Plate 143

Laparoscopic splenectomy is most commonly performed for immune (idiopathic) thrombocytopenic purpura (ITP) or other splenic conditions causing anemia or neutropenia. Massive trauma to the spleen as well as overly large spleens are still best approached with an open laparotomy. However, virtually all other indications for splenectomy listed in the preceding Plate 141 apply for laparoscopic splenectomy. A complete hematologic evaluation, including bone marrow studies, is essential. The patient must be informed of the lifelong consequences of increased susceptibility to bacterial infection. Ideally, the patient should receive polyvalent pneumococcal, H. influenzae, and N. meningitidis vaccination prior to surgery.

Patients for elective splenectomy are usually referred to the surgeon by hematologists or oncologists, because their treatment with blood products, corticosteroids, plasmaphoresis, gamma globulins, or chemotherapy can no longer safely control the primary disease. Accordingly, the patient may require transfusion of blood products to raise the hematocrit or platelet counts to safe levels for general anesthesia and coagulation during surgery. Packed red cells may be given in advance of planned surgery, whereas platelets, with their short life span, may be infused just prior to and during the procedure. When platelet transfusions are contraindicated, endogenous platelet counts are often temporarily boosted with a few days of increased corticosteroid therapy, immune globulin or Rho D immune globulin (winrho) prior to surgery. If steroids are used, then they must be continued during and immediately after surgery. The patient should have a type and screening blood test, and blood products must be available for infusion. The size of the spleen should be determined by physical examination or imaging studies, as massive spleens are more safely approached by open splenectomy.

General anesthesia with endotracheal intubation is required. Two large, well-secured intravenous catheters are placed for easy access by the anesthesiologist. The intravenous sites and any finger pulse oximeters should not be positioned distal to an arm blood pressure cuff. A Foley catheter and an orogastric (OG) tube are passed and pneumatic sequential compression stockings are applied to the lower legs. Care must be taken in the placement of the endotracheal, OG, and Foley tubes in patients with marked thrombocytopenia lest bleeding occur.

The patient is placed in a lateral position with the left arm crossing the chest and lying on top of the right arm. Liberal padding is used between and around both arms. The left hip and chest are elevated with pillows, leaving the flank area open and the left knee flexed, with a padding of blankets between the legs. The patient is secured across the chest and hips to the table with wide adhesive tape, as the operating room table will be tilted.

The skin is prepared from the lower chest to the pubis in a routine manner.

A 5-mm videoscope port is placed either through the umbilicus or in the lateral midsubcostal position using the open technique of Hasson as described in Plate 91. The videoscope is introduced and all four quadrants of the abdomen are examined. The size and location of the spleen and the presence of accessory spleens are noted. A second 10-mm port is placed in the left lateral subcostal position and a 12-mm port is placed just to the left of the midline. These ports are in a line about two fingerbreadths or so below the edge of the costal margin for a normal-sized spleen. Additional locations or ports may be placed according to the preference of the surgeon, the size of the spleen, and the shape of the patient's body. In general, larger spleens require a lower (more caudal) and more medial placement of ports. The patient is positioned with the left side up and then placed in a reversed Trendelenburg position.

The general anatomy of the spleen, stomach, colon, and omentum is shown in Figure 1, which complements the cross-sectional anatomy of this region shown in Plate 141. The splenocolic ligament is visualized along with the greater omentum in its attachment to the transverse colon is visualized. The splenic end of this ligament is elevated with traction (Figure 2) and a suitable zone just above the splenic flexure of the colon is entered with the ultrasonic dissector. This elevation is done with grasping and gentle traction using a dissecting instrument. The dissection proceeds medially around the tip of the spleen, where the gastrosplenic ligament containing the short gastric vessels is identified. Using blunt dissection, the lesser sac is entered and the short gastric vessels are sequentially divided about 1 cm away from the gastric wall (Figure 3). This cuff minimizes potential thermal damage to the stomach. As the dissection proceeds toward the gastroesophageal junction, care is taken to visualize each short gastric vessel within the jaws of the ultrasonic dissector before it is activated. Partial transection of the next short gastric vessel will result in bleeding that is difficult to control. Exposure for this dissection within the gastrosplenic ligament is improved by gentle retraction of the greater curvature of the stomach, using the dissecting instrument to lift the greater curvature forward and medially. The pancreas, with the splenic artery and vein running along its superior or cephalad border, is seen in the base of the lesser sac. The short gastrics are divided almost to the gastroesophageal junction (Figure 4).

The splenorenal ligament is opened by gently elevating the spleen medially with the dissecting instrument (Figure 5). This thin peritoneal layer is easily seen in the left gutter behind the spleen. The ligament has few vessels, but it must be transected with coagulation in a cephalad direction until the top of the spleen is free. The splenic pedicle is inspected in all areas by lifting the spleen from side to side to make certain that no ligamentous attachments remain. The spleen should be completely mobile on its vascular pedicle (Figure 6).

Next >