Splenectomy and Related Procedures
Depending on the type of splenic pathology encountered, the minimal access approaches involve the complete or partial resection of the spleen and splenic tissue. This chapter deals with both total-laparoscopic splenic resection as well as partial-laparosc
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51
Splenectomy and Related Procedures Paul Philippe
51.1
Operation Room Setup
Surgical Team Position
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Chapter 51 Splenectomy and Related Procedures
51.2
Patient Positioning
Right lateral decubitus with a roll under the right flank. If associated with cholecystectomy, a 45° lateral decubitus position is preferred (the table is tilted to the side for the splenic part and returned to neutral position for the biliary part of the procedure).
51.4
Location of Access Points
Port Placement Sites
51.3
• • • •
Special Instruments
EnSeal® (SurgRx, Redwood City, CA, USA) Tissue Sealing Device (TSD) or Ultracision® harmonic scalpel (Johnson & Johnson Medical Products, Ethicon Endo-Surgery, Cincinnati, OH, USA) or 5-mm clip applicator Tachosil® (Nycomed GmbH, Zürich, Switzerland)
Paul Philippe
51.5
Total Splenectomy
51.5.1
Indications
51.5.2
Contraindications
1. Hematologic disorders including hereditary spherocytosis. 2. Immune thrombocytopenic purpura. 3. Sickle cell anemia. 4. Tumors.
1. Hemodynamic instability (trauma). 2. Splenic abscesses. 3. Massive splenomegaly requires advanced skills and experience. Consider preoperative embolization.
51.5.3
51.5.4
Preoperative Considerations
Technical Notes
1. Consider pneumococcal vaccination and perioperative penicillin administration. 2. Consider partial splenectomy in hemolytic disorders. The extent of resection depends on the severity of hemolysis (resect the larger part of the spleen if hemolysis is severe). 3. Type- and cross-matching is prudent in partial splenectomies. Platelet transfusion may be necessary.
1. Insert trocars under visual guidance to avoid splenic injury in cases of splenomegaly. 2. The artery and vein should be dissected and occluded separately. 3. Keep the spleen attached to the left upper quadrant and use gravity to retract the stomach and colon. 4. A large, spring-loaded specimen-retrieval bag allows the surgeon to “scoop” the spleen from its lower pole upward. 5. Retrieve the bag through an enlarged umbilical incision. Use fingers or atraumatic forceps to morcelate the spleen, since rupture of the specimen-retrieval bag carries the risk of splenosis.
51.5.5
51.5.6
Procedure Variations
1. Dorsal decubitus positioning of the patients can be done; however, this requires more ports for exposure. 2. Vascular control can be achieved safely with intracorporeal ligatures, but it is faster with a TSD. 3. The specimen can be extracted through a Pfannenstiel incision in the case of massive splenomegaly or if an intact specimen is required for pathological evaluation.
Laparoscopic Total Splenectomy
Please see Figs. 1–8.
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Chapter 51 Splenectomy and Related Procedures
Figure 51.1
With the spleen lifted by the flank instrument, the colosplenic ligaments are taken down
Figure 51.3
The dissection of the splenic hilus is performed with the intention of isolating the splenic artery from the vein
Figure 51.2
The gastrosplenic ligament (short gastric vessels) is opened with the LigaSure™ tissue-seal
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