LIVE Laparoscopic total splenectomy for cystic lesions of the spleen

This the case of a 32-year-old lady who went to see her medical practitioner for a back pain and a calcification was discovered in the left upper quadrant of the abdomen. A CT-scan was performed and provided the diagnosis of a cyst of the spleen with a lot of calcifications. This cyst does not allow to perform a partial splenectomy, which is sometimes an indication if we have a cyst located at the upper or at the lower pole of the cyst. A laparoscopic live total splenectomy is presented.

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LIVE Laparoscopic total splenectomy for cystic lesions of the spleen

Authors

D Mutter, F Costantino, L Soler, J Marescaux

Abstract

This the case of a 32-year-old lady who went to see her medical practitioner for a back pain and a calcification was discovered in the left upper quadrant of the abdomen. A CT-scan was performed and provided the diagnosis of a cyst of the spleen with a lot of calcifications. This cyst does not allow to perform a partial splenectomy, which is sometimes an indication if we have a cyst located at the upper or at the lower pole of the cyst. A laparoscopic live total splenectomy is presented.

Mots-clés

Laparoscopic total splenectomy, cystic splenic lesions, spleen

Type de vidéo

Vidéo chirurgicale

Durée

26'40''

Publication

2011-05

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, May 2011;11(05).
URL: http://www.websurg.com/doi-vd01en3290.htm

LIVE Laparoscopic total splenectomy for cystic lesions of the spleen

1. Clinical case presentation 00'18''

I will start very briefly, first of all, it is a 32-year-old lady who went to see her medical practitioner for a back pain and a calcification was discovered in the left upper quadrant of the abdomen. A CT-scan was performed and provided the diagnosis of a cyst of the spleen with a lot of calcifications. This cyst does not allow to perform a partial splenectomy, which is sometimes an indication if we have a cyst located at the upper or at the lower pole of the cyst. She has a BMI of 25 so she’s moderately adipose. It’s an ideal case.

2. Patient and trocars position 01'05''

She is in a full lateral position. Here’s the umbilicus, here’s the xiphoid appendix, that is the subcostal margin. We always start the procedure with a first 12mm trocar that is inserted by an open approach at the level of the anterior axillary line, 5cm on the right and the left side. Here’s an upper view. It’s perhaps easier to see how the ports are placed. Here we have the patient’s feet, the head is there up. So this is the anterior axillary line, the mid-axillary line, 5 to 7cm in front, this is the third port, and 5cm behind, we place port number 4. We have only started to very slightly free the left attachment of the colon. So first of all, the objective is to free. Here, you have the sagittal image of the reconstruction on the inferior screen. On this image, you can see why we cannot do a partial splenectomy because the cyst goes far below the medial vascular pedicle of the spleen.

3. Freeing of adhesions 02'32''

I will just free the slight attachment I have here in order to avoid any tear of the capsule of the spleen. I will find my instruments first. I work here with a 30-degree scope, and I use monopolar cautery here, successively used for section and cautery with only 20 Watts. This is no vascularized attachment on the diaphragm. I check if I can free them now. If I cannot, I will do it later on. It’s feasible so again cautery. As soon as these attachments are freed, you can see that the spleen begins to fall on the right side of the patient so we’re going to use a posterior approach.

4. Inferior pole dissection 03'35''

I will start by freeing the inferior pole and the inferior reflection of the spleen, and then I will move to the posterior border. I like very much to use a very old-fashioned device, which is this hook. If we have such type of tension on the peritoneum, it’s very nice to cut and dissect to know exactly what we do. Here we see that the size of the cyst that is mainly on the upper edge of the spleen is certainly at the origin of the lengthening of the vessels. Here you can see the splenic vessels going into the hilum and you see that the spleen is lower than it should be. We have identified the pancreas very clearly here. It is a question of color, you see here the tail of the pancreas and here we have the kidney with Gerota’s fascia. So the beginning of the dissection will only open the peritoneum in order to avoid any possible injury of any vessel and the dissection will move backwards at the posterior edge of the spleen. We are used to keeping 1cm. Again, one of the objectives is to avoid any tear of the capsule of the spleen. We know that it is not the same problem as the operation of a PTI because here the issue is to remove the cyst but nevertheless we like to avoid bleeding because avoiding bleeding is really the best way to have a clear identification of the anatomy, and especially to identify very clearly the vessels. Very interestingly, here we have the tail of the pancreas. We know that the main risk of getting into the hilum of the spleen is to have an injury of the tail of the pancreas and a pancreatic resection. And here, we clearly see the splenic artery.

