Laparoscopic Splenectomy
David I. Watson
For indications, contraindications and preoperative investigations, see “Open Splenectomy.”
STEP 1 Patient positioning and theatre set-up (A)
The patient is positioned in the lateral position (left side up) and with the operating table bent at the level of the patient’s waist to flatten the lateral convexity of the patient’s flank. The surgeon and assistant stand facing the patient, with the video monitor sited opposite.
Port placement (B):
An 11-mm port is placed using an open insertion technique in the left upper quad- rant, halfway between the mid-clavicular line and the anterior axillary line, immediately below the left costal margin. Secondary ports include a 5-mm port in the left mid-axil- lary line immediately below the costal margin, and a 12-mm port in the left anterior axillary line also immediately below the costal margin. An additional 5-mm port can be placed more laterally if necessary (optional). In approximately one-third of cases the splenic flexure of the colon must be mobilized to provide lateral access for port placement.
A
B
STEP 2 Exposure
No retractors are required. In the lateral position gravity enhances exposure of the posterior splenic attachments. A blunt ended 5-mm-diameter grasping instrument is placed through the most medial port is used to manipulate the spleen, lifting it upwards to expose the hilum, or rotating it towards the midline to expose the posterior attach- ments. A search for accessory spleens (see “Open Splenectomy,”“Tricks of the Senior Surgeon”) should be made before commencing dissection of the spleen, as accessory spleens are more easily identified at this stage, and they should be removed as soon as they have been found. Removal later in the procedure can be more difficult.
With the spleen rotated towards the midline, the posterior peritoneal attachments are divided 5–10mm away from the splenic capsule using a diathermy hook or ultrasonic shears. The spleen is progressively mobilized towards the midline, exposing the
“splenic mesentery,” which contains the main splenic vessels inferiorly, the short gastric vessels superiorly, and the tail of the pancreas. For adequate mobilization it is necessary to divide the posterior splenic attachments up to the left side of the oesophageal diaphragmatic hiatus superiorly (see “Open Splenectomy,” STEP 3). A combination of gravity and rotation of the spleen displays an avascular fascial plane behind the splenic mesentery.
It is important to avoid damage to the tail of the pancreas during this dissection.
If bleeding occurs during this step, then dissection is in an incorrect tissue plane.
STEP 3 The vascular attachments are divided next using a 30- or 45-mm endoscopic linear cutting stapler (white cartridge)
This is applied sequentially across the splenic mesentery commencing inferiorly, and
multiple applications of the stapler are required (usually three to five). The stapler is
placed adjacent to the splenic capsule at the hilum, to minimize the risk of damaging the
pancreatic tail. When applying the stapler, the spleen is lifted up by a blunt instrument
passed through the most medial port. With this technique, dissection of individual
splenic vessels is not necessary. Furthermore, attempts to dissect individual vessels may
result in vessel damage and hemorrhage. If, when sequentially applying the stapler,
it becomes apparent that the spleen has not been adequately mobilized superiorly,
additional division of the posterior attachments to the upper spleen is then completed
to enable final division of the short gastric blood vessels, and complete separation of
the spleen from its remaining attachments.
STEP 4 The spleen is next placed in a large specimen retrieval bag
An AutoSuture Endocatch II retrieval bag (U.S. Surgical, Norwalk, CT, USA) is positioned
underneath the spleen, and then opened so that the spleen drops directly into the bag as
the bag is opened. Other specimen bags require additional manipulation to get the
spleen into the retrieval bag and are more difficult to use. The neck of the bag is then
pulled out through the lateral 12-mm port wound.
STEP 5 Morcellation of the spleen
The surgeon’s index finger is placed inside the bag and through the port wound, to break
the spleen into pieces. This is done bimanually with the left hand pushing against the
abdominal wall, and the right index finger pushing the spleen against the abdominal
wall. Blood released from the broken spleen is then aspirated and an empty sponge
holding forceps is used to remove the spleen in pieces. The surgeon must be careful
to avoid spillage of splenic material into the abdominal cavity, which can occur if the
specimen bag is broken. An alternative method for spleen removal is to remove the
spleen intact through a muscle-splitting abdominal incision, usually in the left lower
quadrant.
Tricks of the Senior Surgeon
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