Laparoscopic splenectomy: posterior approach

The video demonstrates a posterior lateral approach to mobilization of the splenic hilum in a patient with a large spleen. The division of the lateral attachments allows the spleen to fall forward and thus open up the window to the vascular pedicles, which are then dissected and clipped and divided. The pancreatic tail is visualized and protected during the dissection. The specimen is put into a large bag and retrieved through an enlarged port site.

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Laparoscopic splenectomy: posterior approach

Authors

D Mutter, J Marescaux

Abstract

The video demonstrates a posterior lateral approach to mobilization of the splenic hilum in a patient with a large spleen. The division of the lateral attachments allows the spleen to fall forward and thus open up the window to the vascular pedicles, which are then dissected and clipped and divided. The pancreatic tail is visualized and protected during the dissection. The specimen is put into a large bag and retrieved through an enlarged port site.

Classification

routine cases

Keywords

spleen, operation, resection, laparoscopy, posterior lateral approach

Media type

Surgical video

Duration

12'00''

Publication

2002-10

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E-publication

WeBSurg.com, Oct 2002;2(10).
URL: http://www.websurg.com/doi-vd01en1340e.htm

Laparoscopic splenectomy: posterior approach

1. Introduction 00'19''

With the patient in a lateral decubitus, 3 trocars are inserted in the left subcostal area. This patient was referred to us for a hemolytic anemia and thrombocytopenia.

2. Mobilization of the spleen 00'40''

The 1st step is the mobilization of the parietal ligament of the spleen. We mobilize the left colic flexure. This maneuver facilitates the section of the inferior pole of the spleen. A ring of 1cm of peritoneal tissue should be left on the lateral edge of the spleen. This tissue can be used for retraction avoiding contact between instruments and the splenic capsule. With the patient in a lateral decubitus, a complete mobilization of the posterior lateral aspect of the spleen allows displacement of the organ towards the right part of the abdomen facilitating access to the vascular structures from behind. In order to achieve adequate mobilization, the dissection should be performed up to the left crura of the diaphragm. In transparency, you might see the superior pole of the kidney. Indeed, this approach is the same as we use for a laparoscopic left adrenalectomy. Here you can see how leaving adequate margins of the peritoneal tissue helps to handle the spleen safely. In this case, due to the size of the spleen, we insert a 4th trocar to allow for a better exposure of the inferior pole.

3. Posterior dissection of the vessels 03'00''

Now you can see the splenic vessels. We are dissecting on the posterior sheet of the splenogastric ligament. Now you can see the greater curvature of the stomach and short gastric vessels. We introduce a 5mm clip applier to control short gastric vessels. However, the Harmonic scalpel or the Ligasure might also be used. The inferior vascular pedicle of the spleen is dissected carefully and progressively to allow for selective ligature of the vessels. The inferior branch of the splenic artery is divided between clips. This venous branch from the inferior pole of the spleen requires clip application as well. As you see, dissection of the hilum of the spleen is performed very carefully due to the close proximity of the tail of the pancreas.

4. Dissection of the hilum 06'29''

The splenopancreatic ligament is approached from posteriorly to anteriorly. Remember that the patient is in a lateral decubitus and the spleen retracted medially while we are wheeling its posterior aspect. The spleen can now be retracted anteriorly in order to better expose the hilum and the remaining attachments.

5. Dissection of the splenic vessels 08'06''

When the hilum of the spleen is exposed, careful dissection allows to isolate splenic artery and vein. The tail of the pancreas is separated from the hilum of the spleen by completing the dissection of the splenopancreatic ligament. In this way, we achieve complete mobilization of the spleen, which will be then only attached to its main vascular structures. This allows a safer use of vascular staplers. The tail of the pancreas is now completely separated from the hilum of the spleen. Section of the anterior sheet of the splenopancreatic ligament is now completed. Note how ligation of the arterial supply significantly decreases the volume of the spleen. This facilitates exposure of the splenic vein. Once complete mobilization is achieved, the spleen is suspended to better expose the vein and allow for a safer use of the circular stapler. At this point, the spleen is completely freed. You can see the 2 branches of the splenic artery that have been ligated and divided. One 15mm Endobag is inserted through one of the trocar sites. A subcostal incision is performed to remove the spleen.

6. Removal of the spleen 11'00''

Control of the operative site shows no source of bleeding and both branches of the splenic artery and the splenic vein appear to be under control. However, a Redon drain might be placed and kept for 24 hours.