Laparoscopic splenectomy after trauma: Who, when and how. A systematic review.

IMPORTANCE: A deep knowledge of the indication for laparoscopic splenectomy (LS) in trauma case can lead trauma surgeon to offer in a wider number of situations a minimally invasive approach to a common injuries.
OBJECTIVE: To present and review the advantages and disadvantages of laparoscopic approach for spleen trauma and to identify patient whose can benefit from a minimally invasive approach versus patient that need open surgery to assess the whole severity of trauma. EVIDENCE REVIEW: A systematic review was performed according to the PRISMA statement in order to identify articles reporting LS after trauma. A literature search was performed through MEDLINE (through PubMed), Embase and Google Scholar from January 1990 to December 2018. Studies conducted on animals were not considered. All other laparoscopic procedures for spleen trauma were excluded.
RESULTS: Nineteen articles were included in this study, reporting 212 LS after trauma. The most study includes blunt trauma patient. All LS were performed in haemodynamically stable patient. Post-operative complications were reported in all articles with a median post-operative morbidity rate of 30 patients (14.01%), including 16 (7.5%) post-operative deaths. CONCLUSIONS AND RELEVANCE: This article reports the feasibility and safety of a minimally invasive approach for common trauma injuries which can help non-advanced laparoscopic skill trauma surgeon to develop the best indication to when to adopt this kind of approach.

INTRODUCTION

Spleen injuries, as reported in literature, represent the most common event among abdominal traumas.[1234567] Spleen trauma prognosis is strictly related to the severity of the splenic injury and the trauma in general. The treatment of blunt splenic injuries (BSI) has changed significantly during the last 30 years with the non-operative management (NOM) that has become a standard of care both in children and in adults.[8910] However, a number of issues regarding the management of adult patients with BSI are still unresolved. Presently, the criteria for NOM of BSI included haemodynamic stability on admission or after initial resuscitation, no peritoneal signs or any associated injuries necessitating laparotomy.[111213] The presence of multiple injuries, high-grade splenic injury, a large haemoperitoneum, age and high Injury Severity Score (ISS) are reported as risk factors for failure of NOM. The feasibility, indications and risks of selection for NOM in such instances are less clear. In these cases, the laparoscopic approach could allow spleen removal, full abdominal cavity investigation and haemoperitoneum evacuation with autotransfusion.[14151617] We performed a systematic review of the published cases of laparoscopic splenectomy (LS) after trauma to explore feasibility and safety of this procedure. Here, we present this analysis.

METHODS

A systematic review was performed according to the PRISMA statement in order to identify articles reporting LS after trauma. A literature search was performed through MEDLINE (through PubMed), Embase and Google Scholar from January 1990 to December 2018. The following keywords and/or medical subject heading terms were used in combination 'laparoscopy' 'minimal invasive', 'spleen trauma', 'spleen injuries', 'splenectomy'. All articles were reviewed and discussed by four different reviewers, and any discrepancies were resolved in a consensus meeting. Only the papers focusing on LS for traumatic lesions of the spleen among adult population were included. Any paper was excluded from the study group whenever it was not possible to quantify the number of patients undergoing LS after trauma. Whenever the same group of authors presented multiple papers through the years, the papers were considered, but the real number of treated patients was quantified. Studies conducted on animals were not considered. All conservative laparoscopic procedures for spleen trauma were excluded. The search was limited to English language papers but not restricted according to study type. PRISMA flow chart is reported in Figure 1. The following criteria were identified and analysed: patient age and gender, indication for LS procedure, type and mechanism of injuries, Abbreviated Injury Scale (AIS) of the spleen, ISS, technical tips aiming to reduce complications such as pre-operative splenic embolisation. The following surgery outcomes were considered: operative time (defined as the 'skin-to-skin' time), blood loss, conversion from minimal invasive to open approach, length of hospital stay (defined as the number of nights the patient stayed in the hospital), intraoperative and post-operative complications (defined as any deviation from the normal post-operative course), including mortality.

