Laparoscopic splenectomy for subcapsular hematoma: medial approach

The spleen is the second most frequently injured organ in blunt abdominal trauma. The radiological diagnosis and prompt management of potentially life-threatening hemorrhage is the primary goal. The preservation of functional splenic tissue is secondary and may be accomplished using non-operative management in selected patients. Any attempt to salvage the spleen is abandoned in the face of ongoing hemorrhage, inability for the patient to respect the instructions or other life-threatening injuries. Emergent and urgent splenectomy remains a life-saving measure for many patients.

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Laparoscopic   splenectomy   for   subcapsular   hematoma:   medial   approach

Authors
Abstract
The spleen is the second most frequently injured organ in blunt abdominal trauma. The radiological diagnosis and prompt management of potentially life-threatening hemorrhage is the primary goal. The preservation of functional splenic tissue is secondary and may be accomplished using non-operative management in selected patients. Any attempt to salvage the spleen is abandoned in the face of ongoing hemorrhage, inability for the patient to respect the instructions or other life-threatening injuries. Emergent and urgent splenectomy remains a life-saving measure for many patients.
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12'54''
Publication
2013-02
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en
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en
E-publication
WeBSurg.com, Feb 2013;13(02).
URL: http://www.websurg.com/doi-vd01en3881.htm

Laparoscopic   splenectomy   for   subcapsular   hematoma:   medial   approach

5. Control of lower pole vessels 04'26''
Dissection is then pursued towards the inferior pole of the spleen. The gastrosplenic ligament is then opened. It is well visible here. It is reaching from the greater curvature of the stomach until the splenic hilum. Once the gastrosplenic ligament has been freed, attachments of the spleen to the splenic flexure can be seen. Dissection is then meticulously carried on towards the spleen’s inferior pole in order to control the entire vessels. Here, the omentum of the greater curvature is visible. It is isolated and kept away. The dissection plane is identified again towards the spleen’s inferior pole and the lower pole vessels of the spleen become visible. The splenic artery and vein are controlled and dissection is performed along a lower pole branch. During the dissection, a left gastro-epiploic artery can be clearly seen. It is progressively dissected along with the vein lying more posteriorly. The left gastro-epiploic artery is clipped and finally divided. The same maneuver is performed with the vein lying more posteriorly. The gastro-epiploic artery is controlled and divided. The posterior left gastro-epiploic vein is dissected. The branching of the left gastro-epiploic vein towards a lower pole splenic vein is clearly visible. The lower pole splenic vein is clipped and divided. Dissection plane after plane as well as the vascular approach is carried out from anteriorly to posteriorly as vascular elements are progressively controlled. Once this vein has been controlled, dissection is performed more deeply and a larger artery can now be observed. Dissection is carried out using cold scissors in order to avoid any contact between the ultrasonic dissector and the clips and any ultrasonic propagation. Dissection is progressively performed along the artery by means of cold scissors. As a result, each vascular element can be controlled and a pancreatic branch can be visualized. A caudal pancreatic artery and a lower pole splenic artery are clearly visible. It is decided to preserve this caudal pancreatic branch and to proceed with the dissection of the lower pole splenic artery only. It is then clipped and divided. This dissection allows to preserve this caudal pancreatic artery. Once the artery has been controlled, it is divided using cold scissors and dissection is carried on in this vascular plane.
6. Control of upper pole vessels 08'11''
At this moment, all lower pole splenic vessels are controlled and the ultrasonic dissector can be used again in order to access upper pole splenic branches. Here, no vascular element can be seen until the upper pole splenic branch is approached. It is visualized at this moment. It is then dissected on each side, hence allowing for an approach by means of the dissector once it has been dissected over a sufficient length. The use of the Sonicision™ cordless ultrasonic dissection device (Covidien) allows for a fine and meticulous dissection of all vascular elements. At this time in the dissection, the upper pole artery and vein are controlled simultaneously given the absence of any evident plane. A suture is placed on the base of the artery and vein in order to control a small venous bleeding. Once the suture has been made, two clips are placed, one on the distal aspect and another on the proximal aspect in order to reinforce the previously made stitch. Division is made using cold scissors. At this time, the upper pole artery and vein are controlled simultaneously. The lower pole branch and the upper pole branch of the spleen are controlled. On exploration at the end, one can observe that there is no ischemia at the uppermost pole of the spleen as well as a small upper pole branch originating from the splenic artery—the latter is dissected, controlled, and divided after clip placement. Once this branch has been divided, all splenic elements coming to the spleen have all been isolated and dissected. The spleen is now free from any vascular supply once the last branch has been dissected.