Transcript Laparoscopic Splenectomy - University of Kentucky | Medical Center

Jessica McQuerry
University of Kentucky
College of Medicine
M1
 Female
in early 20’s presents with abdominal
discomfort and feelings of early satiety
 On physical exam, a palpable mass is found
in the left upper abdominal quadrant
A CT scan was
performed and showed
a splenic cyst
 Uncommon

Incidence of 0.07% in general population
 Majority
of cases are due to parasitic
infection with Echinococcus granulosus
resulting in hydatid disease
 Non-parasitic cysts account for < 1/3 of all
splenic cyst cases


Pseudo cyst (75%)
True cyst (25%)
 Surgical


cystectomy or splenectomy
Depends on the size of the splenic cyst
Depends on the position of the cyst in relation to
the splenic hilum
 Indications:


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
Idiopathic thrombocytopenic purpura (ITP)
Autoimmune hemolytic anemia
Microspherocytosis
Benign tumors and cysts
AIDS-related thrombocytopenia
 Relative


Hematological malignancies
Moderate splenomegaly
 Absolute
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
contraindications:
contraindications:
Massive splenomegaly
Portal hypertension
 Right
lateral decubitis, flexed at waist
 A cushion is placed under the lumbar fossa to
open up the operating field and facilitate
trocar placement
The surgeon faces the patient, the assistant is behind the patient. They
each have their own video screen. The camera person stands next to the
assistant.

Optical trocar, 10mm


Operating trocar, 5mm


Mid-axillary line below
left costal margin
Operating trocar, 5mm


Anterior axillary line
below the left costal
margin
Mid-clavicular line, a few
cm below the left costal
margin
Retractor or operating
trocar, 8-12mm

Mid-scapular line below
the 12th rib
 30⁰
scope
 Atraumatic graspers
 Ultrasonic dissectors
 Linear Stapler
 L-hook Electrocautary tool
 Flexible retractor
 Suction-irrigation device
 Specimen retrieval bag
 Spleen scoop
Exploration


Check for mobility
of the spleen and
location of possible
adhesions.
00:00- 6:40
Exposure

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Dissection of the
splenophrenic
ligament with the
harmonic scalpel.
6:40- 8:43 & 18:3023:20

Dissection of the
splenocolic
ligament.
9:14- 13:53

Check for and
remove any
attachments to the
abdominal wall.
13:53- 15:42

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Exposure and
transection of the
tissue and vessels in
the gastrosplenic
ligament.
23:20- 28:30
An L hook cautery is
used to dissect
some of the
retroperitoneal
attachments.
28:30- 31:32
 Drainage

of Cyst
Locate and drain
the splenic cyst
32:40- 42:20
Dissection of the
splenorenal ligament.
42:20- 46:27
 Careful dissection of
the splenic hilum.
46:27- 56:45
 Identify and staple
the splenic artery.
56:45- 1:02:03
 Identify and staple
the splenic vein.
1:02:03- 1:02:50

Splenic
Artery
 Detachment

Fully detach the
spleen by removing
any remaining
attachments.
1:02:50- 0:40 (2)
 Extraction

A bag is introduced in
the retraction trocar.
3:30 (2)
Insert the spleen in
the bag and close.
3:30- 19:20 (2)
 Pull the tip of the bag
up through the
retraction trocar.
31:20 (2)
 The bag is cut away
from the rim.
 The spleen is
morcellized with
spleen scoops and
removed.

 Closure

Check for tissue
damage and
accessory spleens
00:00- 5:31 (3)
 Liquid
diet- the night of or the morning after
surgery
 Regular diet and discharge from the hospital
by the second postoperative day
 Within two weeks, patients are usually able
to return to work
 Steroid dosages can be tapered rapidly and
then discontinued
 Intraoperative


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Uncontrollable bleeding
Injury to regional organs during dissection
More common with larger spleens
 Postoperative
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complications:
complications:
Minor wound infections
Postoperative ileus
Infection
 ITP:
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Recurrent or persistent decrease in the number
of blood platelets
Chronic ITP
 Curative
in about 50-60 percent of patients
 Improves another 20-35 percent
 Fails to help 5-10 percent
 Primary
benefit of laparoscopic is several
small incisions instead of one large incision
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Shorter hospital stay
Quicker recovery
Better cosmetic result
 Laparoscopic
technique
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procedure is a more demanding
Highly vascularized organ
Fragile parenchyma
Attached by several ligaments to other organs
Hematological disease often associated with a
low platelet count
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Targarona, EM. (2002, March). Laparoscopic splenectomy:
anterior posterior approach. Retrieved from
http://www.websurg.com/ref/media.php?doi=ot02en199a
The University of Texas Southwestern Medical Center at
Dallas. (2010). Laparoscopic spleen surgery. Retrieved
from
http://www8.utsouthwestern.edu/utsw/cda/dept48035/fi
les/89885.html
Adas, G, et al. (2009). Diagnostic problems with parasitic
and non-parasitic splenic cysts. BMC Surgery , 9(9),
Retrieved from http://www.biomedcentral.com/14712482/9/9 doi: 10.1186/1471-2482-9-9
Kalinova K. (2005). Giant pseudocyst of the spleen: A case
report and review of the literature. Journal of Indian
Association of Pediatric Surgeons, 10(3), Retrieved from
http://www.bioline.org.br/request?ip05044