【Abstract】 Objective To compare and contrast the two surgical modalities of toric and in situ splenectomy. Methods To retrospectively analyze the experience of 35 patients who underwent splenectomy for splenic space-occupying lesions from January 2006 to June 2010 in the Department of General Surgery of Henan Provincial Cancer Hospital. Among them, there were 19 cases of splenectomy using the tray-out splenectomy and 16 cases of in situ splenectomy. Results: The difference in bleeding volume and operation time between the splenectomy group and the in situ group was 61.5±16.2 ml and 35.1±6.2 min, compared with 136.2±19.2 ml and 59.3±5.7 min in the in situ group, and the difference in the incidence of postoperative complications and the length of hospitalization was not significant. Conclusion: In situ splenectomy and splenectomy in the in situ group are safe and effective surgical procedures, but in situ splenectomy is not as effective as in situ splenectomy. However, the tray-type splenectomy has the advantages of short operation time, less bleeding and easy operation. Zhao Yuzhou, Department of General Surgery, Henan Cancer Hospital 【Keywords】 Splenic tumor, splenectomy 【Chinese classification number】 R733.2 Clinical Investigations of Orthotopic and Extruded Splenectomy 【Abstract】 Objective: To investigate the two methods of orthotopic and extruded splenectomy. Objective: To investigate the two methods of orthotopic and extruded splenectomy. Method 35 patients received splenectomy in general surgery of Henan tumor hospital. 19 cases use the extruded method, compared with the general surgery of Henan tumor hospital. The bleeding and operation time of extruded splenectomy group were 61.5±16.2ml, 35.1±6.2min, while the orthotopic group were 136.2±19.2ml, 59.3±5.7min. The the differences between the two groups were very significant. complication and time of hospitalization were no significant difference. Conclusion: The orthotopic and extruded splenectomy are both effective and safe methods. While the extruded splenectomy could decrease the time of operation and volume of intraoperative hemorrhage, and it’s more technically simple. Occupying lesions of the spleen are clinically rare, and it is difficult to define their pathological nature before surgery. Malignant tumors often have a poor prognosis and require splenectomy [1]. This position summarizes the general surgery department of Henan Provincial Cancer Hospital from January 2006 to June 2010, 35 patients underwent splenectomy due to splenic space-occupying lesions, and controls the study of in-situ and butt-out splenectomy methods. 1 DATA AND METHODS 1.1 GENERAL DATA The cases in this group were divided into two groups: the observation group (bracketed splenectomy) and the control group (in situ splenectomy). There were 19 cases in the observation group, including 12 males and 7 females; age 33-76 years old, average 60.3 years old. In the control group, there were 16 cases, including 7 males and 9 females; age 29-78 years old, average 61.8 years old. Pathological types In the observation group, there were 12 cases of normal spleen, 7 cases of enlarged spleen, 10 cases of hemangioma, 5 cases of lymphangioma, 1 case of misshapen tumor and 3 cases of lymphoma; in the control group, there were 10 cases of normal spleen, 6 cases of enlarged spleen, 7 cases of hemangioma, 4 cases of lymphangioma, 2 cases of angioendothelial sarcoma, 1 case of squamous skin carcinoma with splenic metastasis, and 2 cases of lymphangioma. 1.2 Clinical manifestations and diagnosis 27 cases of benign tumors, 18 cases of asymptomatic ones found incidentally by physical examination, 9 cases of left upper abdominal pain, 8 cases of malignant tumors, 1 case of asymptomatic one found incidentally by physical examination, 4 cases of fever, 3 cases of left upper abdominal mass, 5 cases of weight loss, 3 cases of fatigue 1.3 Surgical methods 1.3.1 Observation group Adopting bracketed splenectomy: ① adopting the median incision or the left paracentral incision; ② The left hand of the operator probed upward from the lateral side of the spleen to make sure that there was no inflammatory adhesion between the spleen and the lateral peritoneum and diaphragm; ③ Sharp dissection of the splenodiaphragmatic ligament; ④ Top-down incision of the adhesion between the spleen and the lateral peritoneum; ⑤ Incision of splenocolonic ligament and splenorenal ligament in the lower extremity of the spleen, at this time, except for the short gastric blood vessels and the splenogastric ligament, the spleen had been completely freed from its upper, outer, posterior, and lower boundaries; ⑥ Depending on the size of the spleen, the operator lifted the spleen upwards with one or both hands, inwardly from the outer side, even if it was below the incision, and the spleen was not in the lower part. (6) According to the size of the spleen, the operator lifts the spleen to the bottom of the incision with one hand or both hands from the outside inward and upward, and even some patients can lift the spleen out of the incision completely; (7) Cut the splenic and gastric ligaments from the bottom up, and ligate the gastric short blood vessels and splenic arteriovenous veins; (8) After the resection of the spleen, the hemorrhages are carefully stopped, and the drainage tube is routinely prevented from draining in the splenic fossa, and the abdomen is closed at all levels. 