Figure 1

PRISMA 2009 flow diagram

RESULTS

From 1990 to December 2018, 212 LS after trauma were retrieved from 19 articles [Table 1].[17181920212223242526272829303132333435] Median was 30.84 years, ranging from 17 years to 69 years. Pre-operative immunisation (usually with polyvalent pneumococcal vaccine, meningococcal vaccine, as well as confirmation of previous Haemophilus influenzae Type B vaccine) was rarely reported. Clinical features are summarised in Table 2. Trauma mechanism: among 212 LS, 198 (93.4%) were performed for blunt trauma and 14 LS (6.6%) for penetrating trauma. Type of injury: AIS of the spleen was specified in 192 cases. The median AIS was 3,2 ISS was specified in 172 cases. The median ISS was 16.81 (range: 4–26,9). Clinical status: Haemodynamic status and Glasgow Coma Scale (GCS) were reported in 7 and 12 articles, respectively. 18 patients were unstable before operation and median GCS was 14,5. Pre-operative embolisation was reported in three articles, all patients of these articles underwent LS after failure of conservative management attempt with embolisation. Blood loss: excluding haemostatic procedures in an emergency, blood transfusion was reported in four articles with no massive transfusion protocol evidenced. Mean operative time of LS without any other procedure was reported in nine articles, with a mean operative time of 106,6 min. Elapsed Time from hospital arrival to surgery was reported in nine series with a median rate of 5,5 days. Outcomes are summarised in Table 3: Conversion from laparoscopy to laparotomy: among the 212 reported laparoscopic procedures, 0 (0%) required conversion to laparotomy. Post-operative complications were reported in all articles with a median post-operative morbidity rate of 30 patients (14.01%) including 16 (7.5%) post-operative deaths. Length of hospital stay was reported in 16 articles. A mean hospital stay of 5,85 days was recorded.

Table 1

Characteristics of studies included in the systematic review

References	Years	Levels of evidence	Number of patients enrolled	Gender (male %)	Median age (years)	Type of trauma		ISS	Spleen AIS
						Blunt trauma	Penetrating trauma
Shamim A, et al.	2018	3	113	79 (70)	44.2±25	102	11	22±13	3.36
Huang G et al.	2017	3	11	6 (54.5)	47.18	8	3	21.6	3.44
Li H et al.	2017	3	20	16 (80)	35.5±9.9	20	0	NS	NS
Trejo-Avila M et al.	2017	5	1	1 (100)	NS	1	0	4	4
Birindelli A et al.	2017	5	1	1 (100)	59	1	0	22	3
Ermolov AS et al.	2015	3	23	15 (65.2)	22	23	0	17	3
Morsi M. et al.	2014	5	2	2 (100)	NS	2	0	NS	2
Khubutiya M. et al.	2013	3	10	NS	35.1	10	0	NS	3.5
Fan y et al.	2011	5	1	1 (100)	17	1	0	25	3
Carobbi A. et al.	2010	3	10	6 (60)	44.4±12.9	10	0	26.9±6.8	4.1±1.1
Rolton DJ et al.	2009	5	1	0	24	1	0	15	3
Ransom JS. et al.	2009	3	4	NS	NS	4	0	NS	4
Agarwal N	2009	5	1	1 (100)	46	1	0	15	3
Ayiomamitis G et al.	2008	5	1	1 (100)	76	1	0	9	3
Pucci E et al.	2007	5	1	1 (100)	32	1	0	9	3
Dissanaike S et al.	2006	5	1	1 (100)	21	1	0	20	4
Huscher CGS et al.	2006	3	6	5 (90.9)	30.7	6	0	29	3
Nasr WL et al.	2004	3	4	3 (75)	21	4	0	NS	3
Basso N et al.	2003	5	1	1 (100)	31	1	0	10	4

