The secure control of the splenic hilum is the most critical step in LS. In our study, we used the Hem-o-lok clips to control the hilum in all cases. After dissection of the splenic hilum, the splenic artery is controlled first using Hem-o lok clips with double clips proximally and a single clip distally. It is then divided using scissors. This is followed by controlling the splenic vein in a similar manner. This was exactly described by Adetokunbo Fadipe et al. (2022), Haffenden et al. (2021), Ali Aminian et al. (2012), and Murat Derebey et al. (2020). Selective control of the splenic hilum starting by the artery and then the vein revives the traditional concept of splenic autotransfusion [4,5,6,7].

On the other hand, Khiralla et al. (2016) used only the LigaSure™ for controlling the splenic vessels [8].

In our study, the splenic span as measured by preoperative ultrasonography ranged from 10 to 18.5 cm with an average of 13 cm. This is consistent with many other similar studies. Adetokunbo Fadipe et al. (2022) reported that the mean splenic size was 13.4 cm and 12–14.4 cm [4]. Cetin Ali Karadag et al. (2015) reported that 39 of their patients had splenic lengths exceeding the suggested upper limit of normal according to Rosenberg’s study [9].

We had 3 (11.1%) cases of minor to moderate intraoperative bleeding, one from the short gastric vessels and 2 from small pancreatic branches during dissection of the hilum. All were not related to the use of the Hem-o-lok clips, and all were controlled laparoscopically without the need to convert. Ali Aminian et al. (2012) reported they had a bleeding in 1 case (2%) due to tearing of splenic vessels [6]. Haffenden et al. (2021) reported that they had no intraoperative bleeding [7]. Adetokunbo Fadipe et al. (2022) reported that there were no cases of significant intraoperative bleeding [4]. Mohammad Gharieb et al. (2016) reported that 1 case had an injury to the splenic vein, and 4 cases had an injury of the short gastric vessels [8].

So, the rate of bleeding in our study is comparable to the rate in other studies using our technique or other methods for hilar control. It must be noted that for proper application of the Hem-o-lok clips, a segment of both the artery and vein must be skeletonized to allow for application of the clips with safe distance to cut between them. Dissection of the hilum should be done carefully and meticulously.

The mean operative time for splenectomy only (excluding extraction time) ranged from 40 to 85 min with a mean of 67.04 ± 14.02. Adetokunbo Fadipe et al. (2022) reported that the operative duration for LS only was 178 min (156–185 min), and they used Hem-o-lok for hilum control in all cases [4]. Mohammad Gharieb et al. (2016) reported the mean operative time was 85 min for ITP patients and 120 min for thalassemia and spherocytosis, and the LigaSure™ was the only device used in hilar control in their study [8]. Mohamed E. Hassan et al. (2014) reported the operative time ranged from 150 to 210 min, and they used a linear endoscopic vascular stapler for hilar control [10]. Cetin Ali Karadag et al. (2015) reported that the mean operative time for their first 25 cases was 154.6 min, whereas the mean operative time for their last 25 cases was 115.5 min. They did not specify the time needed for extraction, and they used the LigaSure™ for hilar control [9]. So, it is clear that using this method for vascular control does not increase the operative time.

We had no conversion to open splenectomy (OS) in our cases. Adetokunbo Fadipe et al. (2022) reported that there were no conversions to OS [4]. Murat Derebey et al. (2020) reported that conversion was performed in 1 (5.3%) patient in the Hem-o-lok group due to bleeding from the splenic hilum during the dissection [5]. Cetin Ali Karadag et al. (2015) mentioned that 5 (21.5%) of the laparoscopic splenectomies required conversion to an open procedure [9]. Mohammad Gharieb et al. (2016) had 2 cases that were converted to conventional splenectomy due to bleeding [8]. It is also clear that using the Hem-o-lok for hilar control does not increase the rate of conversion to OS.

GB stones were detected only in 3 cases (13.6%). The 3 cases underwent simultaneous laparoscopic splenectomy and cholecystectomy. In Adetokunbo Fadipe et al. (2022) study, 6 out of the 20 cases (33%) underwent concomitant laparoscopic cholecystectomy and splenectomy [4]. Cetin Ali Karadag et al. ( 2015) mentioned that 5 patients (10%) underwent concomitant cholecystectomy and splenectomy [9].