1.3.2 The control group adopts in situ splenectomy: ① position and surgical access are the same as that of the observation group; ② incision of the splenogastric ligament and dissection of the short gastric vessels; ③ ligation of the splenic artery; ④ dissection of the lowermost splenic vessels, and freeing of perisplenic ligaments from the bottom upward in the outer side of spleen; ⑤ inwardly and upwardly turning the spleen, and dissecting splenic colon and splenic-kidney ligaments; ⑥ continuing to inwardly turn the spleen, and cutting off splenic diaphragmatic ligament; ⑦ ligating the splenic arterial veins in situ; ⑧ in situ ligation of splenic arteries. Hemostasis and drainage in the operation field are the same as that of the observation group. 1.4 Observation index: observe the bleeding volume, operation time, postoperative complications and hospitalization time of the two groups. 1.5 Statistical methods SPSS10.0 statistical software was used. The t-test was used to compare the measurement data, and the χ2 test was used to compare the count data. p<0.05 was regarded as statistically significant difference. 2.Results ① There was no surgical death in both groups. ② Bleeding, operation time and hospitalization time are shown in Table 1. The differences in operation time and bleeding between the two groups are significant, while the difference in hospitalization time is not significant. (iii) There were 4 cases of complications in the observation group, 1 case of pancreatic fistula, 2 cases of splenic fever, and 1 case of splenic fossa effusion; 5 cases of complications in the control group, 2 cases of pancreatic fistula, 2 cases of splenic fever, and 1 case of splenic fossa effusion, and the difference between the two groups was not significant. Table 1 Subgroups Number of cases Intraoperative bleeding (ml) Surgical time (min) Hospitalization time (d) Observation group 19 61.5±16.2 35.1±6.2 10.3±1.7 Control group 16 136.2±19.2 59.3±5.7 11.2±2.3 t-value 8.762 4.952 4.036 P-value 0.003 0.033 0.153 P≤ 0.05 is regarded as statistically significant difference 3 Discussion Splenic tumors are relatively rare in clinic, but their pathological types are more numerous and their prognosis varies greatly. Different methods should be used for treatment according to different properties. Simple splenic cysts may be treated with regular follow-up, open drainage, partial splenectomy or total splenectomy depending on their size. Benign tumors of the spleen, such as hemangiomas, malignant tumors, lymphangiomas, etc., are difficult to be differentiated from malignant tumors by preoperative diagnosis through imaging, blood biochemistry, etc., and have a certain degree of malignancy, so it is currently advocated that total splenectomy be performed once detected [2]. For malignant or potentially malignant splenic tumors, such as hemangioendothelioma, hemangioepithelial cell tumor, splenic sarcoma, primary splenic lymphoma, and metastatic tumors of the spleen that are accompanied by resectable primary foci, splenectomy should be performed. Therefore, it is currently believed that any splenic space-occupying lesion whose nature cannot be clarified should be treated surgically as early as possible [1]. The surgical advantage of in situ splenectomy is that the small blood vessels around the spleen and the branch vessels of the splenic hilum are firstly treated, which reduces intraoperative bleeding and oozing. At the same time, the perisplenic ligament is freed immediately from the spleen, and the residual splenic bed is small in size, so it is easy to close the suture to reduce or eliminate the trauma, and there is less postoperative exudation [3]. However, this method also has the following disadvantages: ① long time of surgical freeing, difficult to perform effective operation under clear vision when the spleen is large, and the possibility of accidental bleeding due to injury to the spleen is increased. ② Because ligation of blood vessels is mostly performed in the deep part, it requires higher basic skills of assistants, which may lead to accidental hemorrhage in case of mismatch. ③ Due to the narrow operating space, it is difficult to form a good surgical exposure field after accidental bleeding of the spleen or related vessels, which is not conducive to rapid and effective surgical hemostasis. It also limits the use of instruments such as ligature bundles. However, in the presence of extensive peri-splenic inflammation, in situ splenectomy is preferred to minimize the massive bleeding caused by blindly holding out the spleen. Advantages of the tray-type splenectomy: ① Rapid operation and short operation time. ② All vessels of the splenic hilum are handled under clear vision, which not only reduces the requirements for assistants, but also reduces the chances of accidental injury to the gastric short and splenic hilum vessels during the operation. (iii) The upper 1-2 short gastric vessels are sometimes too short, and ligating the short gastric vessels under clear vision after propping them out can effectively reduce accidental bleeding or damage to the gastric wall. Especially for patients with contracture of the splenogastric ligament, the upper pole of the spleen may be only 1-2 mm away from the gastric wall, or even the two are completely close to each other [4], and the short gastric blood vessels can be cut directly, and then the stumps