the laparoscopic extirpation of normal - sized spleens has become more common in the last few years . since the first attempts less than a decade ago , several reports have described the challenges associated with this type of surgery . contraindications to a laparoscopic approach include severe portal hypertension , uncorrectable coagulopathy , severe ascites , and most traumatic injuries to the spleen . spleen size is expressed in terms of the maximum interpole length and is generally classified into 3 categories : normal spleen size ( < 11 cm ) ; moderate splenomegaly ( 11 cm to 20 cm ) ; and severe or massive splenomegaly ( > 20 cm ) . extremely large spleens present special technical problems that test the current limits of laparoscopic surgery . however , as laparoscopic techniques , surgical skills , and instrumentation have improved , so have the safety and efficacy of this procedure even in the presence of splenomegaly . since june 1997 , 82 laparoscopic splenectomies have been performed for hematologic pathologies including malignancies . starting in september 2003 , we attempted a new approach in cases of severe splenomegaly . the purpose of the study was to examine the safety and efficacy of minimal - access splenectomy ( mas ) in the setting of massive splenomegaly . between september 2002 and october 2003 , 9 patients were identified as having massive splenomegaly potentially treatable through a minimal access approach . six male and 3 female patients underwent mas for the following disorders : non - hodgkin 's lymphoma in 5 cases and idiopathic myelofibrosis in 4 . mean age and bmi ( body mass index ) of the patients were respectively 58.8 years ( range , 41 to 72 ) and 24.3 ( range , 21.4 to 26 ) . patient and disease characteristics preoperative ultrasonography performed to determine the size of the spleen showed a median interpole length of 27.9 cm ( range , 23 to 32 ) . the indications for splenectomy included persistent thrombocytopenia and anemia due to hypersplenism , as well as continuous steroid medication . the subjective symptoms of all the patients included abdominal distension and fullness , difficulty in lying on the left side and left - sided upper quadrant pain . preoperatively , the patients were categorized as american association of anesthesiology ( asa ) class ii ( 5 patients ) and class iii ( 4 patients ) . only 1 patient had a normal platelet count ; the others had thrombocytopenia , with an average count of 65 400/mm ( range , 8000 to 140 000/mm ) . the patients were placed in the supine decubitus position with a sandbag under the left flank . this step afforded access to the gastrosplenic ligament and the opening of the lesser sac in its lateral portion . next , the short gastric vessels were divided by using the ultrasonic dissector or eventually over clips ( figure 1 ) . the uppermost vessels of the gastrosplenic ligament are very short and enlarged in splenomegaly , and they are located in the immediate vicinity of the diaphragm . access to these vessels required combined dislocation of the stomach to the right and gentle retraction of the upper splenic pole to the left . then the dissection reached the hilum and the vessels could be isolated from the pancreas and the surrounding tissues by combining a careful digital dissection with the use of the ultrasonic dissector . if a distributed anatomy was present , the splenic branches were usually dissected and divided between silk ligatures or clipped . in case of magistral anatomy , after providing that the tail of the pancreas is identified and dissected away , we performed separate silk ligation of the splenic vessels with a delayed ligature of the vein , to achieve a volumetric reduction of the spleen . then the splenic flexure was partially mobilized by incising the splenocolic ligament , the lower part of the phrenicocolic ligament , and the sustentaculum lienis . finally , the phrenicocolic ligament was incised all the way to the left crus of the diaphragm by the ultrasonic dissector . this bag was introduced into the abdominal cavity , and the spleen was manually slipped inside to prevent splenosis during the subsequent manipulations . grasping forceps were used to hold the edges of the bag and to effect partial closure . at the end of the procedure , a nasogastric tube and an abdominal drain in the left hypochondrium were left in place . between september 2002 and october 2003 , 9 patients were identified as having massive splenomegaly potentially treatable through a minimal access approach . six male and 3 female patients underwent mas for the following disorders : non - hodgkin 's lymphoma in 5 cases and idiopathic myelofibrosis in 4 . mean age and bmi ( body mass index ) of the patients were respectively 58.8 years ( range , 41 to 72 ) and 24.3 ( range , 21.4 to 26 ) . patient and disease characteristics preoperative ultrasonography performed to determine the size of the spleen showed a median interpole length of 27.9 cm ( range , 23 to 32 ) . the indications for splenectomy included persistent thrombocytopenia and anemia due to hypersplenism , as well as continuous steroid medication . the subjective symptoms of all the patients included abdominal distension and fullness , difficulty in lying on the left side and left - sided upper quadrant pain . preoperatively , the patients were categorized as american association of anesthesiology ( asa ) class ii ( 5 patients ) and class iii ( 4 patients ) . only 1 patient had a normal platelet count ; the others had thrombocytopenia , with an average count of 65 400/mm ( range , 8000 to 140 000/mm ) . the patients were placed in the supine decubitus position with a sandbag under the left flank . this step afforded access to the gastrosplenic ligament and the opening of the lesser sac in its lateral portion . next , the short gastric vessels were divided by using the ultrasonic