Plate 144
###### Figure 10

The area chosen should be distal to the tail of the pancreas but proximal to the trifurcation of the splenic vessels. Dissection is performed until the vessels can be safely encompassed within the jaws of an endoscopic vascular stapler. This instrument currently requires a 12-mm port. It is common practice to use a vascular stapling device to occlude and divide the entire splenic pedicle together. In some cases it is preferable to individually ligate the splenic artery and vein using the endovascular stapler. When this technique is employed the artery should be divided first. If either splenic vessel is entered during the dissection, emergency control of the hemorrhage is obtained by cross-clamping both the splenic artery and vein with the dissecting instrument (Figure 7). As all collateral vessels to the spleen have been transected, only temporary back bleeding should occur. This maneuver allows the surgeon to place another operating port for further proximal dissection and stapling of the splenic artery and vein or to control the hemorrhage during conversion to an open procedure.

When the tail of the pancreatic tissue extends into the hilum of the spleen, the zone for transection of the splenic vessels is quite short. Dissection is more difficult, as the vessels may have divided into their branches. In this case, the pedicle may be taken in serial transections, as opposed to stapling of the vascular pedicle en bloc (Figure 8). In reality, the splenic artery and vein are rarely skeletonized as cleanly as shown in these illustrations, but the general principle is that the tissue to be stapled must be contained well within the span of the stapling instrument's jaws. A useful maneuver is a 180-degree rotation of the stapler to ensure that no tissue or vessels extend beyond the staple zone within the instrument's jaws.

A reinforced oversized plastic bag is placed through a large port site. This special bag comes in an extra-large instrument that usually requires removal of a 10-mm port and finger dilation of this site to approximately 12 mm. The videoscope is used for visualization as the collapsed bag and instrument are passed through the abdominal wall. The bag is opened, noting the arrow orientation on its rim. The spleen is placed into the bag (Figure 9), which is closed. This reinforced bag is then partially withdrawn through the abdominal wall until the open rim of the bag is under control outside of the abdomen. The bag is cut free from the carrier using ...

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