Laparoscopic splenectomy with selective vascular control and deeply involved pancreatic tail

Laparoscopic splenectomy is currently the procedure of choice for elective splenectomy. The indications for this procedure are the same as with open procedures, they range from idiopathic thrombocytopenic purpura, and unresponsive hemolytic anemia to staging procedures and to primary splenic cysts.

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Laparoscopic   splenectomy   with   selective   vascular   control   and   deeply   involved   pancreatic   tail

Authors
D Mutter, L Soler, J Marescaux
Abstract
Laparoscopic splenectomy is currently the procedure of choice for elective splenectomy. The indications for this procedure are the same as with open procedures, they range from idiopathic thrombocytopenic purpura, and unresponsive hemolytic anemia to staging procedures and to primary splenic cysts.
Catégorie
live recorded
Mots-clés
Laparoscopic splenectomy, selective vascular control, pancreatic tail
Type de vidéo
Durée
26'40''
Publication
2011-10
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Oct 2011;11(10).
URL: http://www.websurg.com/doi-vd01en3483.htm

Laparoscopic   splenectomy   with   selective   vascular   control   and   deeply   involved   pancreatic   tail

1. Trocar insertion 00'20''
We start the procedure by performing an open approach in order to safely insert the first trocar. It is a 10-12mm trocar in order to have the possibility to insert the camera and to also insert a stapler inside if necessary to complete the procedure. The second trocar is inserted under direct control. It is a 10mm port inserted on the anterior axillary line. Some peripheral adhesions to the left angle of the colon are freed. The left angle of the colon will be freed from the anterior part of the spleen and therefore, we have to lower the left angle of the colon and this lowering will start by freeing these adhesions. Can you put your patient, your image horizontal as the patient is lying on his back? Now second image. You can see the view: here, just over the spleen, I have a 30-degree scope if I go over the spleen, I show you the white aspect of the cyst but we don’t see it very well from here. Here you can see it. I go posteriorly to the spleen and you can see that the cyst has moved completely the spleen downwards. And then if we look at this, the inferior pole of the spleen is here and just to compare, if I lift a little bit the inferior pole of the spleen, I can see an artery immediately. Due to the size of the spleen, there is a modification of the anatomy of the vascular landmarks with the hilum of the spleen probably much lower than it should be normally. Here with the head of the patient, we have drawn on the skin the mid-axillary line, the anterior axillary line, the posterior axillary line here. We have inserted the first port by an open approach. It is used for the camera on the anterior axillary line; 5cm in front, we have placed a 10mm port, 5mm behind a 10mm port, and sometimes we can work with 3 ports to perform a splenectomy but in this patient with a big cyst, we know that we will need to perform some retraction of the tissue. This is the reason why we have placed a 4th port on the posterior axillary line.
2. Dissection of posterior spleen attachments 03'36''
And I will start to free the posterior attachment of the spleen. The mobile blade is the fixed one. I free the attachments that are under tension because the main risk at this stage is to have a little tear in the capsule of the spleen. So posteriorly, the objective is to identify Gerota’s fascia and to identify the pancreas in order to perform the dissection between the spleen and the pancreas. Here you can see that we guess behind the position of the tail of the pancreas, and I will stay very superficial and I ask my assistant not to move. The best of assistants does not move. And I will free the lower edge of the spleen because one of the objectives is to get a quick access to the lesser sac and here you can see the pancreas. I will try to change the orientation. Here you can see the spleen, the pancreas. One of the dangers of the procedure is to injure the pancreas so very progressively I will free the attachments. Here we see an artery but for the moment it’s not the objective of dissection. Here the pancreas is freed and just over the pancreas, we know that we are going to identify the splenic vein, making a reflection--it’s here. Dissection is carried out very progressively. So behind the vein is the peritoneal reflection. This can be freed safely. Again our opened peritoneal reflection behind the spleen and the progressive mobilization of the spleen will help to get access to the vessels. Here’s the pancreatic tail largely involving all this splenic area. I will change and take the hook a little bit because with the mobile part. At this level, probably there is the impossibility to correctly get access to the main vessels and as quickly as possible, I will try to identify the splenic artery and to clip it even if I don’t have enough space to cut it. I stay 1cm away from the hilum and I will progressively identify a first direct artery. We have the main artery here, and an accessory artery just at this level going from the main artery to the distal part, inferior pole of the spleen. So I will first free the peritoneal reflection around it. And here in it, we have this little artery, which can be controlled with what we want. I think that we will probably place a clip for this. We like to control them with clips because it’s a very safe but also a very didactic way to control these vessels. Next objective from this freeing of the inferior part of the spleen will be to get access to the lesser sac. Here we can see what could be the interest of augmented reality to be sure of the direction of the artery. I don’t want to cut the artery at its origin but really just at the level of the hilum of the spleen. Now we can see that the inferior pole of the spleen begins to be free. I will go ahead in order to increase the quality of the dissection, lower again the pancreas and we know that at this level, there is a risk of pancreatic injury.
3. Pancreas involved in splenic hilum 06'17''