5. Pancreatic dissection 05'59''

The tail of the pancreas, thanks to the color and the very nice dissection that is made possible thanks to laparoscopy, we see that we can do a really millimetric approach of this attachment and we will perform a dissection between the vessels and the tail of the pancreas. I go ahead to free a bit the upper border of the pancreas. I will see if I can see the trunk to control it and if I cannot control the trunk, I will go separately in the 2 branches. As usual, it is not the objective to go first in the hilum but as it is in my field and very easy to access, I can go ahead with the division. I stop the division here. And the risk here is to have a direct branch between the artery and the pancreas and to have some bleeding here. Again it’s interesting to see that it is probably the splenic vein. And you see that the splenic vein is in contact to the tail of the pancreas here and there’s a distance of less than 1cm. So I will leave this place for the moment. We are in the pedicle, an inferior branch, and I will go again posteriorly to free and to lengthen this pedicle. I will take a second peanut and I will lengthen a little bit the pedicle from the posterior edge and free the posterior attachment. I will use the possibility of the 30-degree camera. I go posteriorly. I can go quicker.

6. Posterior dissection 07'53''

The posterior freeing of the lienorenal ligament allows a good progressive mobilization of the spleen. This remains attached to the diaphragm so its upper fixation is still there. It is the same type of posterior approach that we use to get access to the adrenal gland. So here again, I will go up again below the spleen. It’s very interesting this effect of identification of the vein. Mobilization of the spleen allows a lengthening of the vein and in fact, we know that we need 1 or 2cm of vein free to be able to control its safety and to have a longer vein and to be able to go behind the vein. The next landmark that will be identified thanks to this approach will certainly be the lesser sac but from this position, you see that I cannot have an easy access. So I will go again in the conventional dissection plane. Here we can identify the inferior horn of the adrenal gland very clearly. This is the adrenal gland. You see that the color of the adrenal gland is very similar to that of the pancreas, that’s why sometimes it can occur that surgeons have a confusion between the adrenal gland and the tail of the pancreas.

7. Dissection of the upper edge of the spleen 09'44''

And now I go very high. It’s very important to keep this little millimetric safety margin to avoid such bleeding. So here I’m on the diaphragm, thanks to the 30-degree scope, I can go behind the upper edge of the spleen, you can see the contraction of the left crus and the diaphragm, here’s the adrenal vein so I’m in the good plane. And if I go ahead opening here posteriorly, I should have again the same access to the artery but from posteriorly. Here you can again identify with this very low traction. See we have dissected here the tail of the pancreas, here the splenic vein. So it is possible to go ahead to perform this very gentle dissection. Here very slowly, there’s some little vein between the pancreas and the splenic vein, a little venous drain between the tail of the pancreas and the splenic vein, and if there’s a problem, I’ll use bipolar cautery for this. We have seen the lower artery. Here, we certainly have the upper artery with its reflection and you see it’s coming from here going back to the spleen because the spleen falls down.

8. Lesser sac access 11'33''

Now we have access to the lesser sac here so we will certainly cross the route of the short gastric vessels somewhere here. I like to use the 10mm Ligasure® Atlas device in this position, one application. The artery is controlled and the greater curvature of the stomach and the upper pole of the spleen. Here’s the second short gastric here from behind, see I control the stomach. The upper pole of the spleen may be freed. You will divide all the anterior attachment though this way or? Well, I have finished the upper pole of the spleen and I will try to put at least one clip on each artery to diminish the size and the pressure into the vein. Again, it can be the main artery because we are at a longer distance from the spleen. So how do you suggest to control these arteries? We can use GIA, suture, clip. But you see that with this posterior approach, it’s really possible to have a complete and safe dissection of the artery under direct vision. And here I will go ahead to separate the artery from the vein -- usually just coming close to the spleen, they are always together. That’s the lymph nodes. I’m here in the hilum. Probably it is the same artery making the hallway with an S-shaped way. Here’s a little pancreatic branch, you see. The artery is going there. And now a longer dissection allows probably to answer your question and to see what was the problem was. But if it makes it this way, it has certainly an accessory branch going somewhere.

