|Year : 2020 | Volume
| Issue : 5 | Page : 1002-1006
Laparoscopic partial splenectomy of benign tumors assisted by microwave ablation
Qiang Li, ZhiLong Liu, Min Hu, MaoQiang Ou, KangShou Liu, WeiDa Lin, FeiFeng Wu, MingRong Cao
Department of General Surgery, The First Affiliated Hospital, Jinan University, Guangzhou, China
|Date of Submission||30-Sep-2019|
|Date of Decision||01-Jan-2020|
|Date of Acceptance||31-Mar-2020|
|Date of Web Publication||29-Sep-2020|
Department of General Surgery, The First Affiliated Hospital, Jinan University, Guangzhou 510630
Source of Support: None, Conflict of Interest: None
Objective: The aim of this study is to investigate the application and the feasibility of microwave ablation in laparoscopic partial splenectomy.
Materials and Methods: From January 2018 to June 2019, four patients with benign spleen lesions in our hospital underwent laparoscopic partial splenectomy assisted by microwave ablation. The reviewed parameters included the operation time, intraoperative blood loss, ablation time, frequency of ablation, postoperative drainage time, postoperative hospitalization time, and postoperative complications.
Results: All four patients underwent laparoscopic partial splenectomy assisted by microwave ablation successfully, and there were no cases of conversion to laparotomy. The operation time was 100–200 min (mean, 152.5 min) and ablation time was 16–35 min (mean, 22.8 min). The frequency of ablation was 4–7 times (mean, 5.3 times), and the intraoperative blood loss was 5–300 ml (mean, 138.8 ml). The postoperative drainage time was 3–5 d (mean, 3.3 d), and postoperative hospital stay was 3–9 d (mean, 7.8 d). There were no complications such as peripheral tissue injury, massive bleeding, infestation of spleen fossa, and pancreatic leakage.
Conclusion: Microwave ablation is worthy of clinical application in laparoscopic partial spleen resection as it is safe and effective with low rates of bleeding and fast recovery.
Keywords: Laparoscopy, microwave ablation, partial splenectomy
|How to cite this article:|
Li Q, Liu Z, Hu M, Ou M, Liu K, Lin W, Wu F, Cao M. Laparoscopic partial splenectomy of benign tumors assisted by microwave ablation. J Can Res Ther 2020;16:1002-6
Qiang Li and ZhiLong Liu these authors contributed equally to this work
| > Introduction|| |
Since King and Shumacker  reported that patients with splenectomy were prone to infections, increased consideration has been given to retaining spleen function. Indeed, especially in benign spleen tumors, spleen-preserving surgery is becoming more common in clinical practice. In the past two decades, new laparoscopic techniques have developed rapidly, and laparoscopic partial splenectomy has been reported in succession. However, the biggest challenge for laparoscopic partial splenectomy is intraoperative bleeding. We report on our hospital's laparoscopic partial splenectomies assisted by microwave ablation for benign tumors.
| > Materials and Methods|| |
The four patients in this group included three men and one woman, aged 24–68 years (mean, 47.8 years). Spleen masses were found on ultrasound examination in these four patients and increased significantly during periodic follow-up examinations with no significant left upper abdomen discomfort. Upper abdominal enhanced magnetic resonance imaging (MRI) or computed tomography (CT) examination were performed for patients before the surgery to clarify the size of the tumor mass, whether it was benign or malignant, and the anatomy of the blood vessels at the helium of the spleen and its surrounding tissues [Table 1]. The indications for surgery were as follows: significant clinical symptoms, diameter of the spleen mass >5 cm or growing rapidly, and benign tumor mass found on preoperative enhanced MRI or CT examination.
| > Methods|| |
Microwave ablation device: (1) A Nanjing Weijing MTC-3C microwave ablation device (National Machinery Registration Book, 20163252518) with a working frequency of 2450 MHz ±10%, input power ≤700 VA ±10%, output power 5W–120W, was gradually adjusted by 5W. (2) A Nanjing Weijing one time use water cooling microwave ablation needle (MTC-3CA-II21, Shu Application note number, 20162251119), consisting of two parts, a cooling circulation system and microwave ablation needle, was used to assist partial splenectomy in the current study. Normal saline is suitable for the cooling circulation system.
