**5. Discussion**

As the splenic function mentioned above is better understood, spleen surgeries have developed from the early stage of random splenectomy to the second stage of non-selective spleen preserving, and to today's stage of selective spleen preserving. The concept of spleen preserving has become gradually popular, and various procedures to preserve the spleen have been widely applied which has achieved aoptimal result. Current spleen- preserving methods are mainly as follows:


Partial splenectomies can be successfully performed for complication like splenic cyst, splenichemangioma, splenic mass, blunt traumas and splenic cysts. Proper hemostasis and uninterrupted view of the surgical site has always been a surgical concern. With the advent of laparoscopic techniques many flaws have been obviated which makes partial splenectomies more justifiable. The laparoscopic spleen surgeries, which once started with classical four trocarsand electrocautery have evolved to have come long way. The assistance of better HD cameras with robotic zoom in and zoom out function have given the surgeons the most uninterrupted clear view of the surgical site which has bought the ease in locating a structure and active hemostasis. The cameras once used by the fellow operator can now be operated with voice commands and joysticks of the surgeon. The 180degree rotations of the cameras have made the view extremely vivid circumventing accidents. The electro cautery had drawbacks like the eschar formation that have been eliminated with the development of harmonic and plasma scalpels. The harmonic and plasma scalpel and uses of laser prevents escharformation, which prevents postoperative disruption and bleeding. These scalpels works with better precision near the vital structures as the pedicle of spleen. There is minimal thermal tissue damage, which is pivotal for postoperative recovery. The uses of ligatures have become least and the charring and dissication have been minimized. The postoperative healing, pain have also been greatly minimized with lesser hospital stay. A surgeon should choose a specific way depending on experience, overall cost and the simplicity in manipulating instruments. The robotic instruments, the use of harmonic and plasma scalpels in other instance needs a constant technical assistance. Robotic instruments are cumbersome and needs constant upgrading and high cost of compatible instruments prevents worldwide adoption. There is also an operative time delay when using robotics and it needs special training to surgeons.

Laser in the other hand has the advantage of checking blood loss, sealing the most small blood vessels, ability to work in relatively dry field which facilitates visibility, minimum tissue trauma less pain, edema (due to sealing of nerve endings and lymphatics) decreases chance of malignant cells to spread, scarring due to precision and most importantly decreases stenosis which is appropriate for splenic hemangiomas. The use of laser needs a surgical technologist (ST) at all times as its failure during the surgery can cause panic. Strict safety precautions must be enforced, eye protection for patients and all personnel in the room is mandatory for most lasers and flammable prep solutions and other flammable liquids should not be used in the area where the laser is used. All dry materials in or near the operative field must be dampened with saline or water that makes the process more tedious.

The argon beam coagulator has its advantages of its own in giving a competent hemostasis with its "blast effect" which blows away the debris and coagulated blood for excellent hemostasis. It has very good results for splenic abscess as it has a large oozing surface. The major concern in this technique is the potential of gas embolism during the laparoscopic surgery. So the ultrasonography and ECG is constantly needed to check if the embolism has reached the heart and lungs to prevent further damages.

The minimal invasive surgery has become more minimal with SILS. The cameras,suction and cutting shears all fit through one trocar. The single port for the trocar has laparosonic cutting shears (LCS) and the cameras also have all round vision, which makes this method promising. It has single small incision, therefore less invasive and traumatic. Like every technique has its advantage and disadvantages. SILS is not very efficient if the tumor size is large. It is a good option only for the spleens with normal size or only slightly enlarged. Because of the single small incision the macerated spleen is liable to spillage. In case of sudden bleeding it is difficult to control the hemostasis and still needs ergonomic improvement. The fulcrum effect should be minimized to make this technique better so robotic zoom in and zoom out cameras can be a good replacement. The hybrid technique as HALS has eliminated many shortcomings from the laparoscopic surgery. Since, one hand is inside the abdominal cavity it gives perfect retraction and uninterrupted view. The margin of tumor can be felt so dissection margin can be precise without hampering the normal spleen parenchyma. The bleeding site can be actively clamped with just a move of a finger. The splenic parenchyma is frail and the use of hands directly to retract can certainly circumvent bleeding and improper traction. There are many instances in spleen preserving surgeries when the macerated spleen within the bag gets spilled in the abdominal cavity so its recovery is quicker as the spleen gets implanted very soon. This technique can be very efficient in blunt trauma cases when laparotomy is urgently required. The camera in the other hand can work in conjunction with the hand to explore the abdominal cavity. This technique is irrespective of the size of spleen because even the bigger spleen can be handled with care and taken out without spillage and optimum safety. The pitfalls of HALS are the air leakage from the lap pads and the hands getting tired in 20% of the surgeons.
