Predicting operative complexity in laparoscopic splenectomy: a validated preoperative scoring system.

Abstract

Background: Laparoscopic splenectomy poses significant technical challenges due to variable splenic anatomy and patient-specific factors. A robust preoperative difficulty scoring system is essential to integrate critical predictors into a unified framework. This tool enables objective risk stratification, optimizes resource allocation, and enhances procedural safety through tailored surgical strategies. This study aimed to develop and validate a novel preoperative scoring system tailored to these challenges.

Methods: In this dual-center retrospective study, 181 patients undergoing laparoscopic splenectomy were divided into training (n = 118), validation 1 (n = 40), and validation 2 (n = 23) cohorts. Preoperative variables, including demographics, laboratory factors (INR, platelet count, et al.), and imaging indicators (CT-derived thickness, length, width, et al.), were analyzed. Multivariable regression identified predictors of surgical complexity (blood loss, operative time, conversion to open surgery). A difficulty score integrating regression coefficients and clinical feasibility was developed and validated using ROC curves, calibration plots, and decision curve analysis.

Results: Age, INR, splenic thickness, and cirrhosis-related hypersplenism emerged as independent predictors of surgical complexity (p < 0.05). The scoring system (range: 0-23) stratified patients into low- (0-7), intermediate- (8-15), and high-risk (16-23) tiers, demonstrating strong discrimination [training cohort AUC: 0.82 (95% CI 0.74-0.90); validation 1 cohort AUC: 0.80 (95% CI 0.66-0.94); validation 2 cohort AUC: 0.78 (95% CI 0.58-0.98)]. High-risk patients exhibited significantly greater blood loss, prolonged operative time, and higher conversion to open surgery rates. Calibration and decision curve analyses confirmed clinical utility, with net benefit surpassing "treat-all" strategies across risk thresholds.

Conclusions: This scoring system provides a validated tool for preoperative risk stratification in laparoscopic splenectomy, particularly for cirrhosis-predominant cohorts. By incorporating age, INR, splenic thickness, and pathogenesis, it attempts to account for regional epidemiological variations, potentially contributing to more tailored surgical planning in specific clinical contexts.