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Laparoscopic splenectomy: anterior posterior approach
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摘要
The description of the laparoscopic splenectomy: anterior posterior approach covers all aspects of the surgical procedure used for the management of several splenic disorders (benign and malignant hematological diseases, splenic trauma, splenic cysts and splenic artery aneurysms.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection, ligature, mobilization, division, extraction.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection, ligature, mobilization, division, extraction.
Consequently, this operating technique is well standardized for the management of this condition.
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媒體類型
 刊物
2001-03
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普通的
最愛
 音訊
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數位出版
WeBSurg.com, Mar 2001;1(03).
URL: http://www.websurg.com/doi-ot02en199a.htm
URL: http://www.websurg.com/doi-ot02en199a.htm
Laparoscopic splenectomy: anterior posterior approach
1. Introduction
Surgery is indicated in the treatment of several splenic disorders. These include benign and malignant hematological diseases, splenic trauma, splenic cysts and splenic artery aneurysms.Laparoscopic splenectomy (LS) has been shown to be a safe and advantageous approach for splenic resection. As with laparoscopic procedures in general, avoidance of a large incision is the primary benefit to the patient. However, the spleen is the most vascularized organ in the body, and its parenchyma is fragile. In addition, it is attached by several ligaments to other intra-abdominal organs or anatomical structures, and in many cases, hematological disease is associated with a low platelet count. As a result, LS is a demanding technique and requires considerable skill.
2. Anatomy
• Spleen
The spleen plays both a major role in the functioning of the immune system and as the regulator of red blood cell formation. It is interesting to note that these 2 main functions of the spleen were not discovered until the beginning of the twentieth century.The spleen is the most vascularized organ in the body, its parenchyma is fragile, and splenectomy is often performed for bleeding disorders, all of which increase the risk of uncontrollable hemorrhage during laparoscopy. Moreover, it is attached by several ligaments to other intra-abdominal organs or anatomical structures. Perfect understanding of the anatomy of the spleen and surrounding structures is therefore mandatory for a successful procedure.
• Topography
• Location
The spleen is situated in the left upper abdominal quadrant.The axis of the spleen corresponds to the axis of the 10th left rib. Depending on the patient's morphological type, this axis may vary. In obese and/or patients with short limbs, the position of the spleen is high, deep and on a horizontal axis in the abdominal cavity.
• Diaphragmatic surface
The diaphragmatic or posterior external surface is convex and entirely covered with peritoneum.• Renal surface
The renal or inferior internal surface is concave, faces downwards and inwards and is covered with peritoneum.The superior pole or postero-superior surface is curved and lies in the region of the 10th intercostal space.
• Gastric surface
The gastric or anterior internal surface is concave, faces medially and contains the splenic hilum.• Colonic surface
The colonic or anterior inferior surface (the base of the spleen's irregular pyramid shape) is slightly concave, and faces caudally, medially and slightly anteriorly.• Ligaments
• Pancreaticosplenic
The spleen remains fixed in the left hypochondrium to neighboring anatomical structures by ligaments.1. The pancreaticosplenic ligament attaches the posterior margin of the hilum to the tail of the pancreas and to the splenic vessels on the lower renal surface of the spleen. This peritoneal fold is referred to as the mesentery of the spleen. It ranges from 3 to 8 cm in length. The longer the ligament is, the easier the splenectomy will be to perform.
• Gastrosplenic
2. The gastrosplenic ligament attaches the anterior margin of the hilum to the greater curvature of the stomach, on the gastric surface of the spleen. It contains the short gastric vessels and the gastroepiploic artery, which are branches of the splenic artery.• Phrenicosplenic
3. The phrenicosplenic ligament extends from the diaphragm and the anterior aspect of the left kidney to the superior pole of the hilum on the upper diaphragmatic surface of the spleen.• Splenocolic
4. The splenocolic ligament attaches the base of the hilum to the left transverse mesocolon and to the left splenic flexure, on the colonic surface of the spleen. • Phrenicocolic
5. The phrenicocolic ligament is a triangular fold of peritoneum attaching the left flexure of the colon and the diaphragm to the lower extremity of the spleen.3. Indications
Indications- idiopathic thrombocytopenic purpura (ITP);
- autoimmune hemolytic anemia;
- microspherocytosis;
- benign tumors and cysts;
- AIDS-related thrombocytopenia.
