European Journal of Cardiovascular Medicine

Portal hypertension (PH) is a common and serious complication of chronic liver diseases, particularly cirrhosis, and is associated with the development of gastroesophageal varices, hypersplenism, and splenomegaly. Hypersplenism frequently leads to cytopenias, including thrombocytopenia, anemia, and leukopenia, which can complicate the clinical management of patients with PH1. The prevalence of clinically significant PH varies depending on the etiology of liver disease, with cirrhotic patients showing rates as high as 50–60% for variceal formation2.

Splenectomy, often performed with or without esophagogastric devascularization, has been a cornerstone in managing complications of PH, such as massive splenomegaly, severe thrombocytopenia, and recurrent variceal bleeding3. Traditionally, open splenectomy (OS) has been employed for such cases. However, OS is associated with significant surgical trauma, longer operative time, increased blood loss, higher postoperative pain, prolonged hospital stay, and delayed recovery4.

With advances in minimally invasive surgery, laparoscopic splenectomy (LS) has emerged as an alternative to OS. LS has been associated with reduced intraoperative blood loss, lower postoperative pain, shorter hospital stay, faster return to normal activity, and improved cosmetic outcomes5,6. Despite these advantages, LS poses technical challenges in patients with massive splenomegaly or severe portal hypertension, including the risk of intraoperative hemorrhage and postoperative portal vein thrombosis7.

Several comparative studies and meta-analyses have examined the efficacy and safety of LS versus OS in patients with PH, reporting that LS can be performed safely with favorable outcomes in selected patients, though patient selection and surgical expertise remain critical determinants of success8,9. Given the growing adoption of LS, there is a need for further studies evaluating both short-term and long-term outcomes to guide clinical decision-making.

Rationale Considering the high morbidity associated with open splenectomy and the potential advantages of minimally invasive approaches, this study aims to provide a systematic comparison of LS versus OS in patients with portal hypertension. A comprehensive evaluation of perioperative outcomes, complications, and long-term efficacy is essential to optimize patient management strategies and improve overall surgical outcomes.

Aim

To compare the surgical outcomes, safety, and efficacy of laparoscopic versus open splenectomy in patients with portal hypertension.

Objectives

To compare intraoperative parameters such as operative time, blood loss, and transfusion requirements between LS and OS.

To evaluate postoperative outcomes, including complications, length of hospital stay, and recovery time.

To assess long-term outcomes such as recurrence of varices, portal vein thrombosis, and overall survival following LS and OS.

Study Design and Setting: This was a prospective, observational study conducted at the Department of General Surgery, Konaseema institute of medical science Amalapuram AP India, over a period of 3 years from June 2029 to May 2022. The study was approved by the Institutional Ethics Committee and conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants. Study Population Patients diagnosed with portal hypertension and indicated for splenectomy, either due to hypersplenism, recurrent variceal bleeding, or massive splenomegaly, were considered for inclusion. Inclusion Criteria Age ≥ 18 years. Diagnosis of portal hypertension confirmed by clinical, endoscopic, and radiological assessment. Indication for splenectomy, with or without esophagogastric devascularization. Child-Pugh class A or B. Exclusion Criteria Patients with Child-Pugh class C or decompensated liver disease. Coagulopathy uncorrectable by medical therapy. Active infection or sepsis. Previous upper abdominal surgery contraindicating laparoscopy. Malignancy involving the spleen or portal system. Study Groups Patients were divided into two groups based on the surgical approach: Laparoscopic Splenectomy (LS) group: Patients undergoing minimally invasive splenectomy. Open Splenectomy (OS) group: Patients undergoing conventional open splenectomy. Surgical Procedure Laparoscopic Splenectomy: Performed under general anesthesia with the patient in the right lateral decubitus position. Pneumoperitoneum was established at 12–14 mmHg. Standard 3–4 port technique was used. The splenic artery and vein were identified, ligated, and the spleen was mobilized using energy devices or staplers. The specimen was retrieved using an endoscopic bag, with or without morcellation. Esophagogastric devascularization was performed when indicated. Open Splenectomy: Conducted through an upper midline or left subcostal incision under general anesthesia. Standard steps included ligation of the splenic vessels, mobilization of the spleen, and devascularization of gastroesophageal varices if indicated. Data Collection Preoperative data included demographic details, etiology of portal hypertension, laboratory parameters, Child-Pugh score, and spleen size (measured by ultrasonography or CT). Intraoperative parameters included operative time, intraoperative blood loss, need for transfusion, and any surgical complications. Postoperative parameters included duration of hospital stay, complications (graded according to Clavien-Dindo classification), and 30-day mortality. Follow-up data included recurrence of varices, portal vein thrombosis, and overall survival at 6 and 12 months. Outcome Measures Primary outcomes: Operative time, intraoperative blood loss, and postoperative complications. Secondary outcomes: Length of hospital stay, transfusion requirement, postoperative pain, recovery time, and long-term outcomes including variceal recurrence and portal vein thrombosis. Statistical Analysis Data were analyzed using SPSS version 21 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) and compared using Student’s t-test or Mann-Whitney U test, as appropriate. Categorical variables were expressed as frequencies and percentages and compared using Chi-square test or Fisher’s exact test. A p-value <0.05 was considered statistically significant.

