasize that with the present frequent use of medical imaging it is not uncommon to find “incidentalomas” of the spleen that would need further evaluation and treatment .
The exact diagnosis of the nature of a splenic mass may pose a challenge. There are studies about the efficacy and safety of fine-needle biopsy from the spleen, but problems of possible bleeding or tumor dissemination makes the biopsy problematic [12, 13]. This resulted in a tendency to treat any suspected solid tumor of the spleen with splenectomy.
Laparoscopic splenectomy (LS) has became the standard technique for the surgical treatment of many hematological disorders, most commonly idiopathic thrombocytopenic purpura (ITP) [14, 15]. In lymphoproliferative diseases such as lymphoma, laparoscopic splenectomy has been shown to be a safe procedure for staging, for the treatment of symptomatic splenomegaly, pancytopenia, and hypersplenism, and the treatment of isolated splenic disease [16, 17].
The largest series of LS for solid tumors described included ten cases . To the best of our knowledge there is no published data about LS for splenic masses found incidentally.
We therefore collected and analyzed the data on patients who underwent LS for splenic masses in our institute.
Materials and methods
The data of all patients who underwent LS in Tel Aviv Sourasky Medical Center, a tertiary university medical canter, was reviewed, and data of patients who underwent LS for a splenic mass was analyzed. Preoperative parameters were evaluated as well as operative outcome related to complications, conversions, operative times, and final pathological results.
Principles of surgical technique
The surgical technique we use for laparoscopic splenectomy has been detailed in a previously published paper . When this technique is applied for a solid mass, special care is taken to leave large pieces for pathology.
Briefly, most patients are placed in right lateral decubitus position, except for patients with massive splenomegaly, who are placed in the supine position with the left side slightly elevated. Four trocars are used along the left subcostal margin. Dissection is performed using ultrasonic shears in the following order: splenic flexure, anterior aspect of hilum with short gastric vessel ligation, left gutter with separation of attachments to the kidney and diaphragm, leaving some of the attachments to the upper pole of the spleen. The vascular pedicle is divided at the level of the splenic hilum by an endoscopic stapling device with special care not to injure the pancreatic tail.
Final dissection of the spleno-phrenic attachments is completed. The spleen is than placed in a plastic bag, the opening of which is delivered out through the most lateral port. The spleen is than fractured using a regular ring clamp. Care is taken not to completely crush the spleen (as opposed to splenectomy for hematological diseases) in order to leave large pieces of spleen for accurate pathological diagnosis.
During the period from 1997 to 2006, 28 patients underwent LS for a solid splenic mass. Patients age was 54.3 (20–82) years, and 19 (68%) were women.
There was a history of lymphoproliferative disease in seven patients (25%).
Fifteen (53.5%) patients were asymptomatic and were considered as incidental finding. Thirteen patients (46,5%) suffered from abdominal pain, nine (32%) had anemia, and six (21%) had weight loss and a palpable abdominal mass. Preoperative imaging included abdominal ultrasound in 20 (71.4%), computed tomography (CT) in 26 (92,8%), positron emission tomography (PET)-CT in 9 (32%), and RBC isotopic scan in 3 patients (10.7%). Mass diameters by imaging ranged from 4 to 11 cm. In three cases (10 .7%) there was more than one mass in spleen.
An attempt was made to perform LS in all patients. The splenic size and weight were estimated as normal or slightly enlarged in 21 patients (75%). in seven patients there was splenomegaly, of which in five (17.9%) there was massive splenomegaly with spleen weight of 1,100–5,000 g. No preoperative splenic artery embolization was performed regardless of spleen size.
In three patients (10.7%) the mass and spleen were closely adhered to the stomach or pancreatic tail, and complete removal of the spleen with the mass included a partial resection of the adherent organ (stomach wall in two and pancreatic tail in one).
Operating time was 125 (40–180) min. Average blood loss was 200 (0–1,000) ml and was more prominent with increasing splenic size. In 13 operations (46.4%) blood loss was minimal. Three (10.7%) patients were transfused, of which two suffered from preoperative anemia. In four (14.3%) patients the operation was converted to open surgery.
