Impact of Spleen Size on Perioperative Outcomes After Laparoscopic Splenectomy: A Single-Center Retrospective Cohort Study

Technical Summary: Impact of Spleen Size on Perioperative Outcomes After Laparoscopic Splenectomy

Problem Statement
While laparoscopic splenectomy is the preferred approach for benign and malignant splenic disorders due to reduced pain and faster recovery, operative complexity varies significantly with spleen size. Splenomegaly presents technical challenges, including distorted vascular anatomy, increased blood flow, portal hypertension, and limited working space. Although previous literature suggests that massive splenomegaly correlates with longer operative times and higher blood loss, there is no consensus on clinically meaningful spleen size thresholds for predicting postoperative morbidity. Furthermore, the specific impact of spleen size on perioperative outcomes remains incompletely defined, particularly regarding whether linear measurements can serve as effective preoperative risk stratification tools.

Methodology
This study employed a retrospective cohort design involving 63 consecutive patients who underwent laparoscopic splenectomy at a single tertiary referral center between March 2011 and December 2025. Patients with incidental splenectomies or incomplete data were excluded.

• Stratification: Patients were categorized into two groups based on preoperative imaging (CT or ultrasound) maximal craniocaudal splenic length: a smaller group (<150 mm, n=36) and a larger group (≥150 mm, n=27).
• Variables: The study analyzed perioperative variables (operative time, blood loss, trocar count, conversion rates) and postoperative complications within 30 days, graded using the Clavien–Dindo classification.
• Statistical Analysis: Continuous variables were compared using the Mann–Whitney U test, and categorical variables using chi-square or Fisher's exact tests. Multivariable logistic regression was performed to identify independent predictors of postoperative morbidity, including variables with p < 0.1 in univariable analysis.

Key Contributions
The primary contribution of this work is the identification of a specific, clinically applicable spleen length cutoff (150 mm) that serves as an independent predictor of postoperative morbidity. The study provides a detailed analysis of how splenomegaly influences not just technical difficulty (e.g., trocar usage) but also clinical outcomes, while distinguishing between the frequency and severity of complications. Additionally, the study highlights the paradoxical finding that higher morbidity rates in the large spleen group did not necessarily translate to longer hospital stays, attributing this to the low-grade nature of the complications observed.

Results

• Patient Demographics and Indications: The groups were comparable in age and sex. However, the indications for surgery differed significantly; the ≥150 mm group had a higher prevalence of autoimmune hemolytic anemia (40.7% vs. 5.6%) and hematologic malignancies (22.2% vs. 2.8%).
• Operative Variables: The ≥150 mm group required a significantly higher median number of trocars (4 vs. 3, p=0.018). Operative time and intraoperative blood loss were comparable between the two groups (p > 0.05).
• Postoperative Morbidity: Overall postoperative morbidity was significantly higher in the ≥150 mm group (70.4% vs. 36.1%, p=0.007).
• Recovery Metrics: Despite higher morbidity, the ≥150 mm group had a significantly shorter time to drain removal (median 2.0 vs. 3.0 days, p=0.012) and a shorter length of hospital stay (median 4.0 vs. 5.0 days, p=0.008).
• Complication Severity: The increased morbidity in the large spleen group was driven primarily by low-grade (Clavien–Dindo Grade I–II) complications, such as reactive thrombocytosis and minor pleural effusions. There was no in-hospital mortality in either group.
• Multivariable Analysis: Spleen size ≥150 mm was identified as a strong independent predictor of overall morbidity (Adjusted OR 4.46, 95% CI 1.45–13.7, p=0.009). Intraoperative blood loss was also an independent predictor (Adjusted OR 1.007 per mL, p=0.040).

Significance and Claims
The authors claim that preoperative spleen size is a simple, radiologically accessible parameter that can effectively stratify risk for patients undergoing laparoscopic splenectomy. The study posits that a spleen length of ≥150 mm is an independent predictor of increased postoperative morbidity, suggesting that surgeons should anticipate technical challenges and adjust operative planning (e.g., trocar placement) for these patients.

The paper emphasizes that while splenomegaly increases the frequency of complications, these are often low-grade events that do not significantly prolong hospitalization, challenging the notion that large spleens necessarily lead to severe adverse outcomes. The authors conclude that incorporating the 150 mm cutoff into routine preoperative evaluation can aid in surgical planning and perioperative management.

The authors acknowledge limitations, including the retrospective design, small sample size, the use of linear rather than volumetric measurements, and the potential confounding effect of the unequal distribution of underlying hematologic diseases between the groups. They maintain that their findings reflect real-world clinical practice within a homogeneous surgical population.