Original article
Laparoscopic splenectomy experience in the University Hospital “Dr. José Eleuterio González”
R.G. Cueto-Ramos
, G.E. Muñoz-Maldonado, M.A. Hernández-Guedea, J.R. Fernández-Treviño, Q.G. Limas-Rodríguez
Corresponding author
rcuetouanl@gmail.com
Corresponding author at: Servicio de Cirugía General, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero y Av. Gonzalitos s/n, colonia Mitras Centro, C.P. 64460, Monterrey, N.L., Mexico. Tel.: +52 01 81 83467198.
Corresponding author at: Servicio de Cirugía General, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero y Av. Gonzalitos s/n, colonia Mitras Centro, C.P. 64460, Monterrey, N.L., Mexico. Tel.: +52 01 81 83467198.
General Surgery Service of the “Dr. José E. González” University Hospital of the Autonomous University of Nuevo León, Mexico
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"apellidos" => "Cueto-Ramos" "email" => array:1 [ 0 => "rcuetouanl@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "G.E." "apellidos" => "Muñoz-Maldonado" ] 2 => array:2 [ "nombre" => "M.A." "apellidos" => "Hernández-Guedea" ] 3 => array:2 [ "nombre" => "J.R." "apellidos" => "Fernández-Treviño" ] 4 => array:2 [ "nombre" => "Q.G." "apellidos" => "Limas-Rodríguez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "General Surgery Service of the “Dr. José E. González” University Hospital of the Autonomous University of Nuevo León, Mexico" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Servicio de Cirugía General, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero y Av. Gonzalitos s/n, colonia Mitras Centro, C.P. 64460, Monterrey, N.L., Mexico. Tel.: +52 01 81 83467198." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Among the most important advances in the field of surgery is, without a doubt, the development of minimally invasive techniques. Laparoscopic splenectomy (LS) has proven to be safe and effective in different retrospective series, with a lower postoperative rate and a greater reduction in hospital stay compared to the referred data in historic series of open splenectomies.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In 1991, Delaitre et al. reported the first successful LS.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> Since then it has become the procedure of choice for spleen removal in patients with hematologic diseases that require surgical treatment.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Laparoscopic splenectomy is a technically demanding procedure, the knowledge of the distribution of the splenic vascularization is of utmost importance. The challenges are the release of different support elements, vascular pedicle control and the removal of the excised tissue.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The continuous development of surgical skills and growing technological advances have allowed surgeons to reproduce, through the use of laparoscopy, most open surgical techniques; however, in order for a minimally invasive procedure to have universal acceptance, it must meet some conditions: it must be reproducible, morbidity and mortality rates ought to be comparable or lower, base disease control must be equal or better to the results of the open approach, and it must have additional benefits for patients, such as less postoperative pain, a shorter in-hospital stay, a faster return to everyday activities or better cosmetic results.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Approach in the surgical technique (supine – anterior – semilateral, lateral) is the choice of the surgeon and based on the concomitant conditions.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> The most utilized technique in most hospitals is the technique described by Targarona.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The objective of this document is to present an experience with LS in the “Dr. José E. González” University Hospital between January 2008 and October 2014</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materials and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">The study was conducted using a retrospective and descriptive analysis of clinical and surgical aspects of all patients who underwent laparoscopic splenectomy between January 2008 and October 2014, at the General Surgery Service of the “Dr. José E. González” University Hospital.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Different variables were inputed in a database including: age, sex, diagnostic, operative data (operative time, blood loss, presence of accessory spleen, spleen weight, conversion, surgical technique) and postoperative data (major and minor postoperative complications, re-interventions and in-hospital stay length).</p><p id="par0045" class="elsevierStylePara elsevierViewall">The inclusion criteria for the study were: all patients who underwent LS at the “Dr. José E. González” University Hospital between January 2008 and October 2014, independently of age range or gender.