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大多數脾血管瘤患者無(wú)明顯癥狀，本組患者中僅1例有左上腹痛癥狀。隨著(zhù)超聲、CT、MRI等影像學(xué)技術(shù)的進(jìn)步，脾血管瘤的檢出者越來(lái)越多。由于血管瘤可發(fā)生梗塞、感染、纖維化、鈣化等繼發(fā)病變且可出現自發(fā)性破裂出血等嚴重并發(fā)癥，所以一旦發(fā)現，均主張手術(shù)切除，可以行脾切除術(shù)或脾部分切除術(shù)。由于對脾臟具有一定的免疫等功能且脾全切后易發(fā)生兇險性感染的認識加深，近年來(lái)越來(lái)越強調爭取行脾部分切除術(shù)。有學(xué)者提出脾部分切除術(shù)的適應證[5]：①年齡在60歲以下；②外傷性脾破裂為Ⅱ、Ⅲ級；③脾臟良性病變(脾臟血管瘤、動(dòng)脈瘤、動(dòng)靜脈畸形)。其包括規則性脾切除術(shù)和非規則性脾切除術(shù)。前者先按血管分布，處理血管后，再行相應的脾段、葉或半脾切除術(shù)。后者是根據脾組織的血供及活力情況行非規則脾切除。目前對于單發(fā)的良性腫瘤且較小，位于上、下極或局限于某段或位于脾邊緣，尤其是年輕人，可考慮節段性脾切除術(shù)，這樣可以盡可能保留脾臟功能，降低脾切除術(shù)后兇險性感染[6]。本組病例平均年齡39.4歲，對脾功能要求較高，在隨訪(fǎng)過(guò)程中均未發(fā)現爆發(fā)性感染、血栓事件、脾壞死等并發(fā)癥，證明很好地保留了脾臟功能。
隨著(zhù)腹腔鏡等微創(chuàng )技術(shù)的進(jìn)步，腹腔鏡下脾部分切除術(shù)逐漸在臨床中得到運用，特別是用于治療遺傳性球形紅細胞增多癥（hereditary spherocytosis）[7]，對于其他囊性或者實(shí)性腫瘤的切除也偶有文獻報道[8]?？偨Y了上述文獻后，我院近些年逐漸選擇合適病例開(kāi)展此術(shù)式。相比開(kāi)腹脾部分切除術(shù)，腹腔鏡具有創(chuàng )傷小、顯露清楚、術(shù)后恢復快等顯著(zhù)優(yōu)點(diǎn)，但是對術(shù)者要求比較高，需具備相當熟練的上腹部腔鏡手術(shù)經(jīng)驗，對脾門(mén)部血管解剖非常熟悉。同時(shí)也并非所有脾腫瘤均適合，一般選擇位于脾邊緣或者上、下極，外突性生長(cháng)最好。如果腫瘤巨大，導致空間有限，而且腫瘤取出困難，則不強求行腔鏡手術(shù)。另外，如果脾臟周?chē)尺B重，界限不清，術(shù)中容易出現大出血，可先行分離出脾動(dòng)脈，進(jìn)行臨時(shí)阻斷。如果分離困難，應及時(shí)中轉開(kāi)腹，不能單純追求切口的“微創(chuàng )”而導致大量出血等內在大創(chuàng )傷。
Most patients with splenic hemangioma present no obvious symptoms, only one of the patients in the study presented with upper left abdominal pain. With advances in imaging techniques such as ultrasound, CT and MRI, more and more patients with splenic hemangioma are detected. Hemangioma, due to secondary infarction, infection, fibrosis, calcification and its serious complications such as spontaneous rupture and bleeding, is proposed to be resected by splenectomy or partial splenectomy once detected. With the deepening of knowledge on the immunological function of the spleen and overwhelming infection after a complete resection of the spleen, more and more emphasis is placed on the performance of partial splenectomy. Some scholars have presented the indications of partial splenectomy [5]: ① under the age of 60; ②II, III grade traumatic rupture; ③ benign diseases of the spleen (splenic hemangioma, aneurysm, arteriovenous malformation). Partial splenectomy includes regular splenectomy (in which the vessels are severed on the basis of the vascular distribution before the resection of the corresponding splenic segment, lobe or half the spleen) and irregular splenectomy (in which an irregular splenic resection is performed according to the blood supply and vitality of the spleen tissues). Segmental splenectomy is considered to be performed especially on the young people when the single benign tumor is small in size and located in the upper or lower pole or limited within a certain segment or at the edge of the spleen. Therefore, the splenic function can be preserved as much as possible and the occurrence of overwhelming infection after splenectomy can be lowered[6]. The splenic function should be better preserved for the mean age of the patients in the study is 39.4. No complications (overwhelming infection, thrombotic events and spleen necrosis) occurred during the follow up, which demonstrated the function of the spleen was well preserved.
With the advances in minimally invasive techniques such as laparoscope, laparoscopic partial splenectomy has gradually been applied in the clinical especially for the treatment of hereditary spherocytosis[7]. The resection of other cystic or solid tumors was also occasionally reported in the literature[8]. After the review of the literature, our hospital has gradually performed the surgical procedure for appropriate patients.Laparoscopy,with the significant advantages of less trauma, clear exposure and quick postoperative recovery in contrast to the open partial splenectomy, sets high requirements for surgeons who should have quite skilled experience in upper abdominal laparoscopic surgery and be quite familiar with the anatomy of the splenic hilar vessels. Laparoscopy, not suitable for all the spleen tumors though, is especially performed on the tumors in exogenous growth at the edge of the spleen or in the upper or lower pole of the spleen. A laparoscopic surgery is not necessary to be performed if the tumor is huge resulting in limited space and hard to be exteriorized. In addition, Intraoperative massive haemorrhage is prone to occur if there is much adhesion between the spleen and the neighboring organs with unclear boundary. So the splenic artery should be severed and temporarily occluded. If the dissection is difficult，the laparotomy should be performed without delay, the pursuit of the minimally invasive incision would result in inner large trauma such as massive haemorrhage, which should not be encouraged.
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