The laparoscopic treatment of large paraesophageal and mixed hiatal hernias is not only feasible and safe but also offers a good quality of life on a midterm basis. However, the anatomic and functional recurrence rate is high. The next step is to identify the subset of patients who are at risk of failure and to establish technical alternatives that would ensure the durability of the repair.

LS offers advantages for all types of splenic diseases requiring surgery. It provides not only good clinical short-term outcome but also satisfactory long-term hematological results.

Hypothesis: Analysis of the type and characteristics of complications after laparoscopic splenectomy may permit the identification of clinical factors with predictive value for the development of complications. Design: Univariate and multivariate analysis of factors related to complications in a prospective series of laparoscopic splenectomies. Setting: A large tertiary referral university-teaching general hospital. Patients: One hundred twenty-two nonselected consecutive patients, in whom laparoscopic splenectomy was attempted between February 1993 and July 1999. Intervention: Laparoscopic splenectomy. Main Outcome Measures: Immediate complications classified according to the Clavien score. Univariate and multivariate analyses were performed of complications related to age, sex, body mass index, and malignant nature of the hematologic disease; preoperative hematocrit and platelet count; operative time; operative position; need of accessory incision; transfusion status; learning curve; and existence of comorbid diseases. Clinical Outcome Value* Operative time, min 153 ± 59 (60-240) Transfusion, % 18 Morbidity, % 18 Hospital stay, d 4 ± 2 (2-14) Spleen weight, g 493 ± 588 (60-3200) Accessory spleen, % 12 Accessory incision, % 36 *Data are given as mean ± SD (range) unless otherwise indicated. No conversions were related to intraoperative complications. Twenty

LS is a safe and reproducible procedure for most hematological indications, with a similar immediate outcome for benign diseases and a long-term hematological response comparable to the standard results that have been observed in open series.

Hand-assisted laparoscopic surgery (HALS) has been proposed as a useful alternative to conventional open or laparoscopic surgery. However, most information is fragmented and comes from specific or selective indications. To assess the current situation of HALS, a general overview of the fields of application, results, and quality of the evidence of these results is necessary. Data Sources: Current English-language literature review. Study Selection: Case reports, series, and opinion articles on HALS. Data Extraction and Synthesis: Evaluation of the type of study and results. Most of the articles are short case series. Only a few comparative or randomized comparative trials on HALS for splenectomy and colectomy have been published. Conclusions: Hand-assisted laparoscopic surgery seems to be a promising technique that has been applied with success in a wide range of digestive tract-related surgical procedures. The main role is to help in difficult cases before conversion is necessary or for training unskilled surgeons, and not as an alternative to pure laparoscopic surgery. However, not enough evidence-based data are available to know exactly the final outcome of this technique in general surgery. Prospective randomized trials with established open or laparoscopic procedures are lacking, and these trials are needed to support the final role of HALS.

In patients with enlarged spleens, LS is feasible and followed by lower morbidity, transfusion rate, and shorter hospital stay than when the open approach is used. For the treatment of this subset of patients, who usually present with more severe hematologic diseases related to greater morbidity, LS presents potential advantages.

In cases of splenomegaly, HALS assisted laparoscopic surgery significantly facilitates the surgical maneuvers during LS while maintaining the advantages of a purely laparoscopic approach.

LS is a safe procedure in patients with malignant disease requiring splenectomy in spite of the longer operative time and the higher conversion rate.