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The surgical technique utilized in all patients is described below. After the inductions of general anesthesia and endotracheal intubation, the patient is placed in a right lateral decubitus position with a 60° angle. The surgeon remains on the right side of the patient; the camera assistant is to the right of the surgeon and the first assistant on the left of the patient. The pneumoperitoneum is insufflated using the Hasson technique and by maintaining intra-abdominal pressure between 12 and 15<span class="elsevierStyleHsp" style=""></span>mm Hg. Four trocars are placed, (2 of 5<span class="elsevierStyleHsp" style=""></span>mm and the other 2 of 10<span class="elsevierStyleHsp" style=""></span>mm) using 30° optics. The patient is given an orientation in inverted Trendelenburg at 15°, this maneuver allows the spleen to be suspended by its diaphragmatic ligaments, while the force of gravity retracts the stomach, transverse colon and the greater omentum to an inferior position. The abdomen is systematically examined in order to rule out an accessory spleen before starting dissection to avoid darkening of the visual field with cloths. Dissection is performed in 5 stages: division of splenocolic ligament, lower-pole vessel ligation, control of vascular hilum, division of short gastric vessels and detachment of diaphragmatic ligaments. The division of the different splenic ligaments is performed using a harmonic scalpel (Harmonic Shears; Ethicon<span class="elsevierStyleSup">®</span>, Cincinnati, Ohio) and hilum control through the use of medium–large titanium staples (Titanium clips; Weck Horizon), two proximal and one distal, in the splenic vein and artery. Once the specimen is resected it is placed in an extraction bag previously inserted in the abdominal cavity. The piece is morcellated, and then the small fragments are extracted with the use of banding pliers and an aspirator, avoiding spilling of the content in the cavity. Closed drainage systems were placed in every patient.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">A total of 14 laparoscopic splenectomies were performed between January 2008 and October 2014. There were 8 women and 6 men, representing 57.14% and 42.86%, respectively, with a mean age of 20.6 years (range 1–65 years) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Indications for splenectomy included the following diagnosis: idiopathic thrombocytopenic purpura (ITP), 10 patients, 71%; hereditary spherocytosis, 2 patients, 14%; sickle cell anemia and thalassemia, 1 patient, 7%; pyruvate kinase deficient hemolytic anemia, 1 patient, 7% (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Mean operative time was 177.5<span class="elsevierStyleHsp" style=""></span>min (range 110–255<span class="elsevierStyleHsp" style=""></span>min) and mean intraoperative hemorrhage was 223.5<span class="elsevierStyleHsp" style=""></span>ml (range 100–900<span class="elsevierStyleHsp" style=""></span>ml).</p><p id="par0070" class="elsevierStylePara elsevierViewall">A concurrent procedure was performed in one case (7%), represented by cholecystectomy. Accessory spleens were identified in 3 patients (21%). Mean spleen weight was 187.5<span class="elsevierStyleHsp" style=""></span>g. (range 50–900<span class="elsevierStyleHsp" style=""></span>g). Mean postoperative hospital stay was 3.35 days (range 2–16 days). There was no surgical re-intervention. The 4 trocar right lateral decubitus approach was the preferred method for all patients.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Conversion to laparotomy occurred in one patient (7%) due to uncontrollable bleeding with splenomegaly (900<span class="elsevierStyleHsp" style=""></span>g) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The same patient presented as a postoperative complication, a sub-phrenic abscess drained by radio-interventionism using a universal catheter, thus prolonging the patient's hospital stay to 16 days.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">The benefits of laparoscopic surgery are undeniable and well-known. In the case of splenectomy, the main observed advantages are the presence of less postoperative pain, immediate reinstatement of the intestinal passage, shorter postoperative in-hospital stay, a quicker return to everyday activities and excellent cosmetic results.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">LS disadvantages include the need to train the surgical team, a requirement of longer surgical time in comparison to conventional surgery and an increment in costs.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">ITP is the most common indication for LS and in combination with hereditary spherocytosis involves 40–100% of the cases in most of the reported series. In ITP, the size of the spleen in characteristically lower, due to splenic infarction, this can facilitate its laparoscopic manipulation as well as its extraction.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> Preoperative information is of particular relevance in order to achieve a better planning for the laparoscopic approach. For experienced surgeons, as well as those with less experience, LS has a higher morbidity and a higher conversion risk when dealing with patients with splenomegaly.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> Targarona et al. found a direct correlation between conversion incidence and the weight of the spleen. The conversion rate was 0% when the spleen weighed between 400 and 1000<span class="elsevierStyleHsp" style=""></span>g, 25% when it weighed more than 1000<span class="elsevierStyleHsp" style=""></span>g and 75% when it weighed more than 3000.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> However, Owera et al. established that despite higher surgical times, LS recovery time is shorter and less torpid.