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Laparoscopic splenectomy: anterior approach with LigaSureTM

This video demonstrates the surgical approach to performing a laparoscopic splenectomy through an anterior approach. The video discusses the potential benefits of this approach. The use of Ligasure make the anterior approach easier and allows for vascular control of spleen before full mobilization.

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Laparoscopic splenectomy: anterior approach with LigaSureTM

作者群

J Leroy, J Marescaux

摘要

This video demonstrates the surgical approach to performing a laparoscopic splenectomy through an anterior approach. The video discusses the potential benefits of this approach. The use of Ligasure make the anterior approach easier and allows for vascular control of spleen before full mobilization.

分類

basic techniques

關鍵字

laparoscopic, splenectomy, anterior approach, ligasure

媒體類型

手術影片

期間

05'00''

刊物

2005-06

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jun 2005;5(06).
URL: http://www.websurg.com/doi-vd01en1733.htm

Laparoscopic splenectomy: anterior approach with LigaSureTM

1. Patient and trocar positioning 00'10''

This operative video will show the laparoscopic anterior approach for splenectomy. The patient is placed in supine position with the legs abducted. The surgeon is between the legs and the 2 assistants are situated on the right and left side of the patient. The table is in a right lateral tilt with reverse Trendelenburg. Trocars are placed along a linear curve below the left costal margin. The optical trocar is inserted on the mid-clavicular line below the margin and the 2nd 12mm operative trocar is situated on the anterior axillary line. The 3rd and 4th trocars are 5mm in size below this left costal margin, and are inserted a few centimetres to the left and the right of the midline for retraction and exposure.

2. Gastrosplenic dissection 00'49''

The 1st step is the exposure of the anterior side of the splenic hilum. Once the anterior margin of the spleen is visualized the omentum is retracted to the right making it possible to see the gastrosplenic ligament. The dissection continues with opening of the lesser peritoneal sac. This step is done with ease by the Ligasure device, which dissects the short gastro-epiploic vessels. The Ligasure is an electrothermal bipolar vessel sealing device, which is able to apply a consistent hemostatic coagulation effect. Dissection of tissue such as the mesentery is able to be undertaken with ease as it can seal vessels as large as 7mm without clips or suture ligature. The splenocolic ligament is also divided by Ligasure. Some bleeding here is also coagulated by Ligasure.

3. Dissection of splenic hilum 02'12''

The next step is to dissect the pancreaticosplenic ligament extending from the tail of the pancreas; the hilar vessels are dissected with the Ligasure device without using clips. Alternatively, dissection can be done for this procedure without the use of Ligasure with dissection of each vessel, each being clipped. We find significant time savings with this device however. The splenic artery and vein are generally easy to identify and dissected by Ligasure.

4. Cutting the splenic vessels 02'46''

The advantage of the anterior approach is that the splenic artery can be accessed within the lesser sac enabling vascular control of the spleen in a stable position as the spleen is fixed to its attachments at this point. Also the vascular control is obtained prior to mobilization providing less blood loss and lower conversion rates. In a conventional posterior approach, it is often difficult to mobilize the spleen to the midline. Within the anterior approach, the hilum vessels are dissected without this mobilization. The Ligasure device can also be used in blunt dissection as it is approximately 10mm in size. It can be used quite well as a blunt dissector without creating trauma.

5. Posterior and lateral dissection 03'55''

After dividing the hilum vessels the posterior and lateral attachments are dissected. A stable operative field is critical to time savings and safety of the patient during procedures. This is true again in the splenectomy patient. As you can see, the small bowel or other organs are in the way during this procedure. As well, we feel the anterior approach also enables this technique exposure of field.

6. Extraction of the specimen 04'56''

Once the spleen is completely freed, it will be extracted through a trocar opening using an airtight plastic bag. As well, the abdominal wall should be protected with a plastic-coated drape. As you can see, the bag is in view and the spleen is placed within it. A morcellation of the spleen in the plastic bag aids in maintaining a small extraction incision of the spleen; we find a ring forceps does the job just fine.