General anesthesia was used during surgery. The patient was put into the supine position with hands and legs open, head high and feet low, tilting 10°-15° toward the right side. The surgeon stood between the patient's legs, the mirror holder stood at the patient's right side, and one assistant stood at the patient's left side. An observation hole was made by cutting 10 mm under the umbilicus. A veress needle established artificial pneumoperitoneum to an intra-abdominal pressure of 10–12 mmHg (1 mmHg = 0.133 kPa). A 12-mm trocar hole was made as the primary operating hole by cutting 2 cm above the umbilical on the left midclavicular line. A 5-mm trocar was made separately at the upper abdomen midpoint or slightly toward the right for 2 cm and the anterior costal margin of the left anterior axillary to be used as the secondary operation hole [Figure 1]. A 30° laparoscopic exploration of the abdominal cavity, combined with preoperative imaging data, was used to locate the spleen mass and portion of the spleen that should be preserved [Figure 2]. Ligaments between the spleen and stomach were separated to expose the relationship between the hilum of the spleen and spleen. The spleen was lowered by separating the spleen and colon ligaments. Preoperative CT and MRI data were compared to expose the helium of the spleen, and the secondary spleen pedicle vessels were separately carefully. The tumor vessels were identified and isolated while ensuring blood flow to the spleen by preserving the blood vessel branches [Figure 3]. The vessels supplying blood to tumor were double-clamped with a hem-o-lok clip and were resected using an ultrasound knife. An ischemic line on the surface of the spleen could be observed, and the skin on the projection location of the ischemic lines was cut open. The microwave ablation output power was set to 80–100 W with 3–10 min duration. After successfully testing the microwave ablation needle, the needle was inserted into the border line of the ischemic lines [Figure 4]. The specific ablation time was based on the thickness of the spleen tissue and the intraoperative conditions. For thick tissues, the microwave ablation needle location was adjusted and multi-point superposition ablation was applied. No gap should be left between adjacent ablation sites. Attention was paid to the location of the needle tip during the operation to avoid damaging the surrounding tissues. After ablation, needle track ablation was carried out while withdrawing the ablation needles to prevent postoperative needle track bleeding. Samples were collected by extending the umbilical incision and delivered to the lab while frozen in a sample collection bag in order to stud the nature of the tumor. Normal saline was used to irrigate the wound. Bleeding was checked and a drain was inserted from the concave surface of the spleen [Figure 5]. The drain tubing was educed outside the patient's body by cutting a hole and stabilizing it through the left rib margin. Observing the blood flow in the residual spleen [Figure 6].
|Figure 4: Inserting the microwave ablation needle along the ischemic lines|
Click here to view
| > Results|| |
All four cases of patients successfully underwent laparoscopic partial splenectomy without conversion to laparotomy. The surgical time ranged from 100 to 200 min (mean, 152.5 min). The ablation time ranged from 16 to 35 min (mean, 22.8 min), and the frequency of ablation was 4–7 times (mean, 5.3 times). The amount of intraoperative bleeding ranged from 5 to 300 ml (mean, 138.8 ml), and there was no significant bleeding, damage to the surrounding tissues, or other complications during the surgeries. All patients could ambulate and eat at postoperative day 1. The length of drain tube placement from the concave surface of the spleen was 3–5 d (mean, 3.3 d), and the postoperative hospitalization time was 3–9 d (mean, 7.8 d). There were no cases of infection or fluid buildup in the concave surface of the spleen, pancreatic leakage, or other complications during the postoperative ultrasound follow-up examinations. The postoperative pathologies were as follows: two cases of splenic lymphangioma, one case of splenic inflammatory pseudotumor, and one case of splenic hemangioma [Table 2]. Two cases had increased platelets compared to the preoperative data, exceeding the normal range (100–300 × 109/L) [Table 3]. Both cases were prescribed daily oral aspirin (100 mg) until the platelet counts return to the normal range and follow-up ultrasound indicated no thrombus formation at the portal and splenic veins. The four patients are still being follow-up, and no recurrence has been found.