Relative contraindications
- hematological malignancies;
- moderate splenomegaly.
Absolute contraindications
- massive splenomegaly;
- portal hypertension.
Enlarged spleen
An enlarged spleen does not represent an absolute contraindication.
Depending on the skill and experience of the surgeon and the operating team, laparoscopy may be utilized for massive splenomegaly.
Marked splenomegaly
Laparoscopy on enlarged spleens is controversial.
Depending on the skill and experience of the surgeon and the operating team, LS may be utilized for massive splenomegaly. Certain teams (eg, EM Targarona's) have successfully performed laparoscopic splenectomy on spleens weighing over 3000g.
4. Preop period
Hematological conditions are frequently associated with severe disturbances of hematological parameters. Patient preparation includes pneumococci vaccination, normalization of hematocrit and a trial to increase platelet counts, especially in ITP patients. Steroids or hyperimmune globulin administration can be started preoperatively. However, LS can be performed safely with platelet counts of over 50 000. A prudent measure is to include these patients in a self-transfusion program, to avoid heterologous transfusion. Pooled platelets can be administered more freely in AIDS or lymphoma patients.5. Operating room set-up
• Patient
The patient is placed in right lateral decubitus, flexed at the waist. A cushion is placed under the contra-lateral lumbar fossa which opens the operative field, thereby facilitating trocar placement.
• Team
The surgeon faces the patient. The assistant is behind the patient. They each have their own video screen.• Equipment
1. Operating table2. Anesthetic equipment
3. Laparoscopic unit
4. Video monitors
5. Electrocautery
6. Instrument table
6. Trocar placement
• Trocar positions
The trocars are placed along a linear curve situated below the left costal margin. Creating the pneumoperitoneum is a critical step which requires special care, especially in the case of an enlarged spleen. Generally, insertion of the Veress needle is done at a point situated mid-way between the costal margin and the umbilicus.
• A
The optical trocar is inserted on the anterior axillary line below the left costal margin.• B
The second trocar is inserted on the mid-axillary line below the left costal margin.It is an operating trocar through which a scissors, hook, stapler and/or clip applier may be introduced.
• C
The third trocar is inserted on the mid-clavicular line, a few centimeters below the left costal margin. It is an operating trocar through which the atraumatic graspers may be introduced.
• D
The fourth trocar is inserted on the mid-scapular line below the 12th left rib.It is usually utilized for a retractor, but may also be an operating trocar.
7. Instrumentation
• Optical instruments
Most authors use 0° or 30° scopes with a 70° visual field. Certain authors use scopes with a 45° visual field.
• Operating instruments
- atraumatic graspers;- ultrasonic dissectors;
- scissors with or without electrocautery;
- clip applier;
- linear stapler.
• Retractors
- flexible retractor;- fan retractor;
- peanut swab.
• Others
Specimen retrieval bags are recommended.Some of these bags are often too small.
However, those which can contain large spleens require a 15 mm trocar.
8. Exploration
• Abdominal cavity exploration
The videoscopic equipment allows for a full exploration of the abdominal cavity. The mobility of the spleen and possible adhesions surrounding the spleen should be checked for during this step.
• Associated pathologies
The absence of an associated or generalized pathology must be verified, as well as the absence of a secondary spleen, which might be visible before dissection. 9. Exposure
• Freeing of adhesions
The spleen is often hidden by omental adhesions or by the stomach and hanging splenic flexure of the colon. The omental adhesions must be freed in order to expose the spleen.
• Freeing from left splenic flexure
Once the anterior margin of the spleen is visualized, a grasper is introduced through the posterior axillary trocar and retracts the spleen to the left and forward, making it possible to see the gastrosplenic ligament.10. Dissection
• Principles
The first step is the exposure of the anterior side of the splenic hilum.The dissection continues with the opening of the lesser peritoneal sac. This step is done with relative ease by using ultrasonic dissectors which section the short gastroepiploic vessels and then the gastrosplenic vessels after cauterization.
