Applicable Anatomy And Clincical Value Of Endoligature Laparoscopic Splenectomy

Objective: To explore the effectiveness of CDFI for judging of splenic vessels'applicable anatomy in laparoscopic splenectomy, and assess the feasibility and superiority of endoligature laparoscopic splenectomy with silk.Methods: 1.Between January 2006 and January 2008, 22 cases with various hematologic and autoimmune disorders underwent the selective endoligature laparoscopic splenectomies. There were 10 male ones and 12 female ones, whose ages ranged from 3 to 23 years (mean 9.73±4.76 years). Of them, 6 patients with idiopathic thrombocytopenic purpura, 14 hereditary spherocytosis and 2 granulocytopenia with hypersplenia.The anatomic type of splenic pedicle, the adjacent relation between splenic vessel and pancreas were detected by CDFI before operation. The trunk of splenic artery was deligated with silk according to the relation of spleen vascular path and pancreas. The trunk of splenic artery was demeshed and ligated directly through less omentulum cave,if a half distal segment of splenic artery located at the anterosuperior border of pancreas (Ⅰtype); or else, after entering less omentulum cave, uplifting the anus perineum of spleen, the tail of pancreas was segregated in order to reveal and ligate the splenic artery more conveniently if a half distal segment of splenic pedicle located in the pancreas or behind (Ⅱtype). The individual operative route and schedule were formulated on the basis of Michels'classification. The splenic vascular geographies were divided into two types, distributed and magistral. The splenic pedicle trunk was ligated and dissected directly in the magistral type, but the trunk and secondary branches of pedicle were respectively ligated and dissected in the distributed type. The above-mentioned parameters were recorded again by telerecording in LS and compared with those by CDFI (adopt McNemar's Test).2.The clinical data of 20 patients who encountered laparoscopic splenectomy with Endo-GIA between 2005 and 2007 were reviewed retrospectively. There were 9 male ones and 11 female ones, whose ages ranged from 1 to 25 years (mean 10.05±5.13 years), including idiopathic thrombocytopenic purpura 9, hereditary spherocytosis 9 and Evan's syndrome 2. The operative time, estimated blood loss, period of stay and total hospital cost were reviewed. The two ways were assessed for Evidence-Based Medicine, including individual principle, optimizing principle, clinical economy and so on.Results: 1.Two anatomic types of splenic pedicle and the adjacent relations between splenic vessel and pancreas were detected by CDFI. 14 cases were divided into the distributed type and 8 into the magistral type with CDFI preoperation. The relationships of splenic vessel and pancreas were showed as typeⅠin 13 cases and typeⅡ9. They were further determined as the distributed 15, the magistral 7, typeⅠ12 and typeⅡ10 in LS. There were no difference between the indexes by CDFI and those by operation, including the two anatomic types of splenic pedicle(χ2=1, P=0.317>0.05) and the adjacent relations between splenic vessel and pancreas(χ2=0.333, P=0.564>0.05).2.Forty-two laparoscopic splenectomies in two groups were all accomplished. When the pedicle had been intersected with Endo-GIA,a mild degree of intraoperative bleeding was observed in 1 case and the bleeding vessels were ligated with endo-loop snare. There was no conversion.In the Endo-GIA group, the mean operative time was 148.20±45.43 min(83～275 min), estimated blood loss was 147.25±79.13 ml(20～300 ml), period of stay was 19.40±5.60 day (9～29 day) and total hospital cost was 16729.81±4824.62 RMB yuan(9834.21～26180.92 RMB). In the endoligature group, the mean operative time was 155.73±57.53min(60～293min), estimated blood loss was 130.68±87.10ml(20～350ml); period of stay was 17.41±3.96 day(12～26 day) and total hospital cost was 12202.62±3446.23 RMB yuan(6496.24～19861.45 RMB).There were no significant different between the two strategies in the operative time (t =0.4673, P>0.05), blood loss(t =0.6429, P>0.05) and hospital stay(t =1.3407, P>0.05). But the hospital costs with endoligature was lesser than ones with Endo-GIA(t=3.5238, P<0.01).Conclusions: It could be identify the anatomic type of splenic peduncular vessel, the adjacent relation between splenic vascular path and pancreas by CDFI before operation. It could help formulate personal operative design, thereby might make up the limited lack due to the laparoscopic procedures which loss the sense of hand touch and 3D vision effect. Endoligature has been proved to be safe, effective and economical with more minimal side-effects. It presents an advantage over LS with Endo-GIA, resulting in decreaed health cost, reduced waste and relieved patients'financial and psychological suppression, in order to treat human body well and show concern morale. For this reason, the evolvement of laparoscopic splenectomy with endoligature embody the human-oriented concept of minimally invasive surgery sufficiently.