Three-trocar laparoscopic splenectomy for thrombocytopenia

This video demonstrates a three-trocar laparoscopic splenectomy performed for atypical idiopathic thrombocytopenic purpura in a 33-year-old patient. An anterior approach, as in this case, is a very interesting one as the spleen does not need to be manipulated in this patient.

Browse the WORLD
Virtual University
English ▼

Three-trocar   laparoscopic   splenectomy   for   thrombocytopenia

Authors
D Mutter, J Marescaux
Abstract
This video demonstrates a three-trocar laparoscopic splenectomy performed for atypical idiopathic thrombocytopenic purpura in a 33-year-old patient. An anterior approach, as in this case, is a very interesting one as the spleen does not need to be manipulated in this patient.
Keywords
Three-trocar laparoscopic splenectomy, thrombocytopenia
Media type
Duration
12'23''
Publication
2009-09
Popular
Favorites
Favorites Media
Audio
en
Subtitles
en
E-publication
WeBSurg.com, Sept 2009;9(09).
URL: http://www.websurg.com/doi-vd01en2698.htm

Three-trocar   laparoscopic   splenectomy   for   thrombocytopenia

4. Dissection of the spleen\'s inferior pole 01'55''
During freeing of the inferior pole of the spleen, we can identify systematically short accessory vessels, arteries and veins joining the omentum. These little vessels have to be controlled by clip or electrocautery in order to avoid a tear of the capsule. These little vessels are controlled here with direct clip application. It is the safest way to control them avoiding any contamination of the operative field by blood. In this patient, the size of the artery requires to double the clips for safety reasons. The dissection of the inferior pole of the spleen is carried out from downwards to upwards very slowly and very gently in order to identify any further accessory vessels before dissection of the main pedicle of the spleen. Progressive dissection and identification of all the little vessels can be performed very easily. Here a second accessory vessel is controlled by clip application. After this application, the inferior pole of the spleen is completely free with a slight devascularization and dissection of the main splenic pedicle can start. Just anteriorly to the pedicle, a second accessory artery is identified. This artery is progressively dissected and the hook allows to really perform a very high quality dissection avoiding any bleeding in the operative field. Here again, direct application of clips allows to control this artery in a very safe way. The left hand of the operator holds the little peanuts preventing any drop of blood from coming into the operative field and allowing for a very safe retraction of the tissues, avoiding any tear and any blood oozing. The splenic pedicle can be very easily dissected. A grasper is passed behind this vessel but we decide to perform a selective control of the artery and of the vein in order to avoid a late arteriovenous fistula, which can occur in 10 to 15% of cases after several years.
6. Control and dissection of the splenic pedicle 05'28''
The artery is separated from the vein in order to have a separate control. As usually for a splenectomy for thrombocytopenia, we always start with the first control of the artery. This will allow like an autotransfusion of the patient, allowing the platelets located in the spleen to come back in the main circulation. The artery is first controlled with a suture and safety clips are placed on the side of the spleen in order to make a second control of the artery. This control of the artery led to a complete devascularization of the spleen. The surgeon has to make sure to avoid any manipulation of the spleen at this stage, which can lead to an effraction of the capsule and contamination of splenic tissue into the abdominal cavity, leading to postoperative splenosis. A complete control of the artery is achieved. Some more adhesions of the greater curvature behind the artery are freed in order to have a very good access to the vein. This is also done in order to give time to the spleen to be emptied of most of its platelets. The inferior aspect of the splenic vein is dissected. Then the splenic vein is controlled. As there is no more arterial vascularization, the splenic vein becomes very small-sized. Here it can be controlled with simple clip application. If its size is bigger, sometimes there is a need for stapling the vein. In this case, the size of the vein is less than 8mm and clips can be very easily applied on the vein to control it completely. The little stitch placed around allows to manipulate and expose the vein in a very nice way, which facilitates the positioning of the clips. The main splenic vein can be cut after this direct control.