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Due to the high volumes and pressures involved in spleens, in addition to splenomegaly and the vascular congestion that is usually present in these illnesses, on top of the fragility of the splenic capsule, a hemorrhage at this level is hard to control in some situations in open technique as well as in laparoscopy, hence when presented with bleeding during a procedure which could potentially set back hemorrhage control and compromise the patient's hemodynamic state we opted for the conversion to open technique, given the fact that there is more experience and skill with this technique.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Incidence of accessory spleen detection is somewhere between 4% and 27% of the cases during open splenectomy in patients with ITP,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> while different LS series refer to incidences between 11% and 21%.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> In our series we detected accessory spleens in 21% of the patients, usually located in relation to the splenic hilum or adjacent to the pancreatic tail. However, they may be found throughout the splenic vessels’ route, in the gastro-splenic or splenic-renal ligaments, inside the pancreatic tail, on the wall of the intestine or colon, in the greater omentum or the mesentery, and even in the pelvis or scrotum. The detection and characterization of accessory spleens are important due to 3 problems. First, the accessory spleens may be symptomatic, presenting torsion, spontaneous rupture, hemorrhage or cystic formation. Second, it is necessary to detect them when dealing with patients with hematologic diseases which require splenectomy and which could remain sub-treated if the functional splenic tissue is not removed in full. Finally, accessory spleens can be confused with lymphatic adenopathy or tumors of other organs. Usual accessory spleen diagnosis is performed using a tomography, finding an image with precise margins, in general smaller than 3<span class="elsevierStyleHsp" style=""></span>cm, and capturing a homogenous shape with a similar density to the main spleen in its phases with and without contrast. In cases where there is a diagnostic doubt and there is a suspicion of an accessory spleen, the use of centelleographic studies with elements which are taken by the splenic tissue is prescribed. Among these studies a few stand out, like centelleograms with 111 in-labeled platelets, technetium Tc-99m Sulfur Colloid, and heat-denatured red blood cells labeled with technetium-99m (Tc-99m DRBC), the latter being the most specific because it presents a reduced capture by the liver, resulting in a better contrast of white tissue.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In the cases of our study, we were not counting on a diagnostic suspicion because of previous image studies and accessory spleen identification as a result of rigorous surgical examination in the operative field as well as the route of the fixing elements of the spleen. The methodology was performed through the inspection and dissection of the spleen's peripheral structures using laparoscopic instruments.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">15,16</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The frequency of conversion in the literature ranges from 3% to 8%<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a>, which corresponds with the data shown by our study, and most conversions occur as a consequence of bleeding or difficulty in the dissection, especially in patients with a large splenomegaly.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The reported learning curve in the literature for this surgery is 20 procedures, as a standard to accomplish better results and benefits from this surgery.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> This technique is imperative to be taken into account as a part of every general surgeon's training, even when the vast majority of prescriptions represent hematologic diseases. Our objective was not to evaluate the response of these diseases to surgical treatment but to prove the safety and efficacy of the approach.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">LS can be considered as a safe and effective procedure in benign hematological diseases and can be regularly used in our environment. It provides the advantages of minimally invasive surgery with a lower morbidity and mortality compared with open surgery, placing it as the first choice for hematologic diseases which require a surgical approach.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">No financial support was provided.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres542836" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec562185" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-10-13" "fechaAceptado" => "2014-12-08" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec562185" "palabras" => array:3 [ 0 => "Laparoscopic" 1 => "Splenectomy" 2 => "Thrombocytopenic purpura" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To present the laparoscopic splenectomy (LS) experience at the “Dr. José E. González” University Hospital from January 2008 to October 2014.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective and descriptive analysis of clinical and surgical aspects of all patients who underwent laparoscopic splenectomy from January 1st 2008 to October 31st 2014 at the “Dr. José Eleuterio González” University Hospital.