of the blood vessels can be ligated in the gastric wall, which reduces the damage to the gastric wall or even causes gastrointestinal fistula. ④ During the process of inward and upward lifting of the spleen, all the blood vessels in the spleen of the short stomach and the splenogastric ligament and even the splenic artery and vein are in the process of constant relaxation, so there is no possibility of tearing the blood vessels and the spleen. ⑤ Dissection of the pancreatic tail and splenic hilar relationship under left-hand control reduces the chance of pancreatic tail injury and the occurrence of postoperative pancreatic fistula. However, butt-out splenectomy not only requires skillful maneuvers, but also attention should be paid to the adequate freeing of the ligaments around the spleen to reduce the occurrence of uncontrollable hemorrhage due to splenic laceration [5]. Complications such as fever, hemorrhage, thrombosis and pleural effusion are likely to occur after splenectomy [6]. Fever and rebleeding after splenectomy were the most common complications. Fever occurred in 8 patients in the study. We analyzed that it was mainly related to the related splenic fossa effusion and splenic fever. In order to prevent such complications we used the method of placing a double drain in the splenic fossa [7] to enhance the drainage effect and reduce the occurrence of complications such as postoperative effusion. It has been reported that rebleeding from splenectomy is mostly related to (1) hemorrhage from short gastric vessels, (2) hemorrhage from splenic vessels, and (3) injury to the tail of the pancreas or peripancreatic vessels [8]. We believe that these three areas should be handled with extreme care to avoid postoperative rebleeding. In recent years, we have also tried to use ultrasonic knife in the process of splenic tumor resection surgery, which can effectively deal with blood vessels with a diameter of less than 5 mm, except for splenic arteries and veins can be directly closed and cut off, with the advantages of safe use, easy operation and so on. Special type of splenectomy: For patients with particularly severe inflammatory adhesions around the spleen due to splenic infarction or other reasons, especially after repeated splenic interventions, there are often extensive traffic vessels between the spleen and the diaphragm, which makes it difficult to perform either in situ splenectomy or tray-type splenectomy. We performed an in situ subperitoneal resection in this patient [9], and although there was an increase in the amount of surgical bleeding, we were able to complete the surgery safely. For patients with gastric body cancer involving the splenic hilum or splenic hilar lymph node dissection who wish to undergo combined splenectomy, we suggest using tray-type splenectomy, which not only effectively shortens the surgical time, reduces surgical trauma, and repeatedly squeezes the tumor, but also conforms to the principle of lumpectomy of the tumor [10]. Alternatively, the method can be utilized to hold out the spleen only for the purpose of clearing the splenic hilar lymph nodes, and then fix the spleen back to the splenic fossa after the clearance is completed [5]. Splenectomy with preservation of the short gastric vessels is feasible in cases of medical splenic injury during radical surgery for distal gastric cancer [11]. Therefore, both tray-type and in situ splenectomy are more mature surgical methods, but tray-type splenectomy has the advantages of shorter operation time, less bleeding and easier operation. References [1] Shen Jun, Su Mingqi. Diagnosis and treatment of splenic tumors[J]. Chinese Journal of General Surgery, 2005,(07):551-552. [2] Zhang D, Du X. Diagnosis and treatment of splenic tumors. Diagnosis and treatment of splenic tumors (with a report of 30 cases)[J]. Journal of the Second Military Medical University, 2005,(04):458-459. [3] Luo Dayong, Liu Dipi, Liang Jun, et al. In situ bloodless splenectomy with pericardial vascular dissection[J]. Journal of Practical Medical Technology, 2008,(22):2956-2957. [4] JIANG Hongchi, LU Chaoyang, SUN Bei. How to perform giant splenectomy safely[J]. Chinese Journal of Hepatobiliary Surgery, 2006,(09):586-588. [5] WAN Xiang-Bin, REN Ying-Kun, HAN Guang-Sen, et al. The value of retrograde retroperitoneal approach for splenic hilar lymph node dissection in radical gastric cancer surgery[J]. Chinese Journal of Practical Surgery, 2009,(10):839-841. [6] Targarona EM. Portal vein thrombosis after laparoscopic splenectomy: the size of the risk[J]. Surg Innov, 2008,15(4):266-70. [7] Wang JG. Evaluation of splenic fossa drainage after splenectomy[J]. Journal of Yan'an University (Medical Science Edition), 2009,(03):89+91. [8] Yu Shiliang, Xiao Hui, Wang Jian. Clinical analysis of rebleeding after splenectomy[J]. Clinical analysis of rebleeding after splenectomy[J]. Western medicine, 2010,(01):135. [9] Lai M-Bing. Analysis of eight cases of retrograde transabdominal extraperitoneal splenectomy[J]. Chinese Journal of Malpractice, 2010,(09):2228-2229. [10] Wang JB, Huang CM, Lu HS, et al. [Efficacy of combined splenectomy in proximal gastric cancer with No.10 lymph node metastasis][J]. Zhonghua Wei Chang Wai Ke Za Zhi, 2009,12(2):121-5. [11] Yu Changchun, Cheng Zheng, Yu Jieshui. Splenectomy with preservation of short gastric vessels[J]. Journal of Hepatobiliary Surgery, 2007,(02):160.