*Corresponding author:Jayakrishna Reddy Aluru, Junior Consultant, Lifeline Rigid Hospital, 47/3 New Avadi Road, Kilpauk, Chennai-600010, India
How to cite this article:Rajkumar J S, Jayakrishna R A, Anirudh R, Shreya R, Dharmendra K R. Laparoscopic Splenectomy in Non-Cirrhotic Portal Hypertension- A Retrospective Analysis of a Prospectively Performed Series. Adv Res Gastroentero Hepatol, 2021;16(3): 555937. DOI: 10.19080/ARGH.2021.16.555937.
In our institute, laparoscopic splenectomy was performed in 27 patients over a period of 7 years for two major indications: hypersplenism and refractory variceal bleeding. 19 patients had Extra Hepatic Portal Venous Obstruction (EHPVO) and 8 patients had Non-Cirrhotic Portal Fibrosis ( NCPF). All the patients had hypersplenism, with thrombocytopenia( < 50,000/cu.mm),leukopenia (< 4000/Cu mm)as well in 9 (33% )of the patients, and anemia ( Hb<10gm) in 8(30%) . Variceal bleeding requiring Endoscopic Variceal Ligation (EVL) were found in 23 patients,17 in the EHPVO group and 6 in the NCPF group . 4 patients were females and 23 were male. The age range was from 12 to 37 years, the mean being 24 years. The laparoscopic procedure was successful in 25, but 2 patients needed conversion to left subcostal laparotomy because of extensive and giant collaterals around the hilum of the spleen; these conversions happened in the first three years of our laparoscopic splenectomy experience, with no conversions in the subsequent 4 years. Even in the presence of a relative contraindication like portal hypertension, laparoscopic splenectomy is still a viable proposition in the vast majority of cases. Technical considerations , like deployment of powerful energy sources, vascular staplers and preliminary splenic artery ligation are discussed in this article.
Apart from cirrhosis, prehepatic portal hypertension is quite common in the authors’ part of the world, the two major varieties being Extra Hepatic Portal Venous Obstruction(EHPVO) and Non-Cirrhotic Portal Fibrosis(NCPF). Although managed usually with endoscopic variceal ligation on an out-patient basis, some of these patients required surgical intervention because of hypersplenism. Over the past 7 years, all such patients who underwent laparoscopic splenectomy in our institution were studied. This paper constitutes a retrospective analysis of a prospectively performed series.
a.All Extra Hepatic portal hypertension patients presenting with hypersplenism were included.
c.Massive splenomegaly (defined as beyond the umbilicus)
e.Associated chronic pancreatitis
f.Previous surgeries in the upper abdomen
None of the patients had preoperative coeliac angiography or embolization. Shunting was not done in any patients. All patients had polyvalent pneumococcal vaccine and H. influenza vaccine. Pre-operative antibiotics (Cefuroxime)were given. Post-operatively Low Molecular Weight Heparin (LMWH) was given for five days.
Data was analyzed for the following:
a.Ease of laparoscopic completion
b. Time taken
c. Learning curve definition
d. Number of days in hospital
e. Conversion and reasons
f. Post-splenectomy complications in the 30-day period
A right lateral position was used for all. A four-port approach
was used ,all surrounding the left costal margin in a gentle concave
curve. A 10 mm Camera port was inserted, 2 to 3 inches from the
left costal margin along a line drawn from the umbilicus to the
left costal margin, at the inter-section of the left mid clavicular
line. Left-hand and right-hand working ports were put in, at four
fingerbreadths distance from the camera port, on either side.
A fourth port for retraction/posterior dissection was put in,
further down at the inter-section of the left costal margin with
the posterior axillary line (Figure 1). Any additional retraction
was performed using a Verses needle covered by the plastic hub
of the intravenous line needle. Diagnostic laparoscopy was done,
including liver status and biopsy, and checking for splenunculi.
Throughout, the posterior attachments of the spleen to the
kidney and diaphragm(the posterior layer of the splenorenal
ligament and the Lienophrenic ligament) were left in place during
the dissection, to be released as the final step. This is known as the
“hanging clock“ technique, permitting the spleen to stay attached
posteriorly. The first step was to identify the number of splenic
notches along its border. Multiple notches indicate a “distributed“
pattern of the splenic artery, and a single notch indicates a
“magisterial“ type of splenic artery. Based on the notches, the
gastrocolic ligament was opened, either proximally to take a
single artery (24 patients) or more distally to take multiple small
branches (3 patients).
