Laparoscopic splenectomy: anterior posterior approach

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Laparoscopic splenectomy: anterior posterior approach

Authors

Mots-clés

spleen,operation,resection,anterior posterior

Type de vidéo

Vidéo chirurgicale

Durée

08'00''

Publication

2003-03

Popularité

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E-publication

WeBSurg.com, Mar 2003;3(03).
URL: http://www.websurg.com/doi-vd01en1416e.htm

Laparoscopic splenectomy: anterior posterior approach

1. Patient position and trocar placement 00'15''

The patient is placed in a right lateral decubitus with a table break at the iliac crest and a moderate anti-Trendelenburg position. The pneumoperitoneum is induced with a Veress needle inserted in the left upper quadrant. A 12mm trocar is inserted just below the costal margin at the mid-clavicular line. A 10mm trocar is placed at the anterior axillary line, a 5mm trocar below the xiphoid. In some cases, another 5mm trocar is added laterally for spleen retraction. However, it should be added after the mobilization of the splenic flexure.

2. Exposure and freeing of adhesions 00'53''

In most cases, the 1st step is the section of the peritoneal attachments of the splenic flexure performed with diathermy or ultrasonic power. The lower pole of the spleen is elevated and the inferior polar vessels are divided with the ultrasonic dissector or the vessel-sealing device. Monopolar coagulation can also be used.

3. Gastrosplenic dissection 01'50''

The table is tilted to the right to expose the anterior surface of the spleen. The anterior wall of the stomach is retracted anteriorly and to the left to expose the gastrosplenic ligament. A window is created to open the lesser sac and the short gastric vessels are controlled with the ultrasonic dissector or the vessel-sealing device. The 1st short gastric vessel is divided and this is continued from caudad to cephalad. The lesser sac has now been entered and the dissection continues along the greater curvature of the stomach. Care is taken to use the ultrasonic device at a distance from the wall of the stomach. The gastrosplenic ligament is now completely divided.

4. Mobilization of splenic artery 05'10''

The next step is the search for the splenic artery. The splenic artery can usually be seen pulsating at the superior border of the pancreas. The peritoneum is opened and the tortuous artery carefully dissected. The artery is dissected enough to allow for its ligation with a 2/0 silk suture. This will help to reduce the bleeding, will empty the spleen from its blood, which will make it smaller and will allow for some amount of auto-transfusion. Either clips or silk sutures can be applied.

5. Spleen mobilization 06'31''

The table is then tilted to the left to gain access to the posterior surface of the spleen. The spleen is retracted medially and the splenorenal ligament is divided. This dissection proceeds in an avascular plane. The spleen and the tail of the pancreas are mobilized from the lateral surface of the kidney. The posterior attachments of the spleen are divided.

6. Division and extraction 07'29''

The spleen is now fully mobilized. There is usually a 2cm space between the splenic hilum and the tail of the pancreas. The scope is moved to the lateral 10mm trocar and a linear stapler with a vascular load is inserted through the 12mm trocar and placed gently around the splenic vessels. Two or 3 firings are usually necessary. The last attachments of the upper pole of the spleen are divided with the ultrasonic dissector. The 12mm trocar is removed and replaced by a 15cm retrieval bag, which is inserted directly through the abdominal wall. The Endobag is brought out. The fluid content of the spleen is suctioned out and the spleen is morcellated and extracted with a forceps-type clamp. Care should be taken to avoid intraperitoneal spillage of the content of the bag.