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Technique of Laparoscopic Splenectomy
The patient is placed on the right side with the space between the left ilium and costal margin exposed. Placement of access ports is often determined by the size of the patient and the spleen. Insufflation of the abdomen can be performed once access is obtained through an incision 1 cm from the costal margin at the left midclavicular line. A further trocar is inserted close to the costal margin below the xiphoid. A 12-mm trocar is inserted at a similar distance from the costal margin at the posterior axillary line. The splenocolic ligament is divided to give access to the lower splenic pole. The spleen is separated from the kidney and diaphragm before the gap between the splenic hilum and the tail of the pancreas is enlarged. The spleen is elevated to expose the splenic hilum, which is secured and divided with an endoscopic vascular stapler (Figure 70.16). Two or three applications of the instrument may be required to secure the hilum and the short gastric vessels. Any remaining attachments to the diaphragm are divided before a self-retaining bag is introduced through the incision of the open laparoscopy, after removal of the 12-mm port.
Figure 70.16
Photograph showing a stapling device across the splenic hilum for division of the splenic vessels during laparoscopic splenectomy.
Separate division of the splenic artery and vein is preferred during elective splenectomy, when handling large spleens or performing splenectomy with other procedures. In such cases, the splenic artery is ligated first at the superior border of the pancreas as shown (Figure S70.1); this reduces the blood supply to the spleen before approaching the splenic vein or veins, which are then ligated at the hilum. Ligation of the veins first leads to congestion with an increase in size, tearing of the capsule and bleeding.
In most cases, the spleen, after having been completed disconnected from its blood supply and attachments, is delivered from a Pfannenstiel incision in the lower abdomen with the application of a wound protector to avoid contamination of the surgical wound, to decrease postoperative pain and to achieve better cosmesis as the scar is hidden in the pubic hair line (Figure S70.2). Alternatively, the spleen may be placed in the bag, the mouth of which is pulled out of the abdominal opening through a trocar site, and is crushed and retrieved piecemeal with an instrument.