Patient Demographics and Baseline Characteristics

A total of 80 patients were included in the study, with 40 patients in the laparoscopic splenectomy (LS) group and 40 patients in the open splenectomy (OS) group. The mean age of patients was 45.8 ± 12.3 years in the LS group and 46.5 ± 11.9 years in the OS group (p = 0.78). The majority of patients were male (LS: 65%, OS: 60%, p = 0.62). The most common etiology of portal hypertension was cirrhosis due to hepatitis B or C (LS: 70%, OS: 72.5%). There were no statistically significant differences in baseline Child-Pugh scores, platelet counts, or spleen size between the two groups (Table 1).

Intraoperative Outcomes

The mean operative time was significantly longer in the LS group compared to the OS group (165 ± 30 min vs 140 ± 25 min, p < 0.01). Intraoperative blood loss was significantly lower in the LS group (250 ± 80 mL) compared to the OS group (400 ± 120 mL, p < 0.001). Blood transfusions were required in 5 patients (12.5%) in the LS group and 12 patients (30%) in the OS group (p = 0.04) (Table 2).

Table 1. Baseline Characteristics of Patients

Table 2. Intraoperative Outcomes

Postoperative Outcomes

The LS group experienced significantly shorter postoperative hospital stays (6.5 ± 1.8 days) compared to the OS group (9.2 ± 2.4 days, p < 0.001). Postoperative complications occurred in 6 patients (15%) in the LS group and 14 patients (35%) in the OS group (p = 0.03). Complications included wound infection, pleural effusion, and subphrenic abscess. No 30-day mortality was observed in either group (Table 3).

Table 3. Postoperative Outcomes

Long-term Outcomes

At a mean follow-up of 12 months, recurrence of varices was observed in 2 patients (5%) in the LS group and 4 patients (10%) in the OS group (p = 0.40). Portal vein thrombosis occurred in 1 patient (2.5%) in the LS group and 3 patients (7.5%) in the OS group (p = 0.30). No significant difference in overall survival was observed between the two groups (LS: 100%, OS: 97.5%, p = 0.31).

Narrative Summary

In this study, LS was associated with significantly lower intraoperative blood loss, reduced need for blood transfusions, and shorter postoperative hospital stay compared to OS, despite a slightly longer operative time. Postoperative complications were also lower in the LS group. Long-term outcomes, including recurrence of varices and portal vein thrombosis, were comparable between the two groups, indicating that laparoscopic splenectomy is a safe and effective alternative to open splenectomy in patients with portal hypertension.

Portal hypertension is a challenging clinical condition often requiring surgical intervention, particularly in patients with hypersplenism, massive splenomegaly, or recurrent variceal bleeding. Splenectomy, with or without esophagogastric devascularization, remains a cornerstone in the management of such patients. Our study compared laparoscopic splenectomy (LS) with open splenectomy (OS) and demonstrated significant advantages of LS in terms of intraoperative blood loss, transfusion requirements, postoperative complications, and hospital stay, while maintaining comparable long-term outcomes.

Intraoperative blood loss was significantly lower in the LS group, which is consistent with previous studies reporting that minimally invasive approaches reduce bleeding due to better visualization, magnification, and precise vessel control10,11. Although operative time was slightly longer for LS in our study, this difference is commonly observed in laparoscopic procedures and tends to decrease as surgeons gain experience12.

Postoperative complications were significantly fewer in the LS group, and hospital stay was reduced, reflecting the minimally invasive nature of laparoscopic surgery and faster recovery13. Similar findings have been reported in meta-analyses comparing LS and OS in portal hypertension, which showed lower morbidity, shorter hospital stay, and faster return to normal activity with LS14.

Regarding long-term outcomes, our study found no significant difference between LS and OS in variceal recurrence, portal vein thrombosis, or overall survival at 12 months. These findings support previous reports indicating that laparoscopic approaches do not compromise long-term efficacy when performed in appropriately selected patients15,16.

The choice of surgical technique should consider spleen size, portal vein anatomy, and surgeon experience. LS may be technically challenging in patients with massive splenomegaly or severe adhesions; however, it remains feasible and safe in centers with adequate laparoscopic expertise17.

Limitations

This study has several limitations. First, it was conducted at a single center with a relatively small sample size, which may limit generalizability. Second, the follow-up period was limited to 12 months; longer-term outcomes, including late complications and survival, require further investigation. Third, randomization was not performed, which could introduce selection bias.

Clinical Implications

Our findings suggest that LS should be considered the preferred approach in patients with portal hypertension who are suitable candidates, as it offers reduced perioperative morbidity and faster recovery without compromising long-term outcomes. Surgeons should be trained in laparoscopic techniques and careful patient selection is essential to optimize results.

LS offers significant perioperative advantages over OS without compromising long-term outcomes in patients with portal hypertension. It should be considered the preferred surgical approach in suitable candidates, provided adequate laparoscopic expertise is available.

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