NOTES-assisted transvaginal splenectomy: the next step in the minimally invasive approach to the spleen

Laparoscopic splenectomy (LS) has become the gold standard approach for normal spleens. Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been used for transgastric splenectomy in the experimental setting, but there is no information about the application of NOTES or hybrid NOTES in humans; this video shows the case of a NOTES-assisted transvaginal splenectomy performed in a 65-year-old woman, multipara, with no previous abdominal surgery.

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NOTES-assisted transvaginal splenectomy: the next step in the minimally invasive approach to the spleen

Authors

Abstract

Laparoscopic splenectomy (LS) has become the gold standard approach for normal spleens. Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been used for transgastric splenectomy in the experimental setting, but there is no information about the application of NOTES or hybrid NOTES in humans; this video shows the case of a NOTES-assisted transvaginal splenectomy performed in a 65-year-old woman, multipara, with no previous abdominal surgery.

Catégorie

new techniques

Mots-clés

NOTES-assisted transvaginal splenectomy, minimally invasive approach, spleen

Type de vidéo

Vidéo chirurgicale

Durée

07'00''

Publication

2009-06

Popularité

Favoris

Favorites Media

Audio

E-publication

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2669.htm

NOTES-assisted transvaginal splenectomy: the next step in the minimally invasive approach to the spleen

1. Introduction 00'00''

Laparoscopic splenectomy (LS) has become the gold standard approach for normal spleens. Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been used for transgastric splenectomy in the experimental setting4, but there is no information about the application of NOTES or hybrid NOTES in humans.

2. Preoperative planning 00'15''

A 65-year-old woman, multipara, with no previous abdominal surgery, was diagnosed of a 6cm multicystic splenic lesion. Surgery was decided upon and the new approach was approved by the hospital ethics committees. The procedure was fully explained to the patient and written consent was obtained. The surgical technique was divided into 6 steps. To determine the surgical anatomy and the distance from the vaginal vault to the splenic hilum, a CT-scan was carried out. A right lateral 3D reconstruction was performed. The distance between the tip of the vagina and the splenic hilum (27.5cm) was measured.

3. Table position 00'58''

The patient was placed in the standard position for LS: right decubitus with the flank of the table at an angle. To facilitate access to the genital area, the left leg was placed in a stirrup.

4. Pneumoperitoneum and transvaginal trocar insertion 01'10''

After induction of pneumoperitoneum with a Veress needle, three subcostal ports were inserted in the standard position for LS. After abdominal examination, a Trendelenburg tilt of the table was used to check the Douglas’ pouch. A 12mm diameter, 15cm long trocar was introduced transvaginally through the left vaginal sac, reaching the abdominal cavity. Due to the lack of rigidity of the scope, an additional 3mm trocar was used to introduce a grasper to help advance the scope to the splenic fossa. To do so, a silk suture knot was placed at the tip of the scope and hung with the grasper.

5. Spleen dissection under transvaginal fiberscopic visualization 01'51''

The tip of the scope was placed in front of the spleen. Anterior and posterior movements were facilitated by the additional port, and lateral movements were controlled by the endoscopist. Short vessels and posterior peritoneal adhesions of the spleen to the kidney and diaphragm were divided using the three subcostal trocars to introduce the 5mm Ultracision. Once the spleen was completely mobile, the flexible transvaginal scope was retrieved and intra-abdominal visual control was changed to the subcostal 5mm scope.

6. Transvaginal stapling of the spleen 04'03''

An extra-long (44cm), flexible tip stapler with a 6cm white cartridge was inserted through the vagina and advanced to the splenic fossa. After adjusting the jaws, the stapler was applied several times to divide the splenic hilum.

7. Transvaginal spleen extraction 05'04''

Once the spleen was completely free and after checking for hemostasis, a 15mm Endobag was inserted transvaginally and the spleen was introduced in the bag. It was pulled to the Douglas’ pouch under laparoscopic control. The vaginal incision was enlarged and the spleen was retrieved intact. The vaginal vault was closed with interrupted stitches and closure was confirmed by the trans-abdominal view.

8. Conclusion 06'00''

The patient evolved satisfactorily and was discharged 48 hours later. Operative time was 180 min and blood loss was less than 50mL. The histopathological analysis showed a 178g spleen with a polycystic hemangioma. Transvaginal access can be safely used for operative visualization, hilum transection and spleen removal, reducing parietal wall trauma to a minimum. The clinical, cosmetic and functional advantages require further analysis.