ISS: Injury Severity Score, AIS: Abbreviated Injury Scale, NS: Not significant

Table 2

Clinical characteristic

References	GCS	Hypotensive (SBP <90 mmHg) (%)	Haemodynamic status (median SBP/h	Need for blood transfusion	Associated lesion (%)	Operative time	Hospital arrival to surgery (days)	Pre-operative embolisation
Shamim A, et al.	NS	14 (13)	NS	NS	61 (67)	NS	NS	NS
Huang G et al.	15	121.73/90.36	NS	11 (100)	171.18	0.27 (0-5)	13
Li H et al.	NS	2 (10)	NS	NS	NS	110.5±18.7	NS	NS
Trejo-Avila M et al.	NS	0	NS	NS	0	NS	NS	NS
Birindelli A et al.	15	0	NS	0	1	NS	NS	1
Ermolov AS et al.	0	NS	0	NS	180	NS	NS
Morsi M. et al.	NS	0	NS	0	NS	NS	NS	NS
Khubutiya M. et al.	NS	NS	NS	NS	NS	NS	NS	NS
Ying F et al.	14	1	125	1	1	110	0	NS
Carobbi A	12.9±1.0	1	122	6	10 (100)	120 (55-210)	4 (3-11)	NS
Rolton DJ et al.	15	0	NS	NS	1	NS	1	NS
Ransom JS. et al.	NS	0	NS	0	NS	96	NS	4
Agarwal N	15	0	120/70	0	1	NS	2
Ayiomamitis G et al.	15	0	NS	0	1	65	2
Pucci E et al.	15	0	NS	1	0	NS	3
Dissanaike S et al.	15	0	NS	0	1	NS	ns
Huscher CGS et al.	12.1±1.6	6	0	4	0	135.8±28.8	17.3±6.4
Nasr WL et al.	15	0	NS	0	0	175	7.5
Basso N et al.	15	0	NS	0	1	NS	10

NS: Not significant, SBP: Systolic blood pressure, GCS: Glasgow Coma Scale

Table 3

Outcomes of studies included in the systematic review

References	Conversion rate	Morbidity rate (%)	Median LOS (days)	Mortality rate
Shamim A, et al.	NS	22 (19.5)	9	16
Huang G et al.	0	1 (9.1)	9.6	0
Li H et al.	0	4 (20)	4.9±1.3	0
Trejo-Avila M et al.	0	0	NS	0
Birindelli A et al.	0	0	4	0
Ermolov AS et al.	NS	0	NS	0
Morsi M. et al.	0	0	7	0
Khubutiya M. et al.	0	0	3.5	0
Ying F et al.	0	0	8	0
Carobbi A	0	0	4	0
Rolton DJ et al.	0	0	NS	0
Ransom JS. et al.	0	0	4	0
Agarwal N	0	0	6	0
Ayiomamitis G et al.	0	1	16	0
Pucci E et al.	0	0	6	0
Dissanaike S et al.	0	0	5	0
Huscher CGS et al.	0	2 (33.3)	6.8±0.7	0
Nasr WL et al.	0	0	6.7	0
Basso N et al.	0	0	5	0