|Table 3: Perioperative platelet count of the four patients with spleen tumors (×109/L)|
Click here to view
| > Discussion|| |
In the past 30 years, research on the anatomy and immune function of the spleen has increased considerably. The spleen is the largest immune organ of the human body and can produce a variety of immune active factors that have many functions including fighting tumors and infections and immune regulation. After resection of the spleen, the body's immune function declines, making the body prone to wound infection, colds, and upper respiratory tract infections. The spleen also has roles in hematopoiesis, blood storage, and blood destruction. After splenectomy, the number of platelets increase, as does the blood viscosity, making the body prone to embolism. Hongchi Jiang proposed the following reasons for spleen retention surgery: (1) Preserving the normal functions of spleen; and (2) in line with the minimally invasive concept and the development requirements of minimally invasive surgery, meeting the “3W principle: Whatever, whenever, wherever.”,
Since Riegner reported the first case of pediatric splenectomy due to trauma in 1892, the number of splenectomies has been risen. In 1952, King and Shumacker reported an increasing chance of overwhelming postsplenectomy infection, and as a result, partial splenectomy surgery increased to preserve spleen function. With the advent of laparoscopic techniques and the study of spleen function, Delaitre completed the first case of laparoscopic splenectomy surgery in 1991. In the past two decades, laparoscopic techniques have developed rapidly, and an increasing number of patients have undergone laparoscopic splenectomy. Seshadri first reported laparoscopic partial splenectomy in 2000, and in recent years, laparoscopic partial splenectomy for benign spleen tumors has been reported in the Chinese literature.,
The anatomy of the spleen vessels is very important for partial splenectomy, and regular splenectomy often determines the location of resection according to the ischemic zone. Luo et al. reported that the spleen artery locations follow four main distribution rules: (1) Spleen blood vessels are divided into two or three branches; (2) spleen blood vessels are segmental and have a sequential distribution from top to bottom; (3) the number of segments of the spleen is uncertain; and (4) most avascular regions can be seen between the upper and lower lobes of the spleen. Chen et al. proposed a laparoscopic secondary splenic stalk detachment method for splenectomy as it is easy to identify secondary blood vessels at the splenic stalk under laparoscopic amplification. Clarifying the spleen blood vessel anatomy, combined with preoperative enhanced CT or MRI, is the foundation for partial splenectomy. In the four patients in the current study, the spleen blood vessel conditions were clearly shown with preoperative imaging data. High-resolution laparoscopic amplification was utilized during surgery to separate the blood vessels at the secondary splenic stalk, and the ischemic boundary was clearly observed after ligation.
Surgical resection is prone to bleeding due to the brittleness of the spleen and the abundance of blood vessels. Thus, the key issue for laparoscopic partial splenectomy is to control the bleeding. The current literature has reported splenectomy or partial section of the spleen assisted with radiofrequency ablation, microwave ablation, ultrasonic scalpel, Hem-o-lok, and HabidTM 4X.,,,,,, However, there have been no reports on the application of microwave ablation in laparoscopic partial splenectomy. The principle of microwave ablation is to use the heat, produced by friction of high speed polar molecules within the tissue under the microwave field, to cause coagulation and necrosis of the surrounding tissues. Microwave ablation has advantages including a high thermal efficiency, large range, short ablation time, less bleeding, and uniform thermal field. The four patients all had microwave ablation insertion at the ischemic zone after ligation of the spleen vessels, and multiple point ablation was applied to form a “point, line, and surface” ablation zone. The microwave output power and duration were determined based on the thickness of the spleen tissue, and the highest frequency was 100 W. The longest single ablation time was approximately 8 min, and the longest single ablation time for the fourth case was approximately 8 min and 30 s. The ablation needle position is required to be adjusted during ablation in order to carry out multi-point superposition ablation. The four cases had an average frequency of 5.3 ablations. There should be no gap between the adjacent ablation sites to reduce the incidence of bleeding. Laparoscopic microwave ablation was performed under direct vision, so as to avoid damage to surrounding tissues caused by the needle tip. The patients' vital signs were monitored closely during ablation. After the end of the ablation, the microwave output power was reduced, and needle tract ablation was performed while retracting the needle to prevent bleeding along the needle track. The spleen was cut with an ultrasonic knife along the middle of the ablation zone, and regular or irregular partial resection of the spleen was performed. There was no obvious bleeding of the partial splenectomy surface due to ablation; thus, suture was not necessary, which further reduced the surgery time. The resection surface of the spleen can be covered with gelatin sponge or sprayed with bio-adhesive to reduce the bleeding rate. Hemostatic gauze was applied to the spleen resection surface of the four patients. The third case had no drain placement as complete hemostasis of the spleen resection surface was achieved, and the postoperative ultrasound follow-up had no indications for peritoneal effusion or hemorrhage. All four cases had benign spleen tumors, and no recurrence has occurred during follow-up so far. Two cases had increased platelet count, and 100 mg of aspirin was given orally once daily starting 1 week after surgery until the platelet count reduced to within the normal range. There were no complications related to portal vein and splenic vein thrombosis in the four patients with hepatobiliary ultrasonography.
