The role of hand-assisted laparoscopic splenectomy for mega spleens in the da Vinci era

• Published in: Journal of Robotic Surgery
• Main Authors: Di Franco Gregorio, Gianardi Desirée, Bianchini Matteo, Palmeri Matteo, Morelli Luca
• Other Authors: DI FRANCO, Gregorio, Gianardi, Desirée, Bianchini, Matteo, Palmeri, Matteo, Morelli, Luca
• Format: Article in Journal/Newspaper
• Language: English
• Published: 2019
• Subjects: DML
• Online Access: http://hdl.handle.net/11568/994078; https://doi.org/10.1007/s11701-019-00985-4; http://www.haworthpress.com/store/product.asp?sid=LH9C67VBD7PP9PECDFMTMV3RWC3L62U4&sku=J451&AuthType=4

Dear Editor, we read with great interest the article by Cavaliere et al., entitled “Robotic vs laparoscopic splenectomy for splenomegaly: A retrospective comparative cohort study” published on International Journal of Surgery [1]. Laparoscopic splenectomy is nowadays considered the gold standard for normal to moderately enlarged spleens. However, in case of more challenging conditions such as mega-spleens or cirrhotic patients, the laparoscopic approach is still associated with high risk of intra-and post-operative bleeding, high conversion rate, and high morbidity. In this setting, the authors compared the robot-assisted laparoscopic surgery (RAS) with the direct manual laparoscopy (DML), reporting possible advantages with the use of the da Vinci System for splenectomy in case of splenomegaly. In particular, they reported improved outcomes with RAS in terms of reduced intraoperative bleeding and less conversions to open surgery, although if they also admitted the limitations of the study, such as its retrospective nature and the small sample size, which prevent to draw definitive conclusions. Furthermore, they reported the longer operative time and the higher costs as two limitations of RAS, respect to DML. We think that, while it is true that the increased dexterity offered by RAS should reasonably help younger or less skilled laparoscopic surgeons to obtain better results in splenectomies for moderate splenomegaly, in case of mega spleens, due to the reduced operative field and to the lack of a tactile feedback, these advantages could not be translated in the same good results, also in expert hands. Indeed, facing with mega spleens, the robot-assisted intra-corporeal manipulation and the exposure of the hilum, as well of the ligaments dissection can still be very difficult, and this difficulty can be accented by the absence of tactile feedback together with the fragility of the parenchyma, which can easily break and bleed. For these reasons, although if we strongly support RAS for several indications in ...