Study methods
A retrospective comparison was made on the patients' features, intraoperative details, and postoperative outcomes. The study parameters included age, sex, preoperative platelet (PLT) count, the greatest splenic diameter on radiological examination, preoperative diagnosis, final spleen weight, operation time, intraoperative blood loss, length of hospital stay, conversion rate, intraoperative and postoperative complications.

Surgical procedures
LS procedure
After induction of general endotracheal anesthesia, patients were placed in the semidecubitus position with the left side elevated 30˚. The surgeon stood on the patients' right side with the camera operator. Intraabdominal access was obtained by an open technique at superior crease of the umbilicus (Fig. 1, a), used for establishing pneumoperitoneum and inserting the 10-mm 30˚ laparoscope. The 10-mm main operating port was located in the midclavicular line below the level of the inferior pole of the spleen (Fig. 1, b). Other two 5-mm working ports were positioned in the anterior axillary line (Fig. 1, c) and below the appendix ensiformis (Fig. 1, d). The sites of the ports were adjusted appropriately according to the patient's figure and the splenic size.

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Fig. 1. The approach of laparoscopic splenectomy (LS) for splenomegaly.

The first step was to identify any accessory spleen by a careful intraabdominal exploration. The mobilization of the spleen began from the inferior pole usually. The splenocolic ligament and the splenorenal ligament were dissected firstly. Then, the dissection was extended medially along the splenogastric ligament, and next up to the splenophrenic ligament. Although the majority of the mobilization was done with the ultrasonic harmonic scalpel (Johnson & Johnson, USA), any medium- sized vessels (such as the inferior polar vessels of spleen and the short gastric vessels) were ligated or clipped before dissection. At this time, once the stomach was reflected medially, the hilum was isolated. The splenic vascular pedicel was separated at the upper border of pancreas. The splenic artery and splenic vein were ligated and then sectioned respectively, or dissected together with Endo-GIA (Johnson & Johnson, USA) if the vessels enlarged with diameter of >2 cm. In some massive splenomegaly cases, the splenic artery was ligated firstly before the mobilization to interrupt the blood flow into spleen, so as to decrease the giant size and to create enough operative space. At last, the spleen was placed into a retrieval bag and extracted through the umbilical incision after morcellation. It was optional to place a suction drain in the splenic fossa.

In 4 cases, the operations could not be completed successfully with laparoscopic approach only, due to intact spleen required for pathologic examination or the massive size or dense adhesion. So the procedure was converted to laparoscopy-assisted splenectomy, with an additional accessory incision about 6-8 cm via left rectus abdominis (Fig. 1, A) or below the costal margin (Fig. 1, B). Then the spleen was extracted intactly through the accessory incision.

HALS procedure
The anesthesia, body position of patient, and the positions of operators were same as the LS procedure. The 10-mm 30˚ laparoscope was placed at inferior crease of the umbilicus (Fig. 2, a), with which the surgeon could choose the best place to make an accessory incision for the access of the hand. The incision measured 7-8 cm (the size of surgeon's hand) and was located in the middle line of superior belly (Fig. 2, A) in most cases. But when the massive splenomegaly crossed the midline to the right, the incision was positioned in the right subcostal region (Fig. 2, B). Then the hand-assisted device (HandPort, Smith & Nephew, USA or Lapdisc, Johnson & Johnson, USA) was installed. The surgeon's left hand was placed into the abdominal cavity through the device. The 10-mm main operating port was in the midclavicular line at the level of umbilicus (Fig. 2, b). When necessary, additional 5-mm working port was set at left lateral to the main operating port (Fig. 2, c) for retraction of the spleen or at left lateral to the hand incision (Fig. 2, d) for dissection of the short gastric vessels and superior pole.

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Fig. 2. The approach of hand-assisted laparoscopic splenectomy (HALS) for splenomegaly.

The intraabdominal exploration for accessory spleen was the first step too. Again, ultrasonic harmonic scalpel was used for the majority of the dissection. With the assistance of the intraabdominal hand, the inferior pole and medial splenogastric ligament were dissected firstly, and then the splenorenal ligament and superior pole of splenophrenic ligament. After this, the splenic vascular pedicel was separated from pancreatic tail by the fingers' dissection. The splenic artery and splenic vein were ligated and sectioned respectively, or dissected together with Endo-GIA (if diameter of >2 cm). In the cases of massive splenomegaly, same as LS, the splenic artery was ligated before the dissection to gain enough operative space. Finally, the spleen was placed into a retrieval bag and extracted intactly via the accessory incision. If the spleen was too massive to be taken out, the blood was released through splenic vein firstly. If necessary, a suction drain was placed in the splenic fossa.

Statistical analysis
Data were expressed as mean±standard deviation (SD) and range. The Student's t-test was used to assume the equal variance in two groups and the Fisher exact test was used for the corresponding proportions. P value <0.05 was considered statistically significant.

Both groups were comparable in terms of age ((38±12) years (range, 15-61 years) vs (43±14) years (range, 17-65 years), P>0.05), the greatest splenic diameter on radiological examination ((24±5) cm (range, 16-31 cm) vs (27±7) cm (range, 18-40 cm), P>0.05), and preoperative PLT ((118±94)×10⁹/L (range, (38-410)×10⁹/L) vs (97±81)×10⁹/L (range, (42-380)×10⁹/L), P>0.05). In both groups the common indications of splenomegaly for laparoscopic procedure in turn were hereditary spherocytosis (HS), idiopathic thrombocytopenic purpura (ITP), portal hypertension with splenomegaly, non- Hodgkin's lymphoma, splenic cyst and splenic tumor.

The intraoperative details and the clinical results of the 36 cases were given in Table 2. The final spleen weights in both groups were similar ((1185±546)g (range, 720-3900 g) vs (1346±735)g (range, 750-4800 g), P>0.05). In group 1, 4 cases (25.0%) were converted due to the intact spleen required for pathologic examination or the massive splenic size or dense adhesion around splenic hilum; while in group 2, no conversion was required (P<0.05). Furthermore, HALS was associated with shorter operation time ((195±71) minutes (range, 110-320 minutes) vs (141±64) minutes (range, 95-280 minutes), P<0.05), less intraoperative blood loss ((138±80) ml (range, 60-550 ml) vs (86±45) ml (range, 30-350 ml), P<0.05), but longer hospital stay ((5.3±3.8)days (range, 3-13 days) vs (7.4±1.6) days (range, 5-9 days), P<0.05). There was no significant difference in recovery time of gastrointestinal function ((16.3±11.6) hours (range, 8-54 hours) vs (18.7±8.1) hours (range, 12-48 hours), P>0.05) between two groups. Postoperative complications occurred in two patients in group 1, including incision infection in one and DIC in another case, and no complication occurred in HALS cases (P>0.05). There was no perioperative death in both groups.

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Table 2. Intraoperative and postoperative details of 36 cases with splenomegaly underwent laparoscopic approach for splenectomy