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LAPAROSCOPIC SPLENECTOMY FOR SUBCAPSULAR HEMATOMA: MEDIAL APPROACH

1. Case report

Here, we present the case of a 29-year-old young woman. Her medical history is cholecystectomy in 2009 and a Nissen procedure in 2011 for gastric reflux. She was admitted to our unit for acute abdominal pain in the left hypochondrium after minimal blunt trauma. She was hemodynamically stable. A CT-scan was made two days before her admission to a peripheral hospital. This CT-scan showed spleen enlargement with a subcapsular hematoma measuring 6x3cm with minimal hemoperitoneum. On admission, the hemoglobin rate was 12.3, CRP 15, white cell count 7,700. A conservative treatment was first decided upon but after 24 hours, the patient was unable to respect medical instructions. Finally, a surgical treatment was proposed and after the patient gave her informed consent, we decided to perform a laparoscopic splenectomy using a medial approach.

2. Port placement 

Five ports are used. They are all placed in the left hypochondrium. The patient is positioned in a right lateral decubitus, at a 30-degree angle with her left arm on the back. After the creation of the pneumoperitoneum using a Veress needle, we inserted the first optical port (10-12mm) on the mid-clavicular line between the xiphoid process and the umbilicus. Three other 5mm ports are placed, one on the anterior axillary line, the other on the right of the mid-clavicular line one fingerbreadth underneath the left costal edge. Finally, the last port is placed between the optical port and the 5mm port on the anterior axillary line.

3. Exploration

Once the five ports have been introduced, the exploration of the abdominal cavity allows to identify a minimal blood effusion. As a result, a medial vascular approach using the Sonicision™ cordless ultrasonic dissection device is decided upon.

4. Access to splenic artery and vein

Approach to the splenic artery and vein is first performed. The gastrosplenic ligament is very progressively opened and a meticulous dissection is performed underneath and above the two vessels, which are progressively dissected. Blunt dissection allows to isolate both the vein and the artery selectively in order to prevent any bleeding. Dissection is still carried out using the ultrasonic dissector; however, it is completed by means of a 5mm dissector passed through the right subcostal port. This allows to selectively isolate the artery and the vein in turn. A vascular tape is passed around the artery and passed again according to Blalock's technique to prevent any bleeding. Therefore, a clip is placed on this vascular tape to identify the artery. The same maneuver is performed in order to control the vein. The latter is dissected bluntly using the 5mm dissector. Once the vein has been controlled, a tape is placed. Two clips are then positioned on the vascular tape in order to easily and rapidly distinguish the artery from the vein and to prevent any massive hemorrhage during the dissection of polar vessels. The tape is finally passed around the artery and tightened around it according to Blalock's technique. A clip allows to leave the vascular tape under tension.

5. Control of lower pole vessels

Dissection is then pursued towards the inferior pole of the spleen. The gastrosplenic ligament is then opened. It is well visible here. It is reaching from the greater curvature of the stomach until the splenic hilum. Once the gastrosplenic ligament has been freed, attachments of the spleen to the splenic flexure can be seen. Dissection is then meticulously carried on towards the spleen's inferior pole in order to control the entire vessels. Here, the omentum of the greater curvature is visible. It is isolated and kept away. The dissection plane is identified again towards the spleen's inferior pole and the lower pole vessels of the spleen become visible. The splenic artery and vein are controlled and dissection is performed along a lower pole branch. During the dissection, a left gastro-epiploic artery can be clearly seen. It is progressively dissected along with the vein lying more posteriorly. The left gastro-epiploic artery is clipped and finally divided. The same maneuver is performed with the vein lying more posteriorly. The gastro-epiploic artery is controlled and divided. The posterior left gastro-epiploic vein is dissected. The branching of the left gastro-epiploic vein towards a lower pole splenic vein is clearly visible. The lower pole splenic vein is clipped and divided. Dissection plane after plane as well as the vascular approach is carried out from anteriorly to posteriorly as vascular elements are progressively controlled. Once this vein has been controlled, dissection is performed more deeply and a larger artery can now be observed. Dissection is carried out using cold scissors in order to avoid any contact between the ultrasonic dissector and the clips and any ultrasonic propagation. Dissection is progressively performed along the artery by means of cold scissors. As a result, each vascular element can be controlled and a pancreatic branch can be visualized. A caudal pancreatic artery and a lower pole splenic artery are clearly visible. It is decided to preserve this caudal pancreatic branch and to proceed with the dissection of the lower pole splenic artery only. It is then clipped and divided. This dissection allows to preserve this caudal pancreatic artery. Once the artery has been controlled, it is divided using cold scissors and dissection is carried on in this vascular plane.

6. Control of upper pole vessels 

At this moment, all lower pole splenic vessels are controlled and the ultrasonic dissector can be used again in order to access upper pole splenic branches. Here, no vascular element can be seen until the upper pole splenic branch is approached. It is visualized at this moment. It is then dissected on each side, hence allowing for an approach by means of the dissector once it has been dissected over a sufficient length. The use of the Sonicision™ cordless ultrasonic dissection device (Covidien) allows for a fine and meticulous dissection of all vascular elements. At this time in the dissection, the upper pole artery and vein are controlled simultaneously given the absence of any evident plane. A suture is placed on the base of the artery and vein in order to control a small venous bleeding. Once the suture has been made, two clips are placed, one on the distal aspect and another on the proximal aspect in order to reinforce the previously made stitch. Division is made using cold scissors. At this time, the upper pole artery and vein are controlled simultaneously. The lower pole branch and the upper pole branch of the spleen are controlled. On exploration at the end, one can observe that there is no ischemia at the uppermost pole of the spleen as well as a small upper pole branch originating from the splenic artery—the latter is dissected, controlled, and divided after clip placement. Once this branch has been divided, all splenic elements coming to the spleen have all been isolated and dissected. The spleen is now free from any vascular supply once the last branch has been dissected.

7. Dissection of splenic hilum

The hilum is now accessed. At this time in the dissection, the last adhesions to the splenic flexure are taken down and the hilum can be approached in contact with vessels. This dissection stage is extremely risky as a pancreatic injury may occur at any times. Consequently, dissection must be performed while controlling the pancreas kept away and correctly visualized in this case as it is lying posteriorly in relation to previously dissected vascular elements. The pancreas is clearly visible here underneath the ultrasonic dissector. The pancreatic tail is totally preserved. Once the entire hilum has been controlled, the spleen is lifted in order to place traction on the very last posterior adhesions, which are controlled by means of the ultrasonic dissector. At the end of the dissection, one can observe the presence of a 6 by 5cm subcapsular hematoma.

8. Extraction

Vascular tapes along with clips placed on these tapes can now be extracted. The specimen is placed in an Endo Catch™ Gold retrieval bag and extracted through a 15mm port, which replaced a 5mm subcostal port. This 15mm port allows for the passage of the Endo Catch™ Gold bag and the spleen is retrieved using a morcellation technique. Several pieces of the specimen are sent for pathological analysis.

9. Outcome

Control of hemostasis is performed at the end of the intervention and ports are removed under visual control. The postoperative outcome is uneventful and the patient is discharged on postoperative day 2. This video demonstrates that a selective laparoscopic vascular approach to the splenic hilum is a safe technique and allows to perform splenectomy in hemodynamically stable patients.