splenectomy is the preferred treatment for many hematologic diseases and is a necessary skill for any surgeon . in the early 1990s
laparoscopic splenectomy ( ls ) took shape as a viable alternative to open surgery ( os ) and quickly became the standard of care for many splenic disorders .
previously published data have shown that ls is associated with decreased postoperative pain ; shorter recovery time ; decreased blood loss ; and decreased pulmonary , wound , and infectious complications . a report published in 2009 , based on cases recorded in the nationwide inpatient sample ( nis ) database , demonstrated that from 1998 through 2006 only 8.8% of splenectomies were performed with a laparoscopic approach , with no single year having greater than 12% of splenectomies performed laparoscopically .
we used more recent data to update these statistics and identify any trends in the use of ls in the united states .
the nis was queried for both oss and lss performed from the beginning of 2005 through 2010 .
the icd-9 diagnostic and procedure codes that were included covered all splenic diseases , abdominal pain diagnoses ( 789.00 , 789.02 , 789.07 , and 789.09 ) , and procedure codes ( 41.5 for splenectomy ) .
laparoscopic peritoneoscopy ( 54.21 ) and laparoscopic enterolysis ( 54.51 ) were used to capture the laparoscopic cases .
we excluded partial splenectomies and those performed for traumatic injury and vascular anomaly and as part of a pancreatectomy .
the remaining patients were examined for age , comorbid conditions , and conversion to open splenectomy ( cs ) .
we then evaluated for postoperative complications , including deep vein thrombosis , pulmonary embolus , hemorrhage , portal vein thrombosis , postoperative pneumonia , cardiac complications , stroke , shock , renal failure , wound dehiscence , fistula , mortality , and length of stay .
the top 8 admitting diagnoses leading to splenectomy were identified ( table 1 ) . a bivariate logistic regression
was then performed to evaluate for factors that predicted morbidity , mortality , and conversion to an open procedure .
statistical analysis was performed with spss ( ibm corporation , armonk , ny , usa ) .
statistical significance was calculated with the t test or  , as appropriate , with significance set at p < .05 . indications for splenectomy other diagnoses include : essential thrombocythemia , myelodysplastic syndrome , abdominal pain , sezary 's syndrome , evans ' syndrome , thrombocytopenias and reticulosarcomas of the spleen .
of the total cases , 30,108 ( 81.4% ) patients had an open splenectomy ( os ) and 4938 ( 13.3% ) had a successful ls .
the most common indication for splenectomy was idiopathic thrombocytopenic purpura ( itp ) with 10,554 ( 28.5% ) cases ( ls , 2144 ; os , 7,909 ; cs , 501 ) . in 2007 ,
the highest number of splenectomies was performed ( n = 7050 ) with 1428 ( 20% ) attempted laparoscopically and 420 ( 29.4% ) converted to open .
. annual breakdown of splenectomies from 2005 through 2010 the baseline characteristics of the patients were analyzed , and significant differences were found in 13 of the 14 queried factors ( table 3 ) .
the cs group had significantly higher rates of hypertension ( 34.95% ) , diabetes mellitus ( 18.62% ) , hyperlipidemia ( 6.68% ) , obesity ( 8.83% ) , sleep apnea ( 3.83% ) , and mild ( 5.26% ) or severe ( 7.3% ) liver disease than those in the other 2 groups .
the os group had significantly higher rates of coronary artery disease ( 7.81% ) , congestive heart failure ( 4.78% ) , smoking ( 10.74% ) , copd ( 7.45% ) , and chronic kidney disease ( 3.66% ) .
univariate analysis of baseline characteristics sex was not recorded in the database for some of the patients .
the ls group had a lower rate of morbidity ( 7.37% ) when compared to that in the os ( 10.39% ) and cs ( 14.59% ) groups .
when compared to os , ls resulted in a significantly lower postoperative incidence of deep vein thrombosis ( 0.6% vs 0.93% ) , hemorrhage ( 2.49% vs 3.31% ) , portal vein thrombosis ( 0.12% vs 0.55% ) , pneumonia ( 1.34% vs 2.45% ) , shock ( 0% vs 0.49% ) , infection ( 0.91% vs 1.43% ) , fistula ( 0% vs 0.11% ) , overall morbidity ( 7.37% vs 10.39% ) , and mortality ( 1.32% vs 2.53% ) .
