Laparoscopic splenectomy, posterior approach

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Laparoscopic   splenectomy,   posterior   approach

Authors
D Mutter, F Rubino
Mots-clés
splenectomy,operation,laparoscopy,spleen,posterior
Type de vidéo
Durée
26'00''
Publication
2004-09
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1074e.htm

Laparoscopic   splenectomy,   posterior   approach

1. Case demonstration 00'20''
With the patient in a lateral decubitus, 3 trocars are inserted in the left subcostal area. This patient was referred to us for a hemolytic anemia and thrombocytopenia. The spleen was found to be 20cm in size. The 1st step is the mobilization of the parietal ligament of the spleen. We mobilize the left colic flexure; this maneuver facilitates dissection of the inferior pole of the spleen. A ring of 1cm of peritoneal tissue should be left on the lateral edge of the spleen. This tissue can be used for retraction avoiding contact between instruments and splenic capsule. With the patient in a lateral decubitus, a complete mobilization of the posterolateral aspect of the spleen allows displacement of the organ towards the right part of the abdomen, facilitating access to the vascular structures from behind. In order to achieve adequate mobilization, the dissection should be performed up to the left crura of the diaphragm. In transparency, you might see the superior pole of the kidney. Indeed, this approach is the same as we use for laparoscopic left adrenalectomy. Here you can see how leaving adequate margins of the peritoneal tissue helps handle the spleen safely. You can see a small hiatal hernia here. In this case, due to the size of the spleen, we insert a 4th trocar to allow for a better exposure of the inferior pole. Now you can see the splenic vessels. We are dissecting on the posterior sheet of the splenogastric ligament. Now you can see the greater curvature of the stomach and the short gastrics. We introduce a 5mm clip applier to control the short gastric vessels. However, Harmonic scalpel or Ligasure might also be used. The inferior vascular pedicle of the spleen is dissected carefully and progressively to allow for selective ligature of the vessels. The inferior branch of the splenic artery is divided between clips. This venous branch from the inferior pole of the spleen requires clip application as well. As you see, dissection of the hilum of the spleen is performed very carefully. The splenopancreatic ligament is approached from posteriorly to anteriorly. Remember that the patient is in a lateral decubitus and the spleen retracted medially while we are viewing its posterior aspect. The spleen can now be retracted anteriorly in order to better expose the hilum and the remaining attachments. When the hilum of the spleen is exposed, careful dissection allows to isolate splenic artery and vein. The tail of the pancreas is separated from the hilum of the spleen by completing the dissection of the splenopancreatic ligament. In this way, we achieve complete mobilization of the spleen, which will be then only attached to its main vascular structures. This allows a safer use of the vascular stapler. You can see the tail of the pancreas close to venous and arterial branches. The tail of the pancreas is now completely separated from the hilum of the spleen. Division of the anterior sheet of the splenopancreatic ligament is now completed. Note how the ligation of the arterial supply significantly decreases the volume of the spleen. This facilitates exposure of the splenic vein. Once complete mobilization is achieved, the spleen is suspended to better expose the vein and allow for a safer use of the vascular stapler. At this point, the spleen is completely freed. You can see the 2 branches of the splenic artery that have been ligated and divided. A 15mm Endobag is inserted through one of the trocar sites. A small subcostal incision is performed to remove the spleen. Control of the operative site shows no source of bleedings and both branches of the splenic artery and the splenic vein appear to be under control. However, a Redon drain might be placed and kept for 24 hours.