The splenic artery was ligated at the upper border of the
pancreas, after gently dissecting its peritoneal covering with
a right-angled instrument and silk suture (Figure 2). The
gastrosplenic ligament and the short gastric vessels were then
taken down with the ultrasonic shears, staying close to the
spleen (Figure 3). The Ligasure was also found to be very useful,
especially for larger vessels. Inferior attachments to the colon
were then released. Multiple spontaneous lienorenal collaterals
were left alone during this part of the dissection. In two patients
, severe bleeding from these collaterals engendered conversion to
Then the anterior layer of the splenorenal ligaments was
taken down to expose the splenic vessels at the hilum of the spleen
and tail of the pancreas. The latter was dissected off from the hilar
vessels, to avoid pancreatic injury. The splenic artery was ligated
first , which resulted in complete decongestion and pultaceous
appearance of the spleen, followed by splenic vein ligation. The
hilum was taken down with multiple ties in 25 patients, with a
vascular stapler being used in two patients (Figure 4). After the
medial portion of the spleen was freed completely, the posterior
dissection was completed using the fourth (lateral most) port. The
spleen was bagged and removed through a Pfannenstiel incision.
Only two cases required conversion to open surgery. The others
were successfully completed laparoscopically. The operating time
for completion was analyzed using ANOVA (Table 1). The average
blood loss was 150 ml. Perioperative blood transfusion was
needed only in the 2 patients who required conversion to open
There was no immediate or 30-day mortality, and no morbidity,
either to surgery or to blood transfusions in the two converted
patients. In the first nine patients there were two conversions ,and
none thereafter. The average post-operative length of stay was 4.5
days, with conversions patients staying for 7 and 9 days.
a) 1 month(27 patients)
b) 3 months (27 patients)
c) 12 months (22 patients)
d) 24 months (12 patients)
There were no patients with post-splenectomy infections or
deep vein thrombosis. All blood parameters improved significantly
by 3 months follow-up. Analysis of time taken clearly indicates
a learning curve ,probably a combination of experience, more
powerful energy sources, and vascular staplers. The liver biopsies
showed normal liver architecture in 19 (EHPVO) and mild periportal
fibrosis (NCPF)in 8. Long-term follow-up was possible in
12(44%) patients only. The rest were lost to follow-up.
Since the first laparoscopic splenectomy was reported
in 1991, LS has become the gold standard for the removal of
normal to moderately enlarged spleens in benign conditions .
Laparoscopic splenectomy is a straightforward procedure for
diseases like Idiopathic Thrombocytopenic purpura (ITP) and
spherocytosis. On the other hand, even open splenectomy may be
a nightmare for surgeons, especially because of collaterals causing
possibly fatal bleeding .
It was found that primary ligation of the splenic artery (which
supplies 50% of total circulation) made the procedure much
simpler. Utilizing newer energy sources like the Harmonic scalpel
or the Ligasure also enabled a bloodless field around the spleen
. In two difficult cases, using the vascular stapler permitted
completion of hilar vascular transection . Adopting the hanging
clock manoeuvre permitted accurate pericapsular dissection of
the spleen. Staying close to the capsule of spleen helped avoid
the splenorenal collaterals, and unnecessary intra operative
hemorrhage. Combining all the techniques mentioned above made
facile an otherwise technically demanding operation.
According to L R Elkief, et al., patients with Idiopathic Non-
Cirrhotic Portal Hypertension (INCPH), performed retrospective
analyses of patients with INCPH undergoing abdominal surgery
. X Chen, et al., reviewed revealed laparoscopic splenectomy and
laparoscopic splenectomy with devascularization to be safe and
effective in the setting of liver cirrhosis and portal hypertension.
From the comparison articles, laparoscopic procedures appear to
be superior to open procedures regarding blood loss, hospital stay,
complication rate and liver function impairment . R Rajalingam
et al. concluded that Hypersplenism is effectively relieved by both
shunt and non-shunt operations. A proximal splenorenal shunt
not only relieves hypersplenism but also effectively addresses the
potential complications of underlying portal hypertension and can
be safely performed with good long-term outcome .
Laparoscopic splenectomy is being done for cirrhotics,
with hypersplenism, and viral cirrhotics on interferon. A single
case report of laparoscopic splenectomy for left-sided portal
hypertension, preceded by pre-operative embolization, reported
by Patrono et al. . A comprehensive study by ZHAN et al, in the
World Journal of Gastroenterology on laparoscopic splenectomy
for hypersplenism secondary to cirrhosis and portal hypertension,
 also concluded that this was quite a safe operation for this
group of patients.
This paper reviews a single surgical team, single institution
series of laparoscopic splenectomy in non-cirrhotic portal
hypertension. The procedure is feasible and safe in experienced
hands, with the use of assistive devises ,has a definite learning
curve, seems facilitated by prior splenic artery ligation, and
required conversion in less than 10%.