• Gastroepiploic vessels
Dividing the gastroepiploic vessels in an ascending direction allows opening of the lesser peritoneal sac. • Gastrosplenic vessels
• Inferior
Ascending division of the inferior gastrosplenic vessels further opens the lesser peritoneal sac and allows the retraction of the stomach towards the right, exposing the anterior surface of the tail of the pancreas. This region is explored to check for possible accessory spleens, which must be immediately removed for analysis.• Superior
Division of the gastrosplenic vessels is continued cephalad by retracting the stomach towards the patient’s right while the spleen is retracted anteriorly and to the patient’s left, pulling tight the short superior gastrosplenic vessels. These vessels are first skeletonized up to the superior surface of the spleen outside the left crus of the gastroesophageal hiatus, before being divided.
11. Ligature
• Identifying the artery
The splenic artery, situated above the superior margin of the pancreas, is generally easy to identify.• Freeing of the artery
The posterior peritoneum is opened in order to expose the splenic vein and artery. Only the artery is dissected.• Ligature of the artery
The splenic artery is then clipped without being divided. This makes it possible to decrease the size of the spleen, thereby decreasing the risk of hemorrhage during dissection of the spleen. Certain authors recommend placing a ligature especially in the case of an artery of large diameter.12. Mobilization
• Mobilization
The spleen should be mobilized on its pedicle.A right lateral tilt of the operating table facilitates access to the posterior surface of the spleen. This tilting effect may be aided by using a retractor to push the spleen forwards and to the right.
Mobilization is achieved by dividing the splenorenal attachments.
• Splenorenal attachments
The splenorenal ligament is dissected cephalad towards the lateral margin of the left crus. The division of this avascular plane causes the spleen to be displaced medially and the tail of the pancreas to be displaced anteriorly. • Splenic hilum
At this point, the hilar vessels, extending from the tail of the pancreas, are the only anatomical structures keeping the spleen in place. 13. Division
• Division
After anterior and posterior dissection, the freed hilum is divided from its base upwards using an endostapler which should be positioned beyond the tail of the pancreas.• Landmarks
The endostapler should remain in contact with the spleen in order to avoid injuring the tail of the pancreas.• Limits
Division is performed up to the lateral margin of the left crus. In general, 2 to 3 stapler refills are necessary.This operative step may prove to be difficult when the spleen is considerably enlarged, due to the size of the vessels and the difficulty in mobilizing the spleen.
14. Extraction
• Extraction site
This operative step is very important as it is necessary to avoid rupturing the spleen, which could result in contamination of the abdominal cavity. The bag must be sturdy enough not to tear during its extraction, and large enough to contain the entire organ.Extraction is performed in a plastic bag, either through a trocar opening or through another well-adapted incision.
As the objective is to avoid rupturing the bag and spreading its contents in the abdominal cavity, do not hesitate to enlarge the incision in order to allow for uncomplicated removal of the operative specimen.
If the extraction is to be performed through a standard sized trocar incision, the spleen must be morcellated. This may only be done if the pathologist agrees to analyze a fragmented operative specimen.
If a supplementary incision is required, it is performed in the left subcostal region, in the suprapubic region (Pfannenstiel incision) or in another part of the abdominal wall.
• Introduction of bag
We recommend using a specimen retrieval bag. It should be introduced into a 15 mm trocar. The trocar which is the furthest from the operative zone should be chosen. It may also be inserted directly into the trocar opening after first removing the trocar.• Removal of spleen
Ideally, the spleen should be retrieved intact. In agreement with the pathologist, intracorporeal morcellation of the spleen in the extraction bag may be carried out to limit the size of the incision. This option is suitable in certain hematological diseases (ITP, AIDS-ITP or microspherocytosis) and for certain tumors, as it is usually possible to obtain fragments of spleen that are large enough for complete histological analysis. • Variation
Certain malignant conditions or tumors require that the spleen be removed intact. While it is possible to remove very large spleens intact, it may be very difficult to introduce them into a bag.
15. End/procedure
After peritoneal washing, a drain is left in place if needed.The secondary trocar and supplementary incision sites are closed. The peritoneal cavity is then re-inspected with the laparoscope via the camera port.
16. Conclusion
Laparoscopic splenectomy is now a well documented procedure that is fast becoming a gold standard. The anterior posterior approach has been proven to be a safe technique, even for very large spleens of over 3000g.17. Reference