when compared to cs , successful ls results showed fewer postoperative incidences of deep vein thrombosis ( 0.6% vs 1.28% ) , hemorrhage ( 2.49% vs 9.29% ) , shock ( 0% vs 0.51% ) , and overall morbidity ( 7.37% vs 14.59% ) .
there was no significant difference in the mortality rate between patients who underwent ls and those who had cs ( 1.32% vs 1.28% ; ns ) .
< .05 ) and decreased overall morbidity ( 10.39% vs 14.50% ; p < .05 ) when compared to those who whose laparoscopic procedure was converted to open
. patients who underwent cs had lower rates of postoperative portal vein thrombosis ( 0.20% vs 0.55% ) , pneumonia ( 1.43% vs 2.45% ) , and mortality ( 1.28 vs 2.53% ) when compared to those who underwent os .
length of stay was significantly less in the ls group when compared to that in both the os and cs groups .
the results revealed that autoimmune hemolytic anemia ( odds ratio [ or ] 1.36 ; p = .002 ) , nonsplenic lymphoma ( or 1.83 ; p < .001 ) , splenomegaly ( or 1.30 ; p = .007 ) , and hemorrhage ( or 3.23 ; p < .001 ) increased the risk for conversion to os ( table 4 ) .
bivariate logistical regression analysis of factors that led to conversion to open surgery comorbid conditions significantly associated with an increased risk of death were chronic obstructive pulmonary disease ( or 2.22 ; p < .005 ) , peripheral vascular disease ( or 2.15 ; p
< .005 ) , chronic kidney disease ( or 2.58 ; p < .005 ) , congestive heart failure ( or 4.44 ; p < .005 ) , and severe liver disease ( or 5.59 , p < .005 ) .
smoking , obesity , hypertension , and mild liver disease were not associated with increased postoperative mortality ( table 5 ) .
bivariate logistical regression analysis of comorbid conditions that increased the risk of mortality postoperative complications that portended an increased risk of death were identified by using bivariate logistical regression .
pulmonary embolus ( or 1.91 ; p = 0.033 ) , infection ( or 2.53 ; p < .005 ) , hemorrhage ( or 3.25 ; p < .005 ) , wound dehiscence ( or 4.85 ; p < .005 ) , cardiac complications ( or 4.98 ; p < .005 ) , and shock ( or 11.38 ; p <
.005 ) were found to significantly increase the risk of death after splenectomy ( table 6 ) .
bivariate logistical regression analysis of postoperative complications that increased the risk of mortality postoperative morbidity associated with the method of splenectomy was analyzed by bivariate logistical regression , and cs ( or 2.45 ; 95% ci 2.0582.906 ; p < .005 ) and os ( or 1.61 ; 95% ci 1.4221.817 ; p < .005 ) were found to increase the risk when compared to ls .
although there has been a modest increase in the percentage of lss , the overall rate remains low , relative to other advanced laparoscopic procedures ( table 7 ) .
the average rate of successful lss during the study period was 13.4% ( range , 10.6%16.2% ) .
there was a small but significant increase in the rate of completed lss over the study period .
the rate is significantly higher when compared to nis data from 1998 to 2006 ( 8.8% vs 13.4% , p < .05 ) .
published rates of conversion among basic and complex laparoscopic procedures we also found a high rate of conversion from laparoscopic to open surgery .
for example , laparoscopic colectomies and laparoscopic bariatric procedures have , at most , a reported conversion rate of 15.8% and 2.2% , respectively ( table 7 ) .
our data suggest that bleeding and splenomegaly are intraoperative events that can lead to increased conversion , with ors of 3.23 and 1.3 , respectively ( table 6 ) .
in addition , the overall low number of splenectomies being performed may limit the development of the skill and familiarity needed for ls to be performed more often .
the data analysis shows that ls was associated with fewer postoperative complications , lower mortality , and a shorter length of stay when compared with the outcomes of os and cs .
