Totally laparoscopic splenectomy for benign splenic cyst

Splenic cysts are rare lesions. Splenectomy is the treatment of choice. This video demonstrates a totally laparoscopic splenectomy. The procedure is performed with the patient placed in a supine position with a slight right lateral tilt. An open laparoscopy is carried out systematically. Four ports are used: one port to retract, two operating ports and another port to accommodate a 5mm scope with a high definition camera.

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Totally laparoscopic splenectomy for benign splenic cyst

Authors

D Mutter, L Soler, J Marescaux

Abstract

Splenic cysts are rare lesions. Splenectomy is the treatment of choice. This video demonstrates a totally laparoscopic splenectomy. The procedure is performed with the patient placed in a supine position with a slight right lateral tilt. An open laparoscopy is carried out systematically. Four ports are used: one port to retract, two operating ports and another port to accommodate a 5mm scope with a high definition camera.

Mots-clés

Totally laparoscopic splenectomy, benign splenic cyst

Type de vidéo

Vidéo chirurgicale

Durée

08'34''

Publication

2009-10

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Oct 2009;9(10).
URL: http://www.websurg.com/doi-vd01en2684.htm

Totally laparoscopic splenectomy for benign splenic cyst

1. Clinical case presentation 00'19''

We report the case of a patient referred to our emergency unit because of pain in the left hypochondrium. The first etiological examination includes ultrasonography and CT-scan that demonstrates the presence of a tumor located in the splenic hilum. This tumor, although calcified, does not reveal that it is benign or malignant. Diagnosis of splenic artery aneurysm is suggested although there is no revascularization within this lesion. The lesion, about 6cm in diameter, is intimately attached to the vascular pedicle. The second diagnosis suggested is that of a cyst in the upper pole of the spleen. No trauma is mentioned. Faced with the risk of rupture of vascular aneurysm, a splenectomy is decided upon in order to remove this lesion. The surgical procedure is performed laparoscopically. A preoperative simulation with a vascular reconstruction is carried out prior to the actual procedure in order to precisely define the therapeutic modalities. Considering the position of the lesion, spleen preservation is not recommended since the vascular pedicle is intimately inserted in this cystic lesion.

2. Patient and trocar positioning 01'31''

The procedure is performed with the patient placed in a supine position with a slight right lateral tilt. An open laparoscopy is carried out systematically. Four ports are used: one port to retract, two operating ports and another port to accommodate a 5mm scope with a high definition camera. The procedure starts with a primary approach of the splenic pedicle.

3. Gastric fundus mobilisation 01'58''

The gastric fundus is mobilized using ultrasonic scissors. This mobilization helps to access the lesser omentum and approach the splenic pedicle safely. Given the size of the lesion, an anterior approach is preferred in this patient.

4. Lower splenic pole mobilisation 02'24''

The primary vascular dissection being uneasy, the attachments of the lower splenic pole are further mobilized. The objective is to obtain a very good view onto the splenic pedicle.

5. Vessels control 02'47''

The first direct vessels are controlled, dissected and ligated either using electrocautery (with a Ligasure device) or using ultrasonic dissection if these vessels are smaller in size. The gastric fundus is also intimately attached to the cyst. The entire freeing of the lower pole of the spleen helps to expose the vascular splenic pedicle, which is then freed distal to the spleen. The objective is to achieve a total control of the splenic vein and artery respectively before any other mobilization and before any complementary maneuver.

6. Identification of the splenic artery 03'37''

The splenic artery is easily identified: a right-angle forceps allows to control its vascular elements.

7. Ligation of the splenic artery branches 03'46''

The main splenic artery divides into two branches: the inferior branch is ligated first, followed by the dissection of a superior branch. Between these two branches, the splenic vein becomes visible. As for the inferior branch, the superior branch is also ligated using an intracorporeal ligature. The benefit of this ligature is to keep the possibility of using an automatic stapler as it would not be possible should metal clips be used. The gastric fundus is then further freed. In the event of a vascular aneurysm, a primary vascular control precludes any potential bleeding that may occur at the level of this lesion. Very dense inflammatory adhesions are taken down. However, although slightly inflammatory, these adhesions seem old. The freeing is continued in contact to the cyst. The stomach being completely freed, the splenic pedicle now needs to be freed. The initial ligature of the arteries allows to retract the vascular arterial pedicles in order to dissect the artery over a length that is sufficient to apply additional clips and divide them.

8. Splenic vein identification 05'17''

The splenic vein is identified posterior to the arterial pedicle. The arterial ligature is an initial safety measure. The entirely devascularized spleen can also be seen on the right; we are therefore certain that a good arterial control has been achieved, but also that we have the spleen’s complete vascular arterial pedicle controlled. Similarly to the inferior branch, the branch that supplies the spleen’s superior pole is dissected, ligated and controlled by applying complementary clips in addition to the ligature. Associating clips and ligature offers the best results in terms of safety. As the artery and the lesion are completely devascularized, the dissection will now focus on the splenic vein. As the spleen is no longer vascularized, the splenic vein’s blood pressure has diminished and it is therefore easy to dissect the splenic vein all around and to control it. Taking its devascularization into account, a slight traction using a suture passed behind the splenic vein allows to significantly reduce its diameter. It can then be controlled using clips, which once again, are supported by the intracorporeal ligature. The spleen is then completely detached of its main vascular attachments.

9. Freeing the lienorenal ligament 07'19''

The lienorenal ligament’s attachments now remain to be freed posteriorly after having identified the plane posterior to the lesion and in contact to the spleen. This is performed using the ultrasonic dissector. This instrument allows to divide inflammatory, vascular, and connective elements. The spleen’s superior pole is now completely free. As the spleen’s inferior pole was freed earlier, there now remains the posterior lienorenal ligament as a spleen attachment, which we will approach from the spleen’s inferior pole. It can be seen here that this approach in a patient placed in a supine position does not cause any major problems, the spleen’s retraction throughout the whole dissection aside. To avoid having to perform a second ligature of the already controlled pedicle, we complete the freeing of the attachment around the splenic vein where the vein was controlled previously. A venous branch resists: it is a short vessel between the posterior aspect of the stomach and the spleen. This short vessel has a smaller diameter and is controlled by clip application. This allows to entirely free the inferior part of the gastric fundus.

10. Freeing the posterior attachements 08'58''

A few posterior attachments in contact to the pancreas’ anterior aspect are freed using the ultrasonic dissector. The posterior peritoneal fold is approached from its superior section as the spleen is slightly elevated. The latter is now completely free in the peritoneal cavity. It is taken out with the lesion after introduction in an extraction bag. The pathological findings confirm a splenic cyst with no additional aneurysm of the splenic artery. The postoperative outcome is uneventful and the patient is discharged on the 2nd postoperative day.