Pediatric splenectomy for spherocytosis with Ligasure V vessel sealing system & ForceTriad generator

Spherocytosis is a hemolytic disorder with marked heterogeneity of clinical features, ranging from asymptomatic conditions to fulminant hemolytic anemias. Laparoscopic splenectomy is a feasible and safe technique in the hands of skilled laparoscopic surgeons. The special characteristics of the spleen, that may pose a number of technical difficulties (patient position, organ mobilization and retrieval) are explained in this video, permitting the advantages of laparoscopic surgery to become available to patients with spherocytosis that need splenectomy.

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Pediatric splenectomy for spherocytosis with Ligasure V vessel sealing system & ForceTriad generator

Authors

Abstract

Spherocytosis is a hemolytic disorder with marked heterogeneity of clinical features, ranging from asymptomatic conditions to fulminant hemolytic anemias. Laparoscopic splenectomy is a feasible and safe technique in the hands of skilled laparoscopic surgeons. The special characteristics of the spleen, that may pose a number of technical difficulties (patient position, organ mobilization and retrieval) are explained in this video, permitting the advantages of laparoscopic surgery to become available to patients with spherocytosis that need splenectomy.

Catégorie

basic techniques

Mots-clés

Pediatric splenectomy, total splenectomy, spleen, spherocytosis

Type de vidéo

Vidéo chirurgicale

Durée

08'31''

Publication

2009-02

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Feb 2009;9(02).
URL: http://www.websurg.com/doi-vd01en2472.htm

Pediatric splenectomy for spherocytosis with Ligasure V vessel sealing system & ForceTriad generator

1. Clinical case presentation and lower pole of spleen mobilization 00'10''

It is the case of a 9-year-old girl who presented to the emergency room with a history of fatigue and abdominal pain. The laboratory exams showed preoperative hemoglobin levels at 7 g/L. An acute hemolysis was diagnosed due to a spherocytosis. A splenectomy was decided upon. The patient is placed in a dorsal decubitus, with a slight tilt to the right side. We use 4 ports: a 10mm umbilical one for the camera, and three 5mm operating ports (two of which are located in the midline and one in the left flank). We always use a 30 degree lens. The upper midline port is used for retraction; the other midline one placed between the umbilicus and the upper port is used for the surgeon’s left hand. The left port is for the surgeon’s right hand. No urinary catheter is used. We try to avoid changing instruments as much as possible. We use the Ligasure V vessel sealing system for dissecting, sealing and cutting vessels and attachments. The ForceTriad generator provides a faster sealing time and less sticking and smoke effects. The suction probe is used as a retracting tool. The diamond-shaped tip of the 5mm Ligasure device allows to dissect behind narrow spaces in confined operative fields. By using a Maryland dissector in the left hand and the Ligasure device in the right hand, dissection is completed easily, ensuring a safe hemostasis of the surgical field. The left hand is used for both dissection and counter-traction to shorten operative times. It is also always ready to grasp a vessel after its division in case of bleeding. No clips or staplers are used. The sealing capacity obtained with the Ligasure device is clearly shown.

2. Dissection of vessels using Ligasure device 02'32''

We start dissecting the lower pole of the spleen. We then proceed to the upper pole and the short vessels to facilitate exposure of the hilum and larger vessels. Special care has to be taken in order to avoid any thermal or inadvertent lesion to adjacent organs. We finally dissect, seal and cut the splenic arteries and veins. Though not very common, accessory spleens have to be ruled out from the abdominal cavity. In cases such as the present one where they are found, they should be eliminated.

3. Freeing of lateral attachments 04'48''

The last step is freeing of the lateral attachments of the spleen. The surgical steps are as follows: lower pole, upper pole, central vessels, and finally attachments to keep the spleen in place until the end. In our experience, this facilitates exposure and handling of the hilum. The specimen is put in a retrieval bag for its later extraction through the umbilicus. The bag is introduced through the umbilical port after removing the lens. The lens is reintroduced and the spleen is put in the bag. A grasper is used to hold the edges of the bag and direct it to the umbilicus while the lens and umbilical port are removed to exteriorize the bag. The spleen is morcellated in the bag. Splenectomy is indicated in relation to the degree of the anemia and its clinical manifestation. The clinical manifestations and complications such as anemia and cholelithiasis are abolished after total splenectomy, but the patients may be exposed to a later risk of important infection and a preoperative prevention plan is therefore required. By choosing the laparoscopic approach, there is a shorter hospital stay, fewer wound infections, improved pain relief, and better cosmetic results.