A splenectomy (removal of the spleen) is performed in cases where the patient is suffering from certain types of leukemia or blood disease. Spleen Conditions
Splenectomy
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Indications
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Experience and Results
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Laparascopic Anatomy
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Technique
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References
Technique
Laparoscopic splenectomy can be performed with regular laparoscopic tools, without absolute need for more sophisticated instruments like ultrasonic dissectors, electrocoagulators and mechanical stapling devices.
Meticulous dissection with perfect exposure of all anatomic structures around the spleen and perfect knowledge of the anatomy of the region are mandatory for successful accomplishment of laparoscopic splenectomy. In our hands, coagulating hook dissection has proven the most reliable strategy in atraumatic exposure of the vascular pedicle.
Positioning of the patient
The patient is put under general anesthesia with endotracheal intubation. A nasogastric sump tube (18 French) is inserted. The patient lies supine, thighs fully abducted and slightly bent . The operation table has a 20° reversed Trendelenburg tilt and a 15° lateral tilt to the right. The surgeon is standing between the patient's legs, the first assistant is standing to the patient's left, the second assistant to his right.
Placement of trocars
Five trocars (Ethicon, Inc., Somerville, USA) are positioned as for Nissen fundoplication : a 10 mm trocar well above the umbilicus, a 5 mm trocar in the right subcostal area, a 5 mm trocar in the left subcostal area, a 10 mm trocar between the first and the third one, and a 10 mm trocar under the xiphoid appendix. They allow the introduction of an optical system , 30° angled (Olympus optical, Tokyo, Japan), a probe in order to retract the liver and the stomach, a grasping forceps, a coagulation hook, and a second grasping forceps. The second assistant retracts the stomach.
Dissection principles
Unlike in open approach, the spleen cannot be grasped by the surgeon’s hand putting the splenic ligament under traction. Manipulating the spleen is hazardous since the splenic parenchyma is very delicate. Rather than risking a tear in the parenchyma because of the sharp laparoscopic tools, the following strategy is elected.
- Dissection of the lower pole ligaments
- Dissection of the gastrosplenic ligament
- Dissection of the upper pole of the spleen
- Dissection of the short gastric vessels and of the gastrosplenic ligament.
- Dissection of the hilar vessels, away from the tail of the pancreas. Skeletonization and ligation of the vessels.
- Severance of the splenopancreatic ligament.
- Extraction of the spleen.
Dissection of the gastrosplenic ligament
The first step of the procedure in the dissection of the splenocolic ligament and the lower part of the posterior leaf of the pancreaticosplenic ligament, which frees the lower pole of the spleen. The dissection of the anterior leaf of the gastrosplenic ligament is started from there, half an inch away from the medial edge of the spleen and is pursued upwards, gradually closing up to the spleen. The splenophrenic ligament is reached and severed, which liberates the upper pole of the spleen.
Section of the gastro splenic ligament
The short gastric vessels are dissected free, clipped and cut close to the spleen.
Dissection of the hilumt
The hilar vessels are isolated from the pancreatic tail and from one another and ligated separately with 2.0 resorbable sutures, using intracorporeal knotting technique. Finally, the middle part of the posterior leaf of the pancreaticosplenic ligament, which is the only remaining attachment of the spleen, is severed.
Extraction of the spleen
The spleen is introduced in a plastic bag. The bag is closed by tightening the pursestring at its top and is partially pulled out of the abdomen through the lower left trocar site. The pursestring is loosened and the spleen morcellated within the bag and removed with the help of a forceps and a powerful suction device. Drains are no longer used.