9. Division of splenic artery 14'54''

I can put clips at this level. What I do to have a nice presentation, I usually use a Vicryl loop to perform a good presentation, traction. I put clips. How many clips do you think is safe for the splenic artery? 1, 2, 3, OK. I put one on this side, which is the remaining one. That’s the artery. So here we can see that we have 2 effects. First of all, we have quickly the change in color of the spleen. We’ll see if I have the whole branch. But also you can see that the upper vein is no more so big. I will now dissect and control the artery we’ve seen at the beginning of the procedure. Now I have less tension on this artery. The grasper was not well placed from the assistant and I can go again in the preparation of this inferior artery that was seen very early. This is a little one. Again, the section of all this little artery has also the advantage to take away the fixation of the spleen. It means that the spleen will only be attached by the main vein as you see here. And this vein decreases its size because there is no more vascularization. So the problem at this level will be to go all around the splenic vein and to perform a safe but single application of its vascular control. So I have an inferior pole artery very classically and an early division of the artery upwards so again I will free this node. I hope that I will not have any bleeding and that’s the risk here. Now we check again. And the spleen is now changing its color. Interestingly here, the spleen is completely located in the right side of the patient’s body. What is remaining is the attachment, the splenic vein here that will have to be dissected now and the problem will be to go behind. See that there is a little bit too much tension. See that the size of the vein is now much limited in size.

10. Division of splenic vein 19'17''

I prefer to use a GIA but regarding the position of this, I will try to do something. I will change the position of the camera in the 10mm port located here on the right. So I should have a very perpendicular approach to the splenic vein like that so whatever the size of the splenic vein. Here’s the upper pole of the spleen with perhaps some short attachments here. I’m sure but I will show you if I can go from just over here to show you that the stapler is really against the liver. The vein is still controlled. So here you see the stomach. The spleen is in the abdomen, it is freed. I will change again the optic. Put the optic in the original 12mm port. It’s free in the abdomen completely, OK. See the whole pedicle of the spleen here. This pedicle of the spleen is a little bit bleeding. That’s the only problem I have but it’s really the spleen here at the edge. Now I start the most challenging part of the procedure, which will be how to remove the spleen from the abdomen. We’ll check here the quality of the vascular control to be sure that there’s nothing as long as we know that it is the spleen, that it is moving. I’ll try to have an orientation that makes you compare with what we had before. But it’s dirty again. We have the pancreas here, the splenic artery here, one branch, the second branch, the splenic vein, the splenic artery, 1, 2, 3 clips, on the opposite side, 1, 2, 3. Stapler on the splenic vein. Greater curvature of the stomach’s completely free. Here preservation of the diaphragmatic artery. Splenic artery here. No bleeding here. In fact, I have this big spleen. What I’ll do now is to extract the spleen by morcellation.

11. Specimen removal 22'38''

The spleen is there. I’ll need to enlarge a little bit the incision to take the spleen out. What I’ll do, I’ll take a big bag, it’s a 15mm bag to catch the spleen first so I’ll try to avoid too much manipulation and for this, I’ll take away the 12mm port. I know that I’ll have to enlarge the incision over some 2 or 3cm. So I take out the trocar, and from this enlarged incision, which is the largest one with the open approach, I’ll try to put directly and check the orientation of my incision, it’s here. I put the big bag in. We’ve done 2 peritoneal incisions. The big bag is here; now you can look at the spleen. But as I told you, I think the size of the spleen is at the limit of the capacity of the bag because the bag is 15cm in diameter and the spleen is about 12 in its larger diameter. So I can have it in the bag, which is the first very interesting part. Take the metallic part out and now I have the bag here at the level of the skin. I think I cut the system, and now I’ll use this bag as a protective sheath. I’ll enlarge the incision. I will not open the skin. I probably reach a 3cm incision. I put the operative light just to see for one second and then I switch it off again because I don’t see if I’m on the muscle or not here. Because without operative light, I’m in the dark. So in one hand, I’ll have the suction device. So I go into here you see the spleen. So I have opened the cyst to have a better access because it’s a rigid and calcified cyst and it doesn’t want to come out even by morcellation because if I have injury of the bag, then I have a lot of things into the abdomen. See it’s completely calcified, very difficult to take out. So after the specimen extraction, the large incision is closed and the trocar inserted again in order to check the whole operative area. OK, everything is clean. The area of control is nice, the clips are well placed, stapling of the vein is here, there’s no oozing at the level of the vein, the pancreas is well dissected very close to this area so we can remove the trocars under direct control in order to be sure that there is no bleeding from the port and the closure of the biggest incision can be controlled here again. There is no leak, no problem, control of the colon. The operation is now complete.