Overall, complications were observed in ten (35.7%) patients, of which two were major complications—bleeding and subphrenic abscess, which were managed by reoperation. Minor complications were postoperative fever in five patients (50% of complications). Four patients (14.3%) were readmitted, of which three had a subphrenic hematoma that was drained percutaneously. All these patients were patients with large spleens. One patient (3.6%) was readmitted for a partial small bowel obstruction that was managed conservatively.
Mean postoperative hospital stay was 4.7 (2–35) days. There was no postoperative mortality.
Pathological diagnosis after laparoscopic splenectomy for splenic masses in 28 patients
Compound splenic cyst
Patients, n (%)
Space-occupying lesions of the spleen are a rare entity that may be discovered incidentally on imaging studies or may be found as part of evaluation for different clinical symptoms. In our series about half of the tumors were found incidentally in imaging studies carried out for unrelated causes.
Isolated splenic masses are less common. They may represent primary malignancies including primary non-Hodgkin’s lymphoma  and sarcoma, mainly angiosarcoma . Solitary splenic metastasis from lung cancer, malignant melanoma, ovary, and other nongastrointestinal primaries were reported as well [2–6]. Benign solid tumors are even rarer and may include hemangiomas, littoral cell angiomas, hamartomas, granulomatous disease, and inflammatory pseudotumors [7, 8, 10, 23, 24].
Recently, PET was evaluated in assessing splenic masses . PET was highly accurate in differentiating malignant from benign lesions when assessing patients with a known primary malignant disease elsewhere but was less accurate in assessing splenic tumors without a known malignant disease and was also positive in patients with granulomatous disease. In our study PET was used in nine patients and was positive in lymphomas but also in inflammatory pseudotumors.
We believe that PET scan is an important tool in assessing patients with a known malignant disease or with suspected lymphoma to evaluate other malignant sites; however, there is currently not enough data to support its routine use to differentiate between benign and malignant disease, or to use it in an algorithm that will determine which patients can be treated conservatively.
Fine-needle aspiration biopsy may be utilized to establish a tissue diagnosis; however, this technique may be associated with bleeding complications and the risk of tumor dissemination [12, 13] and therefore, splenectomy is still necessary for diagnostic and therapeutic purposes.
LS is the standard surgical procedure for management of most benign and malignant hematological diseases of the spleen. This technique is well established and offers substantial advantages over the traditional open approach [28–30]. Complications following LS seem to be determined by the size of the removed spleen regardless of the underlying disease, so that if patient selection is attempted, basing it on splenic size only will be a reasonable option. The potential benefit of laparoscopy in splenic tumors includes the known advantages of laparoscopy with a specific advantage for malignant tumors allowing rapid convalescence and early initiation of chemotherapy when needed .
Many patients presenting with a solid lesion in the spleen will eventually be diagnosed with a malignant tumor. In our series 76% of the patients were found to have malignancy, all with lymphoma. In another smaller reported series, 50% of patients with a splenic solid lesion had a malignancy, with a variety of pathologies including lymphoma and metastases .
There are no large series on laparoscopic splenectomy for solid lesions of the spleen. This is probably due to the rarity of this entity and due to some reluctance in treating splenic tumors laparoscopically, specifically when they are associated with a large spleen.
Yano et al.  reported their experience with hand-assisted laparoscopic splenectomy (HALS) for splenic tumors in ten patients. They advocated the HALS approach for splenic tumors as it allowed them easier mobilization of the spleen in cases of splenomegaly and easier resection of adjacent organs or tissue in cases when it was necessary.
We believe that most of the cases of splenic tumors can be performed in a total laparoscopic approach. In our series there were three cases in which a partial resection of the gastric wall was necessary that were completed laparoscopically with no significant difficulty. However, when the tumor is associated with a massive splenomegaly, a total laparoscopic approach may be difficult and HALS may be considered [31, 32]. In our series four patients had to be converted to open surgery due to a substantial splenomegaly. Consequently, we believe that a total laparoscopic approach can be attempted in all cases; nevertheless, when the surgeon encounters difficulty in handling an enlarged spleen during surgery a conversion to HALS should be considered.
Primary tumors of the spleen are a rare entity. Most of these tumors are malignant, and splenectomy is recommended. This study has demonstrated the feasibility and safety of LS for diagnosis and treatment of both benign and malignant tumors of the spleen. The role of HALS as a primary approach or an alternative to conversion in splenomegaly needs further evaluation.