We see here how the pancreas is involved in the hilum of the spleen. If there is some oozing coming from here, I can also put a swab to get this little oozing out of the way. Here again, I go to open the peritoneal reflection. The pancreas is really into the spleen at this level and probably we will have to change a little bit the orientation. You see that the hook again allows to have a real control of what is inside because here the risk again is to go behind the vein and to have an injury of the vein. Again I try to find a plane. Here there is one of the divisions of the artery; we have seen on the reconstruction preoperatively that we have a division so probably that will be one branch going up. The second thing is to try to find the plane if I have to make an emergency clamping of the artery, it’s good to have it on a longer distance. Here I have the artery at a distance of 2cm so it’s better. That is the direction of the short gastrics and the lesser sac. Here we are in contact to the splenic vein, which is attached to the pancreas at this level. Here we begin to find the plane between the splenic vein and the splenic artery. And we know that the risk here is to have a short vein between the pancreas and the splenic vein, that’s why I’d like to free the vein on a longer distance. But before clamping the vein, I really need to clamp the artery otherwise there is no way to control this. For the moment, I cannot free the pancreatic tail from the spleen completely. I will just try to go ahead with the mobilization of the spleen in order to see if a better exposure will give me an access from a different angle of view. Usually we try to go from a total posterior approach but in this patient, the problem for the posterior approach is the size of the spleen, which prevents us from going posteriorly. You can see that anteriorly we can have the complete freeing of the splenic vein here. From a posterior point of view, I can also free the same vessels. Here you can see that we have just devascularized the spleen inferiorly. Now thanks to what we’ve done, I let the spleen go as it goes spontaneously in the operative field. I will change the orientation of the camera and try to see upwards what can be done for the freeing of the spleen.
5. Artery control 11'55''
That is the right clamp; I try to go behind the artery first. From there, I don’t have access. So I will change, I will try to put this clamp from the opposite way. I pay attention since I can be at the level of the division of the artery. I will dissect again a little bit more. I cannot find a way behind the artery and there are still more things that I can free. These are probably nodes around the artery. Here it’s done. OK I take here a non-absorbable stitch of about 15cm. I hold it with a needle holder. The position of the trocar is very bad for making the suture here because I am not in triangulation so typically don’t make what you see. Can we use hemoclips for vessels? Yes, you can use hemoclips. I think that at this level it is not a major problem. The reason I do this is because when I put a suture, I know that I will devascularize the spleen and the second advantage is that with a suture, I am still able to place a stapler to control it. If I place clips, I will have no other possibility to place again clips and I will not be able to place a stapler. We know that hemoclips are today contraindicated for the renal graft and transplant due to leak because one question here is why I don’t put. You know that hemoclips could be fine here but they are contraindicated in renal transplants because of failure of some clips. Now you see that the spleen is decreasing and the vein at this level is much thinner. I will certainly control this vein from behind, it’s always a little bit dangerous. From the front part, I have this here. Here we can see that it was a division branch and the main artery is probably here higher. Here is the main pedicle. Perhaps I will preserve the branch I have ligated because it’s maybe unnecessary to get this stitch in control depending on where I will control the artery. I can keep the stitch I have because it will depend on where I will control and cut the artery. Here I have a little conflict. The problem of this grasper is that it is not a rotating one so I have a complete conflict as I touch the camera. So I have an angle of view that changes progressively you see. Now I have a better triangulation, I just turn again the camera on a correct orientation.
9. Completion of dissection and specimen extraction 22'14''
Now the spleen is freed inferiorly. Now I will be able to complete the preparation of the vein here and to control the vein certainly again with clips. The second reflection line of the short gastric vessels, the avascular plane in the hilum of the spleen, and the second division branch of the splenic vein. You see that the vein is becoming smaller and smaller here. I prepare again the vein here. And then, we’ll begin the challenging part of the operation, a tricky part, which will be to take the spleen out and as usually, at this level, we take the spleen out by morcellation. Here we’ll take the stitch. You see the direct link with the portal vein. It appears smaller in size, and can be controlled with simple clips. It’s a big one. My assistant will say perhaps it’s too much perfection in a vascular control but I sleep much better if I see no blood during the operation and at the end and if I see some… What I’ll do, if you can show just the external view. You have the external view now. I put the trocar in the anterior one. Please give me the big sac. So I take a big extraction bag, which is a 15mm one, and as I cannot insert it through a 12mm port, in order to avoid any further system, I will extract the beginning of the closure. The tip of the extraction bag will be taken out to mimick a trocar, and I will enter the bag like that completely at the place of my first trocar, which mimicks a trocar and inside, you have it inserted like that. So this big bag, and this is the hole through which we will extract the spleen. Second challenge, I hope that my spleen is not too big. It’s a 15cm bag. It should go in. don’t take the trocar out. It should be a bag big enough for the spleen. See that the spleen comes in the bag. As usually, the spleen is extracted by morcellation after introduction into a bag in order to limit the size of the incision. It is sometimes a long part of the procedure but the only way to have very limited scars. The camera is reintroduced to control the lack of bleeding and the quality of the operative field before closure with separate stitches on the main incision and subcutaneous stitches. A drain is never placed or left after this type of resection. The trocars are removed under direct control to avoid any bleeding.