Laparoscopic splenectomy or removal of the spleen has largely replaced open splenectomy for the treatment of many diseases when the spleen tends to remain normal in size. This procedure is also referred to as minimally invasive or keyhole splenectomy.
Splenectomy for the diseases listed below (with the exception of cancer) is usually a second-line treatment after steps at medical management have failed.
Idiopathic thombocytopenic purpura (ITP)
Primary and secondary hypersplenism
Thombotic thrombocytopenic purpura
Cysts and tumors
Significant trauma to the spleen
Spleens that become enlarged through an underlying disease process should strongly be considered for open splenectomy.
Surgical Details of Procedure
1. The greater omentum at the attachment of the transverse colon is visualized and grasped with laparoscopic forceps and retracted laterally toward the right side of the body.
2. The splenocolic ligament is visualized.
3. The splenic side of the splenocolic ligament is elevated through traction with grasping forceps.
4. An ultrasoud dissector (e.g, Harmonic Scalpel) is used to cut the splenocolic ligament with care taken to sufficiently obliterate any small vessels running in this plane.
5. The gastrosplenic ligament containing the short gastric vessels is then visualized.
6. The greater curvature of the stomach is grasped and gently retracted to medially to facilitate exposure and transected of the tissue and vessels in the gastrosplenic ligament
7. Using a blunt dissector, a small hole in an avascular space in the gastrosplenic ligament is made.
8. An ultrasound dissector is used to obliterate and cut the short gastric vessels approximately 1 cm from the greater curvature of the stomach to decrease the likelihood of thermal injury to the stomach.
9. As the dissection proceeds toward the esophagus, meticulous care must be made to visualize each individual short gastric in the jaws of the ultrasound dissector before the device is activated to obliterate and cut the tissue and vessel (partially cutting the next most cephalad vessel will result in bleeding that is difficult to control).
10. The division of the short gastric vessels is carried up to the gastroesophageal junction (the area where the esophagus joins the stomach).
11. The spleen is then gently lifted medially by using a dissecting forceps to expose the splenorenal ligament (i.e., the tissue between the spleen and left kidney).
12.The ultrasound dissector is used to transect (cut) the ligament tarting caudally (toward the feet) and proceedidng cephalad (toward the head).
13. The splenorenal ligament is completely transected so that the spleen is completely mobile on its vascular pedicle (the artery and vein to the spleen).
14. The spleen is then gently lifted upwards to better expose the vascular pedicle.
15. The splenic artery lying superior (on top of) the splenic vein is then carefully dissected free.
16. Care must be taken to dissect distal to (i.e., past) the tail of the pancreas but proximal to (i.e., before) the trifurcation (three-way splitting) of the artery at the splenic hilum.
17. In some patients, the tail of the pancreas obscures the single splenic artery and the individual branches of the trifurcated splenic artery are dissected free.
18. The now dissected splenic artery is placed between the jaws of an endoscopic vascular stapler (usually white-colored) placed through one of the 10 mm ports in the abdominal wall.
19. The grasped artery is rotated 180 degreess to gain visualization of the tips of the stapler to insure that no tissue has been grasped that would prevent full approximation of the stapler jaws.
20. The endovascular stapler is fired transecting the artery.
21. The underlying splenic vein is dissected free from the surround tissues and transected in a manner similar to the splenic artery.
22. One of the previously placed 10 mm ports in the abdominal wall is removed with blunt finger dilation of the site to approximately 12 mm.
23. A large, reinforced plastic bag mounted on an introducer is then placed through the 12 mm port site and the bag is opened so that the arrows marked on one side of the rim are pointing to the left flank.
24. The spleen is placed into the bag, the bag is closed, and the spleen is pulled partially through the 12 mm site until one edge of the rim is visualized.
25. The bag is then cut away from the rim.
26. The spleen is then morcellized (pulverized) bluntly using the finger or with a rigid ring forceps.
27. The spleen is then removed in pieces with care taken during this process to not puncture the plastic bag.
28. After the spleen and bag have been removed the left upper quadrant is lavaged (rinsed with clear fluid) and a careful inspection of the dissection planes is undertaken to look for bleeding.
29. The tail of the pancreas is inspected for damage with placement through one of the port sites of a closed suction drain (e.g., Jackson Pratt) if there is concern. Many surgeons routinely leave a drain even in the absence of visual damage to the pancreas.
30. A search for accessory spleens is performed and if present are excised using the ultrasound dissector.
31. The ports are removed from the port sites under direct visualization.
32. The Hasson cannula site and the 10-12 mm sites are closed with interrupted 0 absorbable or delayed absorbable suture (e.g., Vicryl or Maxon).
32. The skin sites are closed with a 4-0 subcuticular suture such as Monocryl.
33. Steri-strips are placed on the wound sites.
The oralgastric (OG) tube or nasogastric (NG) tube is generally removed before the patient emerges from anesthesia. Clear liquid diet is started with 1-2 days and advanced as tolerated. Sequential compression devices and chemoprophylaxis (e.g., heparin or enoxaparin) for deep vein thrombosis prevention is started by the morning of the first postoperative day. The patient is placed out of bed on the first post-operative day.
Corticosteroids are tapered over a several day to week period to baseline levels. If the indication for surgery was a hematological abnormality, serial blood counts are performed for several days. Consultation with an oncologist or hematologist is almost always sought.
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