lateral versus anterior approach for laparoscopic splenectomy

We read with great interest the review article entitled “A systematic review and meta-analysis of anterior versus lateral approach for laparoscopic splenectomy” published by Rehman et al.1 We agree with the conclusions of the authors that the lateral approach is superior to the anterior approach in laparoscopic splenectomy. This assertion is supported in their meta-analysis by the fact that the need for blood transfusion, the intraoperative blood loss, conversion to open surgery, postoperative morbidity, operative time, time to oral intake, need for reoperation, and length of hospital stay was higher with the anterior approach in the analyzed studies. However, we would like to add and discuss some points on the basis of our large series of laparoscopic splenectomies, whose data have been published in the literature.2,3 First, we think that an analysis should be made considering also the body weight of the patients. Obese patients are technically more challenging in several laparoscopic procedures. In laparoscopic splenectomy, it can be very difficult to visualize and dissect the gastrosplenic ligament and the splenic hilum in the presence of a large amount of adipose tissue. In these cases, the lateral approach is probably more suitable. With the patient in the right lateral position, body contents and fat usually fall in the right abdominal quadrants. With a proper elevation of the spleen and leftward traction of the stomach, in this patient’s position, it is usually less difficult to identify the short gastric vessels that can be appropriately sealed. This reduces significantly the risk of intraoperative bleeding and conversion to open surgery. Moreover, the lateral approach in obese cases allows better visualization of the splenic artery, which we usually occlude with clips in the early surgical phases. This maneuver is essential to prevent bleeding during the following steps of the procedure. In addition, it allows the rescue of blood cells from the splenic parenchyma through the splenic vein. Second, although in Rehman’s review,1 spleen size does not show any statistically significant difference between the anterior approach and the lateral approach groups, in our opinion, the authors should better discuss this issue. For splenomegaly (spleen longitudinal length >20 cm), several studies of the literature4,5 report a preference for the lateral approach in their technique. This approach seems to be more convenient for better exposure of the gastrosplenic, splenocolic, splenophrenic, and pancreatic splenic ligaments. Furthermore, it contributes to making laparoscopic splenectomy a safe technique, not anymore contraindicated in splenomegaly. However, it should be noted that, for some authors,6 the lateral or posterolateral approach is less efficient for laparoscopic splenectomy in patients with huge splenomegaly (longitudinal diameter >25 cm), as the excessively large spleen cannot be properly flipped to expose the splenic hilum. Third, no mention has been made in Rehman’s study on the advantages, if any, of the lateral versus anterior approach for the intraoperative detection of accessory spleens. In some hematologic indications for laparoscopic splenectomy (eg, idiopathic thrombocytopenic purpura and spherocytosis), detection and removal of accessory spleens are mandatory for achieving the therapeutic surgical results.7 Although radiologic workup might help identify accessory spleens preoperatively, intraoperative detection is often needed. Accessory spleens, whose incidence varies from 14% to 30% of cases, are usually located in the left abdomen, and, with the patient in the right lateral position, their visualization and removal are technically easier than in the anterior approach. Finally, we would like to draw attention to the fact that, in some hematologic indications, laparoscopic splenectomy should be associated with cholecystectomy for concomitant biliary lithiasis. In this situation, the anterior approach could facilitate both procedures. However, for the above-mentioned advantages of the lateral approach, several surgeons, including us,8 perform first the laparoscopic cholecystectomy with the patient in the supine position and then complete the operation performing the splenectomy by changing the position to the right lateral one. Vecchio Rosario, MD, FACS*† Intagliata Eva, MD, PhD*† *Department of General Surgery and Medical-Surgical Specialties University of Catania †Policlinico Vittorio Emanuele Hospital Catania, Italy REFERENCES 1. Rehman S, Hajibandeh S, Hajibandeh S. A systematic review and meta-analysis of anterior versus lateral approach for laparoscopic splenectomy. Surg Laparosc Endosc Percutan Tech. 2019. [Epub ahead of print]. Cited Here 2. Vecchio R, Gelardi V, Intagliata E, et al. How to prevent intraoperative risks and complications in laparoscopic splenectomy. G Chir. 2010;31:55–61. Cited Here | PubMed 3. Vecchio R, Milluzzo SM, Troina G, et al. Preoperative predictive factors of conversions in laparoscopic splenectomies. Surg Laparosc Endosc Percutan Tech. 2018;28:e63–e67. Cited Here | View Full Text | PubMed 4. Casaccia M, Sormani MP, Palombo D, et al. Laparoscopic splenectomy versus open splenectomy in massive and giant spleens: should we update the 2008 EAES Guidelines? Surg Laparosc Endosc Percutan Tech. 2019. [Epub ahead of print]. Cited Here 5. Shin RB, Lis R, Levergood NR, et al. Laparoscopic versus open splenectomy for splenomegaly: the verdict is unclear. Surg Endosc. 2019;33:1298–1303. Cited Here | PubMed | CrossRef 6. Mahon D, Rhodes M. Laparoscopic splenectomy: size matters. Ann R Coll Surg Engl. 2003;85:248–251. Cited Here | View Full Text | PubMed | CrossRef 7. Vecchio R, Intagliata E, La Corte F, et al. Late results after splenectomy in adult idiopathic thrombocytopenic purpura. JSLS. 2015;19:e2013.00272. Cited Here | CrossRef 8. Vecchio R, Intagliata E, Marchese S, et al. Laparoscopic splenectomy coupled with laparoscopic cholecystectomy. JSLS. 2014;18:252–257.