A Clinical Comparative Study Of Total Laparoscopic, Hand-Assisted Laparoscopic Versus Open Splenectomy Plus Periesophagogastric Devascularization For The Treatment Of Portal Hypertension

Objective: Portal hypertension(PH) is one of the most common clinicalsyndromes in our county with high morbidity, high mortality and greatdifficulty to treat. Currently, the main methods for the treatment of PH includemedicine, endoscopic therapy, interventional therapy and surgery, etc. Themain purpose of surgery is to prevent and control the hemorrhage of esopha-geal variceal bleeding. Surgery, as the most important treatment, is dividedinto portosystemic shunt and portoazygos devascularization. At present, thelatter one is most used in clinical. With the rapid development and innovationof laparoscopic technology and equipment, there is an increasing applicationof laparoscopic surgery in the treatment of PH and a variety of methods iscreated. In this study, three common used surgical methods for PH wereretrospectively analyzed including total laparoscopic, hand-assisted laparos-copic and open splenectomy plus periesophagogastric devascular-ization inorder to evaluate the feasibility and safety of laparoscopic technology, espe-cially the total laparoscopic splenectomy plus periesophagogastric devascul-arization for PH. The difference of clinical indications, complications andrelated treatments were also analyzed between laparoscopic splenectomy plusperiesophagogastric devascularization and open surgery for the further clinicalapplication of laparoscopic surgery treatment in PH.Methods:134patients were recruited from2011to2013. All of themwere diagnosed with liver cirrhosis, portal hypertension, hypersplenism andesophageal varices and underwent splenectomy plus periesophagogastricdevascularization in the department of Hepatobiliary Surgery of the secondhospital of Hebei Medical University.83patients were males and the other51 patients were females(1.63:1). The mean age was44.94±7.46years with arange from19to58years old.80patients were performed traditional opensplenectomy plus periesophagogastric devascularization, while the other54patients were performed total laparoscopic(28) or hand-assisted(26) lapar-oscopic splenectomy plus periesophagogastric devascularization. The follo-wing clinical data were also recorded: Child-Pugh score, the size of spleen,operation time, volumes of intraoperative bleeding and infused blood, passageof gas by anus, time for drainage tube removal from abdominal cavity, totalhospital stays, postoperative hospital stays, time for stitches removal,hospitalization costs, postoperative complications, and incidence of follow-uprebleeding. The difference of preoperative, perioperative, postoperativecomplications, hospitalization expenses, and incidence of follow-up rebleed-ing were analyzed between laparoscopic group and open group.Results: All the three operative approaches were performed successfully.No conversion to laparotomy and intraoperative complications happened inthe laparoscopic group. No significant difference was observed in the analysisof general information between the laparoscopic group and open surgerygroup(P＞0.05). The same result was observed between total laparoscopicgroup or hand-assisted laparoscopic group(P＞0.05). Compared with opensurgery, laparoscopic group needed longer operative time, and statisticallysignificant difference was obtained (P<0.01). The laparoscopic group showedless blood loss (P＜0.01), less blood transfusion (P＜0.01), less time toremove drainage tube and stitches (P＜0.01), decreased postoperative exhausttime (P＜0.01), less hospital stays and postoperative hospital stays (P＜0.01).Besides, laparoscopic group had a little higher hospitalization expenses withstatistically significant difference (P＜0.01).Comparing with the hand-assisted group, total laparoscopic group had alittle longer operative time but without statistically significant difference(P＞0.05). Except the operative time, the other clinical parameters showed nosignificant difference between these two groups including the blood loss, theblood transfusion, passage of gas by anus, time to remove drainage tube and stitches, total hospital stays and postoperative hospital stays (P>0.05). Ahigher hospitalization expenses was observed in hand-assisted laparoscopicgroup (P<0.05).The incidence of surgical incision infection and postoperative comp-lications was higher in open surgery group than the laparoscopic group with aP value less than0.05. There was no significant difference in postoperativecomplications between total laparoscopic group and hand-assisted laparo-scopic group (P>0.05). The follow-up results from3months to2yearsindicated that all the patients’ general conditions improved and no hepaticencephalopathy, hematemesis or melena and deaths occurred.Conclusions:1. Laparoscopic splenectomy plus periesophagogastricdeva-scularization had great advantages over the open surgery with longeroperative time but less blood loss and transfusion, quicker recovery ofgastrointestinal function, less hospital stays and postoperative complications.2.Although the application of novel instruments adds the surgical expense, theexcellent surgical effects are worth it.3. Except the higher hospital expense ofhand-assisted laparoscopic surgery, there is no significant difference with thetotal laparoscopic surgery in therapeutic effects, surgical time, blood loss andtransfusion, recovery of gastrointestinal function and postoperative comp-lications.4. Laparoscopic splenectomy plus periesophagogastric devasculari-zation is a complicated laparoscopic technique, thus it requires perfectivesurgical skills of the operators and high quality of the surgical equipment.5.Laparoscopic splenectomy plus periesophagogastric devascular-ization is asafe, effective and feasible surgical method for the treatment of PH.