Laparoscopic anterior splenectomy for hydatid cyst of the spleen

This video demonstrates a laparoscopic splenectomy for hydatid cyst using an anterior approach with patient in supine position. This approach was utilized to minimize splenic handling and to get control of hilar vessels early. A LigaSure bipolar cautery device was used to divide all the vessels including splenic hilar vessels. The spleen was removed through a muscle-splitting subcostal incision. This video provides the anatomic landmark and surgical approach for splenectomy using anterior approach.

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Laparoscopic anterior splenectomy for hydatid cyst of the spleen

Authors

J Leroy, J Marescaux

Abstract

This video demonstrates a laparoscopic splenectomy for hydatid cyst using an anterior approach with patient in supine position. This approach was utilized to minimize splenic handling and to get control of hilar vessels early. A LigaSure bipolar cautery device was used to divide all the vessels including splenic hilar vessels.
The spleen was removed through a muscle-splitting subcostal incision.
This video provides the anatomic landmark and surgical approach for splenectomy using anterior approach.

Classification

complex cases

Keywords

Anterior splenectomy, Hydatid cyst

Media type

Surgical video

Duration

07'00''

Publication

2006-01

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E-publication

WeBSurg.com, Jan 2006;6(01).
URL: http://www.websurg.com/doi-vd01en1911.htm

Laparoscopic anterior splenectomy for hydatid cyst of the spleen

1. Case presentation 00'13''

This is the case of a young patient with a hydatid cyst of the spleen. His main symptoms were discomfort and pain in the left hypochondrium and there was a palpable mass on examination. Specific immunological tests were positive and he had an associated severe eosinophilia. The preoperative diagnosis was established using ultrasound and CT-scanning and medical treatment without bendazole was placed in the form of adjuvant therapy before surgery in order to reduce the risk of recurrence. The patient is placed in a supine position with the legs abducted.

2. Patient positioning 00'56''

The table is in a right lateral tilt with reverse Trendelenburg. The surgeon is between the legs and the 2 assistants are situated on the right and left side of the patient.

3. Trocar placement 01'07''

The 5 trocars are placed along a linear curve below the left costal margin. The optical trocar is inserted on the mid-clavicular line below the left costal margin. The 2nd 12mm operative trocar is inserted on the anterior axillary line below the left costal margin. The 1st step of the procedure as we can see is exposure of the anterior surface of the splenic hilum. Once the anterior margin of the spleen is visualized, the omentum is retracted to the right making it possible to see the gastrosplenic ligament.

4. Exposure of gastrosplenic ligament 01'50''

The spleen is the 3rd common location for hydatid disease after the liver and lung. However, it still remains a very rare entity. The dissection continues with the opening of the lesser sac. This step is done with the use of the Ligasure. It also dissects the gastro-epiploic vessels and the splenocolic ligament. The next step is to dissect the pancreaticosplenic ligament extending from the tail of the pancreas. The hilar vessels are dissected with the Ligasure device without using clips. Alternatively, dissection can be done without the use of a Ligasure with dissection of each vessel and each being clipped. We find that there are significant time-savings using the Ligasure device. The splenic artery and vein are generally easy to identify and are dissected by the Ligasure.

5. Transection of splenic hilum 03'42''

The advantage of the anterior approach is that the splenic artery can be accessed within the lesser sac enabling vascular control of the spleen in a stable position. Also the vascular control is obtained prior to mobilization providing less blood loss and lower conversion rates. In the conventional posterior approach, it is often difficult to mobilize the spleen to the midline but in the anterior approach, the hilar vessels are dissected without requiring this mobilization. After dividing the hilar vessels the posterior and lateral attachments are dissected. A small swab can be utilized at the end of a retractor in order to retract the spleen atraumatically in a medial fashion. This aids dissection and at all times, close attention must be paid to hemostasis. The dissection continues anteriorly. The Ligasure allows the tissue to be coagulated and then divided. The spleen becomes increasingly mobile. It can at times be difficult to handle as it loses its attachments. However, with the atraumatic retraction, this can be allowed and performed so that the dissection can continue. The spleen is now fully mobilized and has been released from its attachments and now will be extracted through the left upper quadrant.

6. Extraction of specimen 05'48''

A customized bag is made in order to facilitate extraction. The incision in the place of the 5th trocar is increased in size and a bag is introduced through this incision. The bulky spleen is placed into the bag then it is removed by gentle traction on the bag through the left upper quadrant. The abdominal cavity is reinsufflated and the splenic bed is checked for any bleeding. This includes irrigation of the left upper quadrant in order to examine and ensure that hemostasis has been gained. The wound is then closed in 2 layers.

7. Wound closure 07'52''

This is the intact specimen following the procedure.

8. External view of specimen 07'54''

You can see the cyst which is now incised revealing its contents. Total splenectomy is advocated by most surgeons since it provides a minimal risk of recurrence and laparoscopic splenectomy has been successfully used for this disease.