With the recent advances in technique and equipment in laparoscopic technology, several comparative series have suggested the feasibility and safety of LS, including liver cirrhosis and portal hypertension, trauma spleen, benign hematological disorders.[15–17] LS had been widely accepted.[2] With increasing numbers of LS, studies have shown that may increase the difficulty of the surgical procedure, longer operative time, and higher conversion rate, it is associated with greater morbidity.[9, 14]
As we all know, HALS, first described in 1995 by Kusminsky.[18] In fact, hand-assisted laparoscopic technology has been applied in many disciplines, even radical surgery for malignant tumors.[10, 19, 20] But HALS has not been widely recognized and accepted. Recent years, with the rapid development of interventional technology, Hypersplenism due to liver cirrhosis and Portal Hypertension maybe alleviated by transjugular intrahepatic portosystemic shunt (TIPS) or splenic artery embolization[10, 19, 20]. From my study, pure splenectomy due to Portal hypertension is only three patients. Splenic rupture occurs in most cases of our study. Patients with a ruptured spleen underwent an enhanced computed tomography (CT) scan on admission, which evaluated by the 2018 American Association of Surgery of Trauma (2018-AAST) classification.[13] A series of studies had suggested HALS for massive splenomegaly.[11, 12, 23] Few previous studies about splenic rupture have reported on HALS. Two splenic rupture patients in LS group were transferred to traditional laparotomy with poor vision due to blood clot and hemodynamic instability. So, by 2020, the majority of splenic rupture surgeries were performed by traditional laparotomy. Fortunately, HALS group outcomes are shown that the operation time was shorter, estimated blood loss, and conversion rate were lower than LS group. For the splenic rupture patients with hemodynamic instability, emergency operation is necessary. The surgeon can combine the tactile feedback and hand-eye coordination, together with blocking the splenic hilum, which can clear the blood clot as soon as possible. With a better view, the bleeding can be controlled more quickly, reducing potentially dangerous for the patients. With the aid of the intraperitoneal hand, detection and operation are made easier, faster and safer.
Excluding these patients with splenic rupture for HALS, our results also show that less intraoperative transfusion, lower conversion, less estimated blood loss, shorter operative time and postoperative hospital stay compared to LS group. Between the two groups, HALS did not increase the surgical trauma. Thus, HALS not only maintained the advantages of LS, but also overcome the disadvantages of LS, it can achieve the perfect combination of minimally invasive surgery and safety.
For HALS, we believe that the subxiphoid incision is the most suitable. The median incision does not destroy the muscle, which convenient access to the upper abdominal organs. Blunt finger dissection of attachments can be usually severed even in areas that are hidden from the endoscopic view because of the retained tactile feedback.[9] With the pursuit of minimally invasive surgery and enhanced recovery after surgery (ERAS), how to complete the surgery high quality and efficiency is the most important. However, the present study has several limitations. On the one hand, the sample size was small and retrospective. On the other hand, there was no follow-up on the long-term outcome of the surgery.