morbidity was highest in the cs group ( 14.6% ) and was associated with a higher rate of hemorrhage ( 9.3% ) .
mortality was significantly lower in the ls group when compared to that in the os group ( 1.32% vs 2.52% ; p < .001 ) . despite the potential for significantly reduced morbidity , mortality , and length of stay
a specific reason for this can not be determined from the database , but it may be related to the surgeon 's skill and comfort in performing the procedure , the relative scarcity of splenectomies overall , and the challenging anatomy and pathophysiology that can coexist in a patient .
thrombocytopenia and splenomegaly are frequently encountered when performing splenectomy and , although challenging , the ls approach has been shown to be safe and associated with decreased length of stay , transfusion requirements , and mortality compared to those factors with os .
we must emphasize that patient safety is paramount , and if the surgeon elects to use an open procedure or converts to open , it should not be viewed as a failure . to increase the number of cases
being completed laparoscopically and decrease the conversion rate , we suggest that fellowship - trained , advanced laparoscopic surgeons perform ls in most instances .
it has been shown that the addition to a general surgery practice of a physician who is fellowship - trained in minimally invasive surgery increases the proportion of procedures that are completed laparoscopically .
the advanced surgical training acquired during fellowship promotes meticulous dissection techniques , as well as a greater comfort level with the minimally invasive approach for more complex procedures and confidence in managing intraoperative complications without converting to open surgery .
as the number of fellowship - trained , advanced laparoscopic surgeons increases , we anticipate that more lss will be successfully completed .
however , the technical challenges associated with ls can not be underestimated . even in the most experienced hands ,
this decision obviously requires consideration of the given disease process , individual patient factors , and intraoperative findings .
the nis database used in this study ( it was redesigned in 2012 ) is a record of data compiled from discharge and procedural diagnoses across 1000 hospitals of all types and sizes and in all types of locations .
it is designed to capture data on a sample of 20% of the patients across the united states .
it is dependent on the coders of the institution who base their codes on chart documentation .
there is also a lack of standardization among some complications , which contain unquantifiable data such as hemorrhage .
although the nis is a robust database , it is retrospective and nonrandomized , thus allowing the data to be marred with selection and input biases .
although ls is regarded as the most desired approach , it remains underused for reasons that remain unclear .
the rate of conversion to an open procedure in splenectomies is the highest among advanced laparoscopic procedures ; splenomegaly and hemorrhage predict a conversion .
 background and objectives : laparoscopic splenectomy ( ls ) has been shown to offer superior outcomes when compared to open splenectomy ( os ) . despite the potential advantages associated with the minimally invasive technique 
 , laparoscopy appears to be underused . 
 we sought to evaluate the nationwide trends in ls.methods:the nationwide inpatient sample ( nis ) database was queried for both os and ls procedures performed from 2005 through 2010 . 
 partial splenectomies and those performed for traumatic injury , vascular anomaly , or as part of a pancreatectomy were excluded . 
 the included cases were examined for age of the patient and comorbid conditions . 
 we then evaluated the postoperative complications , overall morbidity , mortality , and length of hospital stay.results:a total of 37,006 splenectomies were identified . 
 of those , os accounted for 30,108 ( 81.4% ) cases , ls for 4,938 ( 13.3% ) , and conversion to open surgery ( cs ) for 1,960 ( 5.3% ) 
 . the overall rate of morbidity was significantly less in the ls group than in the os group ( 7.4% vs 10.4% ; p < .0001 ) . 
 the ls group had less mortality ( 1.3% vs 2.5% , 
 p < .05 ) and a shorter length of stay ( 5.6  8 days vs 7.5  9 days).conclusions : despite the benefits conferred by ls , it appears to be underused in the united states . 
 there has been an improvement in the rate of splenectomies completed laparoscopically when compared to nis data from the past ( 8.8% vs 13% ; p < .05 ) . 
 the conversion rate is appreciably higher for ls than for other laparoscopic procedures , suggesting that splenectomies require advanced laparoscopic skills and that consideration should be given to referring patients in need of the procedure to appropriately experienced surgeons . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSIONS