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Despite the publication in 2009 of a paper on 'terms and definitions of immune thrombocytopenia' (ITP), some unresolved issues remain and are reflected by the disagreement in the treatment suggested for primary ITP in adults. Considering that these disagreements could be ascribed to non-shared goals, we generated a 'consensus' on some terms, definitions, and assertions useful for classifying the different lines of treatment for primary ITP in adults according to their indications and goals. Agreement on the appropriateness of the single assertions was obtained by consensus for the following indicators: 1 . classification of four 'lines of therapy'; 2 . acceptance of the expression 'sequences of disease' for the indications of the respective four lines of treatment; 3 I . practicability of splenectomy; 3 Ib . acceptance, with only some exceptions, of a 'timing for elective splenectomy of 12 months'; and 4 a-d . 'goals of the four lines of therapy.' On the basis of the consensus, a classification of four lines of treatment for primary ITP in adults was produced. In our opinion, this classification, whose validity is not influenced by the recently published new guidelines of the American Society of Hematology (ASH) and reviews, could reduce the disagreement that still exists regarding the treatment of the disease.

Hypothesis: Hand-assisted laparoscopic surgery (HALS) is a safe therapeutic approach to remove megaspleens of any size. Conventional laparoscopic splenectomy for splenomegaly is difficult because of limited exposure and complex vascular control, with increased risk of intraoperative bleeding and conversion to open surgery. HALS can overcome some of these limitations, reducing the risk of conversion to open surgery and resulting in a postoperative course similar to that of conventional laparoscopy., Design: Single-institution single-surgeon retrospective review., Setting: University hospital., Patients: An analysis was performed of all patients with splenomegaly (splenic weight, >700 g) seen during a 10-year period., Main Outcome Measures: Preoperative data, indications for splenectomy, splenic weight, operative variables, clinical outcome, and rates of conversion to open surgery, complications, and operative mortality were compared between patients undergoing HALS vs conventional laparoscopy., Results: Splenomegaly was present in 85 patients, of whom 43 underwent HALS splenectomy and 42 underwent conventional laparoscopic splenectomy. The HALS group had larger spleens. Rates of conversion to open surgery and operative mortality were similar in the HALS group vs the conventional laparoscopy group (2.3% [1 of 43] vs 2.4% [1 of 42] and 2.3% [1 of 43] vs 0.0% [0 of 42], respectively), with no difference in hospital length of stay in the absence of morbidity. Portal system thrombosis was the most serious complication., Conclusions: HALS can minimize surgical trauma in patients with massive splenomegaly who otherwise would be candidates only for open surgery and results in a clinical outcome similar to that of conventional laparoscopy. With the availability of HALS, any patient with splenomegaly can be offered a minimally invasive surgical option. Portal system thrombosis is common, regardless of the surgical technique.