LOS: Length of stay, NS: Not significant

DISCUSSION

Growing evidence supports that laparoscopy has become a good alternative in the management of abdominal trauma.[3637383940] Nevertheless, it had a slow acceptance among trauma surgeon. It has become clear that a negative laparotomy carries the risk of increased morbidity and mortality, and that minimally invasive procedures significantly reduce additional surgical trauma or, in the case of negative laparotomies, avoid it entirely.[414243] We all realised the advantages of this approach include less post-operative pain, faster recovery, quicker return to everyday activities and low incidence of incisional hernias and surgical site infections.[4445] Another advantage described in trauma is that by selecting correctly the patients who are candidates for this approach, we can avoid unnecessary non-therapeutic laparotomies, thus reducing morbidity and mortality. Recognised limits of NOM and major complications after angioembolisation including spleen infarctions (in 19%–100%), abscesses and bleeding (in 6%–27%), persistent pain (in up to 33% of the cases), recent trend towards a mini-invasive attitude, introduction of new tools for dissection and vascular ligation and enhanced visibility have played a role in the recent diffusion of LS after trauma.[464748] According to the results of our review and as report by Di Saverio et al.,[36] LS after trauma is feasible and safety only in haemodynamically stable or stabilised patient.[171819202122] The present data indicate that there is no indication for LS for unstable patients who must be treated with open procedure.[1819202122232425262728293031323334353637383940414243444546474849] Mechanism of injuries is predominantly blunt trauma such as motor vehicles accident and fall from height. Laparoscopy for penetrating trauma is performed only in the centre with high rate of penetrating injuries and advanced experienced surgeon in these fields.[505152] In these setting as shown by Sosa et al.,[53] laparoscopy can be 100% accurate in identifying peritoneal stab wounds According to series article review, the attitude is to attempt at first a NOM with or without splenic embolisation and in case of failure of this proceed with LS.[172122232425] In this retrospective data set, we were unable to elucidate the clinical factors prompting the decision to perform surgery; however, prior reports showed that factors which lead to failure of NOM include age older than 55 years, ISS >25, haemoperitoneum >300 mL, rupture of subcapsular haematoma or intraparenchymal pseudoaneurysms active contrast extravasation on computed tomography and delayed bleeding.[545556] These findings correlate with the data that emerged from our analysis, which shows that most of the procedures are carried out 24 h after trauma. From a technical point of view, most reports do not concentrate on differences in the surgical technique. There are publications that focus mostly on surgical access to the peritoneal cavity rather than the technique of dissection of the splenic hilum and control of the vascular pedicle of the spleen.[171819202122232425] Some authors advocate the use of spleen-preserving operations such as splenorrhaphy, partial splenectomy or haemostatic collagen application to avoid the overwhelming post-splenectomy sepsis and immunodeficiency. However, the incidence of post-splenectomy sepsis in adults is very low (<1%). Moreover, whether spleen preservation improves immunologic function remains a matter of debate.[575859] Regarding the use of post-operative drainage, it is well known that are directly related to the occurrence of surgical site infections, but unfortunately, there is a lack of reliable data concerning recent use of drains, and we could not include this parameter in our analysis.[606162] The results of the current reviews showed less blood loss and longer operating room times with the laparoscopy group. The longer operating times could be associated with the setup of the laparoscopic equipment, as well as technique-related difficulties: intra-abdominal blood obstructing visualisation and morselising the spleen. However, according to the reports, LS is associated with lower post-operative pain, reduced surgical trauma and better cosmetic effect.[171819202324] Moreover, the most important technics advantage of the laparoscopic approach is allowing to carry out a complete exploration of the abdominal cavity to exclude other associated injuries and thus allow the patient to be discharged early avoiding long clinical observation and prolonged imaging examination. Although the conversion rate is widely quiet low, the need to convert splenectomy from a laparoscopic approach to open surgery should probably prompt surgeons not to underestimate LS technical difficulty. In our opinion, the best indication for LS is in the one hand, stable patient with spleen injury that failed NOM, and on the other hand, stable patient with spleen injury and the suspicion for other possible injury such as hollow viscus injuries or diaphragmatic rupture. Not to forget patient who asks for splenectomy for a safety and shorter recovery. The largest series in the literature show how spleen injuries are associated in more than 65% of cases with other intra- and extra-abdominal al injuries. Spleen AIS is not correlated with the choice of approach, while a threshold of lower ISS is correlated with the choice of minimally invasive procedure. Huscher et al.[33] published a case series on LS, and further reports by Huscher, Dissanaike and Frezza and Basso et al.[32333435] all highlighted the successful use of LS when managing patients with a high Grade IV or V splenic injuries. Regarding outcomes, the literature on LS in a trauma setting is limited, but there are published reports that demonstrate successful management of trauma patients via LS. Huang et al.[18] published a report regarding 11 trauma patients managed via LS and noted similar post-operative courses compared with overall survival patient. Nasr et al.[34] reported a series of four stable patients undergoing delayed LS for blunt trauma with favourable outcomes. Recently, Shamim et al.[17] reports a series of 113 consecutive patients underwent LS for trauma with a morbidity and mortality rate of 19.4% and 14.1%, respectively. In another series of Li et al.,[19] the mortality rate was 0. According to the reports, mortality and morbidity rate remains stable during time suggesting that above all the mortality rate obtained is reflective of the overall injury burden incurred by the patient and is not attributed to the surgical intervention.[171819202122232425262728293031323334353642] In light of these findings, as surgeons become more experienced and comfortable in laparoscopic techniques, the use of LS in trauma patients is expected to rise. From the results of this study, we advocate that in a haemodynamically stable trauma patient with splenic injury, LS should be entertained by surgeons with the appropriate skills.

CONCLUSIONS

In conclusion, the results of this study support the feasibility and safety of laparoscopic approach in the management of spleen injuries in stable trauma patient in whom initial NOM fails. However, further studies are needed before we can draw an objective conclusion. A well-designed, ethically sound, randomised, multicentre trial in haemodynamically stable patients in whom NOM has failed is warranted. Nevertheless, such a review may allow surgeons to acknowledge LS indications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.