Laparoscopic splenectomy following an embolic septic abscess in a young patient

This video shows a laparoscopic splenectomy in a young patient who developed several septic emboli originating from a skin wound. One of these septic emboli induced a splenic abscess. Due to vegetations on a cardiac aortic valve, cardiovascular surgeons ask to remove the spleen along with the intrasplenic abscess prior to envisaging an intervention on the valve.

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Laparoscopic splenectomy following an embolic septic abscess in a young patient

Authors

J D'Agostino, M Vix, J Marescaux

Abstract

This video shows a laparoscopic splenectomy in a young patient who developed several septic emboli originating from a skin wound. One of these septic emboli induced a splenic abscess. Due to vegetations on a cardiac aortic valve, cardiovascular surgeons ask to remove the spleen along with the intrasplenic abscess prior to envisaging an intervention on the valve.

Mots-clés

Laparoscopy, splenectomy, embolic septic abscess, splenic abscess

Type de vidéo

Vidéo chirurgicale

Durée

15'00''

Publication

2010-12

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Dec 2010;10(12).
URL: http://www.websurg.com/doi-vd01en3135.htm

Laparoscopic splenectomy following an embolic septic abscess in a young patient

1. Clinical case presentation 00'15''

This young patient has developed several septic emboli originating from a skin wound. One of these septic emboli induced a splenic abscess. Due to vegetations on a cardiac aortic valve, cardiovascular surgeons ask to remove the spleen along with the intrasplenic abscess prior to envisaging an intervention on the valve.

2. Dissection of adhesions 00'44''

During the abdominal approach, several inflammatory adhesions between the spleen, the omentum, and the colon can be immediately observed. The first step of the procedure will consist in the dissection of the splenic flexure portion where adhesions are to be found. An anterior, then posterior approach is used in turn. First of all, the resection of the greater omentum is performed distally from the stomach in order to preserve the left gastroepiploic arterial arch. Dissection is carried out slowly in order to re-identify the plane of the lesser sac.

3. Dissection of short vessels 01'47''

The whole of the short vessels is then divided until the left crus. The splenic capsule is seen through the lesser sac. Dissection is extended along the left crus and pursued on the diaphragm to initiate the freeing of a few adhesions. Dissection is then pursued caudally and posteriorly.

4. Dissection of colosplenic adhesions 02'30''

Colo-splenic adhesions are freed. A plane is searched for by means of the hook. The use of the Ligasure® vessel-sealing device helps to detach the remaining portion of the omental adhesions. The splenic flexure is visualized and the omentum of the splenic flexure whose inflammatory portion is attached onto the spleen is taken down while trying to re-identify the plane between the spleen and the omentum. This maneuver aims to take down the splenic flexure. There are tight adhesions between the splenic flexure and the inferior portion of the spleen. However, a very inflammatory plane is found again and the inferior portion of the spleen can be freed. A retrosplenic space is then identified. As a result, the spleen is freed on its anterior part, on its inferior part, and then partially on its posterior surface. Adhesions are dissected.

5. Dissection of splenic pedicle 04'15''

As soon as the plane disappears, the splenic pedicle can be approached. Once again, a few omental adhesions are taken down. Dissection is performed slowly in order to avoid any vascular injury. The hilar portion is accessed using the Ligasure® device, which allows for the resection of a few omental adhesions and for the freeing of the plane of the splenic vein and artery. The splenic artery is easily identified thanks to its beating. The hook is used once again in order to skeletonize the splenic artery. Here a loop of the splenic artery is perfectly visible. An anterior, then posterior dissection is carried out in order to achieve its ligation. A port is added in order to lift up the spleen and facilitate the access to the splenic pedicle. The splenic pedicle is dissected towards the parenchyma. A few adipose adhesions are dissected.

6. Division of splenic artery 07'01''

The splenic artery is then totally dissected at its posterior surface. It can now be ligated. An external knot is tied using non-absorbable thread. A second ligature is applied likewise. In order to secure these two ligatures, a clip is placed on each side. The artery is divided. Dissection is pursued in the splenic hilum in order to precisely identify the splenic vein.

7. Splenic vein dissection and division 08'10''

The splenic vein is identified and dissected. It will be ligated immediately in order to limit the risk of bleeding. Once again, a non-absorbable thread is used to tie an external knot. With regards to the vein, no clip is necessary. Its division is carried out immediately. Dissection is then extended towards the superior pole of the spleen where very dense and very inflammatory adhesions are found. For the time being, the spleen is not punctured to better understand the anatomical boundaries. Dissection is made uneasy because of several inflammation and bleeding areas. Dissection is performed almost with one finger.

8. Spleen dissection 10'02''

The adhesions between the spleen and the pancreas are then divided using three firings of the linear stapler, white cartridge. From then onwards, the remaining attachments of the spleen constitute the posterior plane. The entire pedicular surface is totally dissected. The external part is accessed and a space is found in-depth along the diaphragm. Dissection is carried out using the Ligasure® device first and then the hook in order to identify a plane between the spleen and the diaphragm. The different adhesions are extremely tight, inflammatory and hemorrhagic. The spleen is then punctured in order to allow for an easier dissection along the diaphragm. Thanks to this emptying, the plane is identified more easily. The adhesions against the diaphragm are extremely intimate and one might fear an effraction of the splenic collection in the pleura if the procedure had not been performed. From then onwards, the entirety of the splenic attachments can be divided. A bag is introduced for specimen placement.

9. Spleen extraction 13'02''

The spleen will be retrieved after enlarging the two trocars’ incision sites. A final view of the entirely freed splenic space is obtained. No bleeding can be observed. The major adhesions along with the fibrotic portion of the diaphragm are perfectly visible. A second bag is used for the retrieval of a few blood clots and placement of a dressing used to facilitate the dissection. A drain is placed for draining purposes. The postoperative outcome is uneventful. No pancreatic fistula may be noted. The drain will be retrieved on postoperative day 5.