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Laparoscopic splenectomies were performed on 14 patients, with a mean age of 20.6 years. Indications for splenectomy included the following diagnosis: idiopathic thrombocytopenic purpura (ITP), 71%; hereditary spherocytosis, 14%; sickle cell anemia and thalassemia, 7%; pyruvate kinase deficient hemolytic anemia, 7%. Mean operative time was 177.5<span class="elsevierStyleHsp" style=""></span>min. Mean intraoperative hemorrhage was 223.5<span class="elsevierStyleHsp" style=""></span>ml. Conversion to laparotomy occurred in one patient (7%) associated with uncontrollable bleeding with splenomegaly. Accessory spleens were identified in 3 patients (21%). Mean spleen weight was 187.5<span class="elsevierStyleHsp" style=""></span>g. Mean postoperative hospital stay was 3.35 days. There was no surgical re-intervention. The 4 trocar right lateral decubitus approach was the preferred method for all patients.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">LS can be performed as a safe and effective procedure in benign hematological diseases in our everyday environment.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Mean age: 20.6 year, range (1–65 years).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Women \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Men \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Total \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Procedures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (57.14%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (42.86%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab871750.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Prevalence by gender.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: ITP, idiopathic thrombocytopenic purpura; HS, hereditary sphericytosis; SCAT, sickle cell anemia and thalassemia; PKDHA, pyruvate kinase deficient hemolytic anemia.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Diagnoses \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">ITP \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">HS \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">SCAT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">PKDHA \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (71%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (14%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab871749.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Indications for splenectomy.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Origin: Surgical registry Outpatient Surgery and Laparoscopy Center, CCAyL HU.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Conversion to open technique caused by splenomegaly and splenic vein bleeding.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Splenectomies by laparoscopy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Converted to open Technique. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Total \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Procedures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (93%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab871751.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Conversion to open technique index.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Esplenectomi¿a laparosco¿pica: resultados a largo plazo de una serie prospectiva de 257 pacientes en funcio¿n del diagno¿stico hematolo¿gico" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. 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| Year/Month | Html | Total | |
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| 2021 July | 3 | 4 | 7 |
| 2021 June | 8 | 7 | 15 |
| 2021 May | 10 | 7 | 17 |
| 2021 April | 24 | 6 | 30 |
| 2021 March | 15 | 9 | 24 |
| 2021 February | 2 | 7 | 9 |
| 2021 January | 16 | 11 | 27 |
| 2020 December | 8 | 9 | 17 |
| 2020 November | 7 | 6 | 13 |
| 2020 October | 3 | 10 | 13 |
| 2020 September | 5 | 12 | 17 |
| 2020 August | 8 | 7 | 15 |
| 2020 July | 4 | 6 | 10 |
| 2020 June | 6 | 2 | 8 |
| 2020 May | 7 | 7 | 14 |
| 2020 April | 6 | 5 | 11 |
| 2020 March | 7 | 4 | 11 |
| 2020 February | 6 | 5 | 11 |
| 2020 January | 6 | 4 | 10 |
| 2019 December | 15 | 8 | 23 |
| 2019 November | 7 | 2 | 9 |
| 2019 October | 13 | 2 | 15 |
| 2019 September | 12 | 0 | 12 |
| 2019 August | 6 | 3 | 9 |
| 2019 July | 13 | 23 | 36 |
| 2019 June | 22 | 10 | 32 |
| 2019 May | 49 | 2 | 51 |
| 2019 April | 4 | 14 | 18 |
| 2019 March | 5 | 1 | 6 |
| 2019 February | 7 | 2 | 9 |
| 2019 January | 6 | 6 | 12 |
| 2018 December | 8 | 4 | 12 |
| 2018 November | 11 | 2 | 13 |
| 2018 October | 3 | 8 | 11 |
| 2018 September | 3 | 7 | 10 |
| 2018 August | 5 | 6 | 11 |
| 2018 July | 3 | 6 | 9 |
| 2018 June | 1 | 1 | 2 |
| 2018 May | 3 | 13 | 16 |
| 2018 April | 6 | 2 | 8 |
| 2018 March | 9 | 1 | 10 |
| 2018 February | 7 | 1 | 8 |
| 2018 January | 4 | 3 | 7 |
| 2017 December | 5 | 3 | 8 |
| 2017 November | 4 | 6 | 10 |
| 2017 October | 7 | 5 | 12 |
| 2017 September | 7 | 9 | 16 |
| 2017 August | 9 | 14 | 23 |
| 2017 July | 6 | 9 | 15 |
| 2017 June | 10 | 11 | 21 |
| 2017 May | 14 | 8 | 22 |
| 2017 April | 6 | 17 | 23 |
| 2017 March | 12 | 88 | 100 |
| 2017 February | 5 | 6 | 11 |
| 2017 January | 1 | 7 | 8 |
| 2016 December | 13 | 6 | 19 |
| 2016 November | 15 | 10 | 25 |
| 2016 October | 28 | 9 | 37 |
| 2016 September | 31 | 6 | 37 |
| 2016 August | 20 | 10 | 30 |
| 2016 July | 19 | 4 | 23 |
| 2016 June | 31 | 20 | 51 |
| 2016 May | 21 | 14 | 35 |
| 2016 April | 24 | 19 | 43 |
| 2016 March | 19 | 21 | 40 |
| 2016 February | 19 | 14 | 33 |
| 2016 January | 20 | 13 | 33 |
| 2015 December | 17 | 15 | 32 |
| 2015 November | 18 | 19 | 37 |
| 2015 October | 32 | 22 | 54 |
| 2015 September | 9 | 8 | 17 |
| 2015 August | 3 | 3 | 6 |
Show all