In cases of combined laparoscopic splenectomy and cholecystectomy, we always start by cholecystectomy first, and this was exactly reported by Faisal G. Qureshi et al. (2005) [11].

We extracted the spleen in a homemade retrieval bag in 15 cases (40.7%), in a commercial endo bag in 1 case (3.7%), and via a Pfannenstiel incision in 11 cases (55.6%). The spleen was fragmented in the bag after extending the umbilical port incision in the midline. Khiralla et al. (2016) reported that they used the retrieval endo bag in 20 patients, while they extracted the spleen via a Pfannenstiel incision in 40 cases [8]. Adetokunbo Fadipe et al. (2022) reported that they used the endo bag for all cases [4]. Using an endo bag avoids the use of another incision, although hidden, with its tissue trauma, pain, and added operative time, promoting ileus and potential complications. So, we opt to extract only very large spleens through a Pfannenstiel incision. The homemade endo bag is less costly but more difficult to manipulate than the commercial endo bag.

In our study, postoperative feeding was tried after 6–8 h in all cases who had their spleen extracted in a bag (16 cases) and all of them tolerated. Patients who had their spleen extracted via a Pfannenstiel incision (11 cases) started oral feeding after regaining peristalsis or passing flatus and all of them tolerated except 3 cases who had vomiting that was medically managed with success. Mohamed E. Hassan et al. (2014) reported that postoperatively, oral feeding was resumed within 6 to 8 h as they extracted all the spleens by an endo bag [10]. Early feeding, especially in children, alleviates their postoperative discomfort and anxiety and could shorten hospital stay as well.

Twenty-four of our patients had an intraperitoneal drain postoperatively; in 22 of them, it was removed after 24 h, and 2 drains were removed after 48 h. Mohamed E. Hassan et al. (2014) inserted a drain in cases of massive splenomegaly which was removed within 24 h [10]. Mohammad Gharieb et al. (2016) mentioned that they put a drain in all cases that was removed on the 2nd day as they discharged all the cases on the 3rd day [8].

In our study, we had no major complications in the postoperative period, specifically no bleeding or failure of the Hem-o-lok clips. Haffenden et al. (2021) reported no incidences of post-operative haemorrhage or surgical complications [7]. Mohammad Gharieb et al. (2016) mentioned that they had 5 cases of subphrenic collections; 2 cases required ultrasound-guided drain, and the other 3 cases were treated conservatively and recovered [8]. The absence of postoperative haemorrhage or clip failure emphasises the safety of using the Hem-o-lok clips for controlling the splenic hilum.

In our study, the mean hospital stay was 1.3 days range (1–2 days). The main cause for delaying hospital discharge was the delay in tolerating full oral feeding in cases who had a Pfannenstiel incision. There was a significant positive correlation between the type of splenic extraction and the period of hospital stay (P-value 0.004). Cases with spleen extracted via a Pfannenstiel incision had a longer stay. Mohamed E. Hassan et al. (2014) mentioned that the mean hospital stay was 36 h in the LS group, extracting all spleens by an endo bag, starting oral feeding after a mean 7.5 h, and removing all drains after 24 h [10]. Haffenden et al. (2021) and Adetokunbo Fadipe et al. (2022) reported that the mean postoperative length of stay was 2 days (2–3 days). Both of them used the endo bag as a method of splenic extraction [4, 7].

In this study, we opted to early postoperative feeding and found that it is tolerated by all cases who had their spleens extracted by an endo bag. This helped to shorten the hospital stay. We also removed the nasogastric tube in all cases at the end of the operation which gives great comfort to our patients.

As regard the cost of the operation, we used 1 cartridge of Hem-o-lok clips/patient which costs US $28 = 686 LE, and the cost of the homemade endo bag was with a cost of US $4.5 = 110 LE. On the other hand, we used a commercial endo bag in 1 case, and it cost US $62 (1519 LE). Murat Derebey et al. (2020) also supported our results regarding the cost, as they reported that the mean cost of surgical instruments used to divide the splenic hilum was significantly lower for the Hem-o-lok group (US $22–$44) than Tri-Staple group (US $126–$253) with an average of US $34.1 vs US $165.4 [5].

Our study had some limitations including small sample size, and it is not a comparative study Table 1.