Splenectomy by laparoscopic posterior lateral approach for idiopathic thrombocytopenic purpura (ITP): selective vascular control

This video demonstrates an alternative approach to perform splenectomy by commencing with the dissection of the postero-lateral aspect. In this way, the splenic artery and vein are ligated first at the hilum before division of the short gastric arteries. This video is recommended to general surgeons.

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Splenectomy   by   laparoscopic   posterior   lateral   approach   for   idiopathic   thrombocytopenic   purpura   (ITP):   selective   vascular   control

Authors
D Mutter
Abstract
This video demonstrates an alternative approach to perform splenectomy by commencing with the dissection of the postero-lateral aspect. In this way, the splenic artery and vein are ligated first at the hilum before division of the short gastric arteries. This video is recommended to general surgeons.
Mots-clés
splenectomy, hilum, splenic artery, short gastric arteries
Type de vidéo
Durée
13'40''
Publication
2007-10
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Oct 2007;7(10).
URL: http://www.websurg.com/doi-vd01en2178.htm

Splenectomy   by   laparoscopic   posterior   lateral   approach   for   idiopathic   thrombocytopenic   purpura   (ITP):   selective   vascular   control

2. Postero-lateral mobilisation 00'52''
At the beginning, we always begin to mobilize these little adhesions, which are in the way of the dissection plane. This is complete lateral decubitus position. There is a very slight bending of the table. Here is the spleen and its attachments. We will stay all the time approximately 1 to 2cm behind the spleen in order to avoid any risk of injury. I always go from the lower part to the upper part of the spleen, and during all this mobilization, I have always new tissues that appear in front of my dissection plane that are under tension. This is a similar approach than doing a left adrenalectomy. We use the bipolar cautery. There is probably an intercostal branch for the adrenal. We can use this approach even if the patient is obese, but it’s probably more difficult to identify the landmark if you are not used to it. But then the anterior approach is difficult as well. I will clear my hook and I will insert port number 4. It’s very posterior and very important because it will enable the assistant to hold a little peanut, which will put some tension on the tissues. So the dissection always goes downwards, then upwards successively in order to have tension on the tissues and to completely free the inferior edge of the spleen. Here we have a better orientation from the posterior plane. I will use the angulation of the 30 degree optic. Here we can identify the splenic vein. I don’t put any tension on the spleen as it holds by itself. You can see the left crus at the top: it will be my upper landmark of dissection. But usually this landmark is identified a little bit later. We go to the lower edge of the spleen again. Here we can see very well the lower attachments of the spleen, which can be sometimes vascularized. We will go very slowly with the dissection, and if there is a vessel here, we can control it with the Ligasure. Here we see an artery. It’s probably either the splenic artery or an inferior polar artery. At the moment, we don’t do anything. Usually, thanks to this approach, you see very well the artery, it can be completed until the dissection of the short gastric vessels with the hook. The only problem is the presence of this little vessel, and usually I switch to the Ligasure when I have to cut the short gastric vessels. I have to open somewhere here to go into the lesser sac and identify the short gastric vessels. I will go ahead and finish the mobilization of the upper pole of the spleen and here the tension of the tissues is obtained only by the weight of the spleen. Did you leave that upper peritoneal reflection till this stage of the operation to stop the spleen from falling down towards you? No I think it’s not a major problem. I will mobilize the upper pole of the spleen by cutting the peritoneum. As you see here the objective is now to find the lesser sac, so I have a low dissection of the spleen, I need its upper mobilization in order to very safely identify the splenic vein and the splenic artery. The objective is to identify the crus, and then the lesser sac once the crus is identified. The upper pole is not completely free but I will again go down to get to the level of the pedicle. The artery is clearly identified.
3. Isolation and division of splenic vessels 07'03''
Now I will show you the main anatomical landmarks. The stomach is here, the liver is there, the spleen is down here, and here you can identify the tail of the pancreas that we see just behind this little peritoneal sheet, which will be opened to get on it. And here is the splenic artery, and the splenic vein will be just behind this. The kidney is here. I would like to make a complete vascular approach and to completely isolate the artery. It can be very safely performed. If there is any bleeding from the spleen now you can see that the artery can be controlled very easily. The artery is almost controlled. I will look for the vein, which should be just behind here. Would you consider just clipping that artery because you did such a beautiful dissection? Yes I could. Usually I prefer using a GIA and at this level as long as I have a good exposure, there is no benefit to clip it immediately or in 5 minutes further in the dissection. The upper pole is completely free as you see here and to complete it will allow a much more didactic exposure of the artery and vein. Here you can see very well the control of the upper pole of the spleen. These are the last attachments to the diaphragm. I go back to the vessels now and I will control both artery and vein. We will use the GIA with the white cartridge to control the artery from the posterior plane. It will allow to slightly decrease the size of the spleen, and I can leave my little stitch into the suture. I will do the same procedure with the vein. I will now have to finish the dissection of the vein. Here is the vein, and I can check if I can go behind it. Again the same type of exposure as previously seen, and now I’m sure that I have everything here. Again I will put the GIA at the level of the optic and put the optic a little bit more laterally. Here again thanks to the position of my little stitch, I’m sure to have everything. And the vein is separately controlled from the artery as you can see at the 1st plane. You see that the surgical procedure is completed.