The number of cases in this study is small, and we will continue to observe the efficacy of this surgical method in subsequent studies. We also intend to conduct multi-center clinical studies to verify the results from this study. In summary, microwave ablation should be considered for clinical application in laparoscopic partial splenectomy as it is both safe and feasible and demonstrates an obvious hemostasis effect.
Financial support and sponsorship
The present study was supported by grants from the Cultivation Fund of the First Affiliated Hospital of Jinan University (2019315), Guangzhou Science and Technology Program (202002030087), and Administration of Traditional Chinese Medicine of Guangdong Province (20201078).
Conflicts of interest
There are no conflicts of interest.
| > References|| |
King H, Shumacker HB Jr. Splenic studies. I. Susceptibility to infection after splenectomy performed in infancy. Ann Surg 1952;136:239-42.
Mu Z, Hongchi J. A view of spleen-preserving measures today. Chinese J Pract Surg 2009;29:377-8.
Hongchi J. Relentless pursuit of the development of minimally invasive surgery. Chinese J Pract Surg 2004;24:472-4.
Lucas CE. Splenic trauma. Choice of management. Ann Surg 1991;213:98-112.
Delaitre B, Maignien B. Splenectomy by the laparoscopic approach. Report of a case. Presse Med 1991;20:2263.
Seshadri PA, Poulin EC, Mamazza J, Schlachta CM. Technique for laparoscopic partial splenectomy. Surg Laparosc Endosc Percutan Tech 2000;10:106-9.
Wang L, Zhang JB, Qi X, Zhe ZF. A case of laparoscopic partial splenectomy. Chinese J Minim Invasive Surg 2016;16:286-8.
Li ZF, Xiu DR, Jiang B, Ma CL, Li L, Yuan CH, et al
. Laparoscopic partial spleen resection (report of 6 cases). Chinese J Minim Invasive Surg 2013;13:224-7.
Luo GH, Ding ZH, Li ZH, Su XG, Ran M, Zhong SZ. Advances in application anatomy of spleen blood vessels and current status of spleen preservation treatment. Guangdong Med J 2011;32:256-9.
Chen XW, Wang WD, Feng JP, Liu QB. The application of secondary splenic stalk cutting in laparoscopic excision. Chinese J Minim Invasive Surg 2008;8:24-5.
Hao FL, Tian YS, Wang WP, Xu ZW, Yang M. The application of microwave ablation in laparoscopic partial spleen resection. J Hepatobiliary Pancreat Surg 2017;29:61-3.
Zhang JS, Ren JH, Li B, Yuan JL. The application of microwave solidification in spleen preservation surgery. J Hepatobiliary Pancreat Surg 2012;25:145-6.
Patrzyk M, Glitsch A, Hoene A, von Bernstorff W, Heidecke CD. Laparoscopic partial splenectomy using a detachable clamp with and without partial splenic embolisation. Langenbecks Arch Surg 2011;396:397-402.
Gumbs AA, Bouhanna P, Bar-Zakai B, Briennon X, Gayet B. Laparoscopic partial splenectomy using radiofrequency ablation. J Laparoendosc Adv Surg Tech A 2008;18:611-3.
Wang WD, Lin J, Wu ZQ, Liu QB, Ma J, Chen XW. Partial splenectomy using a laparoscopic bipolar radiofrequency device: A case report. World J Gastroenterol 2015;21:3420-4.
Huang Y, Mu G, Qin X, Lin J, Li S, Zeng Y. 21 cases reports on haemangioma of spleen. J Cancer Res Ther 2016;12:1323.
Sohn M, Fuchs M, Rohrbach H, Iesalnieks I, Agha A, Liesche F. Intrapancreatic mass: A rare cause. J Cancer Res Ther 2017;13:378-80.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]