dissector or eventually over clips ( figure 1 ) . the uppermost vessels of the gastrosplenic ligament are very short and enlarged in splenomegaly , and they are located in the immediate vicinity of the diaphragm . access to these vessels required combined dislocation of the stomach to the right and gentle retraction of the upper splenic pole to the left . then the dissection reached the hilum and the vessels could be isolated from the pancreas and the surrounding tissues by combining a careful digital dissection with the use of the ultrasonic dissector . if a distributed anatomy was present , the splenic branches were usually dissected and divided between silk ligatures or clipped . in case of magistral anatomy , after providing that the tail of the pancreas is identified and dissected away , we performed separate silk ligation of the splenic vessels with a delayed ligature of the vein , to achieve a volumetric reduction of the spleen . then the splenic flexure was partially mobilized by incising the splenocolic ligament , the lower part of the phrenicocolic ligament , and the sustentaculum lienis . finally , the phrenicocolic ligament was incised all the way to the left crus of the diaphragm by the ultrasonic dissector . this bag was introduced into the abdominal cavity , and the spleen was manually slipped inside to prevent splenosis during the subsequent manipulations . grasping forceps were used to hold the edges of the bag and to effect partial closure . at the end of the procedure , a nasogastric tube and an abdominal drain in the left hypochondrium were left in place . the operative time ranged from 75 minutes to 165 minutes ( mean , 124 ) . the average weight of the spleen was 2500 g ( range , 1700 to 3200 ) . the average intraoperative blood loss was 572 ml ( range , 150 to 1000 ) . five patients received an average of 3u of packed red cells , and 4 of the splenectomies were performed without such a transfusion . in all patients , oral intake was assured from the second to the sixth postoperative day ( mean , 3 ) . postoperative complications occurred in 2 cases : one patient had pleural effusion and another patient developed pneumonia , which were treated medically . one perioperative death occurred 15 days after the operation in a patient with idiopathic myelofibrosis as a consequence of a secondary blast crisis . perioperative features of patients who underwent minimal - access splenectomy ( n=9 ) mean postoperative hospital stay was 9.1 days ( range , 6 to 15 ) . the average preoperative platelet count was 108 911/mm ( range , 8000 to 457 000 ) . the average postoperative platelet count was 479 111/mm ( range , 6,000 to 1 262 000 ) . massive splenectomy virtually always relates to hematological malignancies . in these patients , the local discomfort from massive splenomegaly and open splenectomy has been associated with substantial morbidity and mortality , and the rates may be higher in patients with splenomegaly , patients with myeloproliferative disorders , and the elderly . we consider all patients with massive splenomegaly as potential candidates for laparoscopic splenectomy , and the laparoscopic approach has been used since june 1997 . starting in september 2002 , in cases of massive splenomegaly , we have adopted the mas technique for 2 reasons . first , in the laparoscopic approach , a service mini - laparotomy is always performed when pathologic examination of the surgical specimen is required to document the hematological disease . second , laparoscopic - assisted removal of the entire spleen via an accessory mini - laparotomy does not affect the duration of surgery , rate of complications , or length of hospital stay . its use is advocated in every step of the procedure : from the dissection of the splenocolic to the gastrosplenic ligament , from the dissection of the hilar vessels to the spleno - diaphragmatic ligament . the use of a clip applier or a vascular stapler was necessary in only a few cases . separate ligation of the hilar vessels was performed whenever possible . once the lesser sac is opened , the next step is the identification and ligation of the splenic artery . volumetric reduction of the spleen after this manoeuvre is important , thus enabling the surgeon to perform the next steps of the dissection more easily . manual handling succeeds in creating a working space that would be difficult to achieve with the simple manipulation of the laparoscopic instruments . furthermore , hand assistance , by regaining tactile feedback , also increases the safety of the procedure , because it enables the surgeon to rapidly identify vascular structures and , in the case of accidental bleeding , allows immediate hemostatic control by digital compression . postoperative morbidity was low ; no pancreatitis was observed because dissection in the mas technique tends to identify and dissect away the tail of the pancreas . a severe blast crisis not directly related to surgery was responsible for the only perioperative death that occurred in a patient affected by idiopathic myelofibrosis . median length of hospital stay for the rest of the patients was 7.5 days . in regard to massive splenomegaly in malignancies , this value is comparable to that reported in the literature and to that of our historic patients treated with a fully laparoscopic approach . we believe that experience with laparoscopic splenectomy is necessary to perform mas ; in fact , the laparoscopic skills of the surgeon greatly facilitate dissection with this approach . mas in patients with severe splenomegaly represents a viable option , because it is feasible and effective . we found mas to be an attractive alternative to laparoscopy in cases of massive splenomegaly . it combines the advantages of hand assistance , shorter operative times , and increased safety of the procedure with the classical benefits of minimally invasive surgery .