Laparoscopic splenectomy by posterior approach

This "live" surgery demonstrates the posterior approach to splenectomy. Dr. Mutter, MD, PhD, describes each step of the procedure as he performs it. There is an interactive discussion with the audience. The tail of the pancreas was adherent to the splenic hilum and the LigaSure device is used to discover this plane. The authors mark the margin of costal margin and place a 12-mm trocar through an incision at the anterior costal margin. They then place a 5-12 mm trocar 5 cm anterior to the first trocar, and a third 5-cm trocar 3-4 cm below the costal margin.

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Laparoscopic   splenectomy   by   posterior   approach

Authors
D Mutter, J Marescaux
Abstract
This "live" surgery demonstrates the posterior approach to splenectomy. Dr. Mutter, MD, PhD, describes each step of the procedure as he performs it. There is an interactive discussion with the audience. The tail of the pancreas was adherent to the splenic hilum and the LigaSure device is used to discover this plane.

The authors mark the margin of costal margin and place a 12-mm trocar through an incision at the anterior costal margin. They then place a 5-12 mm trocar 5 cm anterior to the first trocar, and a third 5-cm trocar 3-4 cm below the costal margin.
Keywords
splenectomy, posterior approach
Media type
Duration
19'00''
Publication
2007-01
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Jan 2007;7(01).
URL: http://www.websurg.com/doi-vd01en2033.htm

Laparoscopic   splenectomy   by   posterior   approach

2. Posterior mobilization of the spleen 01'13''
The 1st step if the dissection will be an inferior and posterior mobilization of the attachments of the spleen. I’ll show that there is little risk of colic injury but you must always control the position of the left flexure of the colon if you have to insert your instruments; you see here that’s a safe insertion and we are far away from the colon. The dissection will first give a little place to create an operative field since I’m sure that I don’t have any problem with the colon. Here you see that due to the size of the spleen and to identify the landmarks I have to remove slightly the spleen. And for this I don’t use this grasper, which may be traumatic but I’ll use a little peanut and so the dissection will start with the inferior mobilization of the attachments of the spleen. The objective is to have the spleen fall down in the right part of the abdomen thanks to the freeing of all small attachments. Port number 4 is placed posteriorly and has the objective to put some tension on the tissues. This will be a 10mm port that will allow insertion of peanuts for gentle retraction. The orientation of the trocar is towards the operative field in order to avoid any traction and tension on the parietal wall during the whole procedure. The position with these ports is very important to get the right aspect. It’s essential to reproduce the triangulation, and here again the objective will be to free the spleen. The main danger of this posterior approach can be the pancreas. So we have to avoid going too deep in the fat until we identify the pancreas. Is the patient in true lateral decubitus or partially rotated? It’s not a 90 degree lateral position but an 80 degree one. It’s a lateral position but with the patient’s back not completely vertical; this allows the spleen to fall down and to keep an easier posterior access and we can still tilt the table to the right or to the left if we have to modify a little bit the position of the spleen. This posterior dissection will be continued until the identification of the left crus. At this stage, there are fewer risks, no major organs there. The only risk is to get an injury of the spleen and hereby get bleeding in the operative field. I will open this fascia in order to join the upper pole of the spleen. Then we will start again going from the inferior pole to the upper pole of the spleen. One of the objectives will be to join the lesser sac. So probably the pancreas which we don’t want to mobilize due to the size of the tumor, we’ll try to identify the pancreas completely. One of the advantages of the posterior approach is to control the vessels really in the hilum with a total identification of the pancreas. We really want to avoid any injury of the pancreas. Do you have a maximum size for the laparoscopic approach? Well, we always try using laparoscopy and it’s sometimes strange to say that very big spleens we’ve done 27cm, it’s difficult in terms of exposure but usually there’s a big distension of all the meso and attachments, and if you can identify the vessels, it’s a little bit longer but not very much difficult. So we are progressively opening the fat and look for any vessel that can be here in the operative field. Here we guess there’s something between the spleen and the pancreas. Here you see a little vessel and probably the freeing of this vessel will give us access to the lesser sac anteriorly.
3. Dissection of pancreas 07'00''
And this would be an interesting landmark for the dissection. Here you can clearly see the pancreas, the spleen, and now I have my dissection plane between the pancreas and the spleen. That’s an interesting landmark for carrying on the dissection. Through this route, we’ll have access to the lesser sac. The tail of the pancreas is here really impacted in the splenic hilum. I will now go ahead with the upward freeing of the different adhesions. I like your idea of the sponges. You see very often that people injure the spleen with their regular instruments so it’s a great idea. And this little sponge has to be bigger than the instrument. You see that every time that you can cut 1 or 2 more millimeters of peritoneum, your spleen is mobilized laterally. Again the objective is to free the upper pole and the lower pole of the spleen. The assistant puts some tension on the upper pole of the kidney and the adrenal gland at this level. Here we are on the diaphragm; at this moment we did not identify clearly the stomach because we have a big upper tumor, and the objective is to have a good identification of the stomach and the possibility to control the short gastric vessels. The only danger here is to have a small direct vessel that can bleed. We need to go closer to the spleen and we will try to lower the pancreas to control such vessels. If we can separate them from the pancreas, we should get access to the lesser sac this way. And this access should allow us to have an anterior control of the anterior part of the pancreas. It’s very unusually dense tissue. Is that near the tumor? At this level, I don’t think so. The tumor seems to be much more at the upper pole of the pancreas. The hook does not go through. I will once again change the position of the dissection. This presentation is quite unusual but this big tumor has pushed the whole pancreas and vessels down. We have a direct vessel here.
5. Division of short gastric vessels 15'10''
We will free the greater curvature of the stomach. We cut the short gastric vessels. See the spleen has completely changed in size and color. So I have cut the main artery, there’s probably some accessory artery coming from the hilum. Here I have the pancreas so now that I have a safer dissection, I will be able to go ahead. Probably a little artery remaining here, and then I will finish this posterior dissection after the anterior one. I go ahead with the blunt dissection of the greater curvature here. We control the short gastric vessels. Dissection is now completed upwards. One or 2 applications, which is the safest bipolar cautery we can do, and thanks to this control, we can lower the pancreas very safely. We have to finish with application of some Ligasure device because the pancreas is into the spleen. We will control after placing the specimen in a bag. Now that we have removed we can see very clearly. The spleen is slightly bleeding but there is no artery anymore. The pancreas was in the tail. Here we have dissected what was the difficult part into the spleen. We have to complete the mobilization of the specimen posteriorly here. And we just have a short gastric vessel here close to the stomach. Here dissection is completed anteriorly and posteriorly. And we go in the spleen. And we have the last short gastric artery, we see very well the vessel upward. We can see here the stomach, which is free, and the specimen is free in the abdomen.