Evolution from Open to Minimally Invasive Splenectomy Over 16 Years: The Bridging Role of Hand-Assisted Laparoscopy in a Single Center

The transition from open splenectomy (OS) to minimally invasive splenectomy is often described in the surgical literature but rarely documented longitudinally within a single institution. Hand-assisted laparoscopic splenectomy (HALS) has been proposed as a bridging technique between OS and total laparoscopic splenectomy (Lap-S), but empirical single-center accounts of this transition are limited. We retrospectively documented 139 consecutive total splenectomies (97 OS, 22 HALS, 20 Lap-S) performed at a tertiary military referral center between 2000 and 2016. Because the three approaches were introduced sequentially, we present between-approach outcomes descriptively rather than as controlled comparisons and complement them with (i) an overlap-era analysis restricted to 2003–2007, when OS and HALS were performed contemporaneously; (ii) an era-adjusted robustness check of the multivariable length-of-stay (LOS) model; and (iii) a within-technique analysis of the HALS learning curve. Median postoperative LOS was 7 days for OS, 3.5 days for HALS, and 2 days for Lap-S, but this pooled difference reflected a combined technique-plus-era effect: in the overlap era (2003–2007), OS and HALS did not differ significantly in LOS (7.0 vs. 5.5 days; p = 0.488) despite comparable spleen size ( p = 0.153) and demographics. Adjustment for era in the multivariable LOS model attenuated the approach effects to non-significance (HALS p = 0.997; Lap-S p = 0.707), with era emerging as the dominant predictor. The HALS learning curve, which is era-independent, showed a reduction in conversion from 63.6% in the first 11 cases to 9.1% in the subsequent 11 ( p = 0.024), with comparable spleen size across phases ( p = 0.273). All six in-hospital deaths occurred in trauma patients; no elective mortality was observed. Minimally invasive approaches were rarely attempted for spleens ≥ 18 cm (1/28). In this 16-year single-institution account, the pooled LOS difference between approaches cannot be causally attributed to technique because the approaches were largely sequential; the era-adjusted model shows era as the dominant factor. The internally consistent findings are the documented learning curve of HALS and its role as a bridging technique during the institutional transition to minimally invasive splenectomy. These observations may inform programs undertaking a similar adoption pathway.