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Mutter D, Marescaux J. Laparoscopic splenectomy for acute and major thrombocytopenia. Epublication: WeBSurg.com, Jan 2013;13(1). URL: http://www.websurg.com/ref/doi-vd01en3878.htm

D Mutter (France), J Marescaux (France)

English - 21'48''
January 2013

A 50-year-old patient was admitted in an emergency 8 days ago for spontaneous hematomas, consciousness disorders and mucosal bleeding. Diagnosis of acute thrombocytopenia was established (1000 platelets/mm3). Medical treatment was started, including transfusion of platelets, gammaglobulins, corticosteroids) but the platelet count never went over 10,000 and after 2 days, it fell down again at 1000 platelets. It was decided to rapidly perform a splenectomy. The patient has a BMI of 30. The size of the spleen was estimated at 12cm. A laparoscopic approach was proposed.

Palabras clave: Laparoscopic splenectomy, acute major thrombocytopenia

00'18'' Clinical history
This is the case of a 50-year-old patient who was admitted 8 days ago in emergency for an acute low level of platelets. The patient was admitted with a hemorrhage on the mucosa and he had 1000 platelets. Medical therapy tried to increase the number of platelets by transfusion, by gammaglobulins, by every therapy possible but the platelet rate could not be increased over 10,000 and after 2 days, it fell down again at 1000 platelets – that is today’s level.
01'00'' Imaging
The imaging shows an enlarged size of the spleen. CT-scan shows that the spleen is enlarged over 14cm. You will see that it is probably a little bit more in the abdomen, about 17 or 18cm, and the objective is to perform a splenectomy for this thrombocytopenia, probably due to secretions in the spleen.
01'20'' Patient position
The patient weighs 125Kg, so with a BMI of 30. He is placed in a full lateral position, with the head up here, legs down here and that’s the abdomen. Here’s the umbilicus. I have drawn the costal margin, the iliac crest and I have started to insert the 4 trocars. Splenectomy can be performed with 3 or 4 trocars but in this patient, we prefer to use 4 trocars due to the fat.
01'59'' Ports
The camera is 5cm anterior to the anterior axillary line. Two 10mm trocars will be used for the surgical procedure and one more trocar is placed behind for retraction. Here I stopped the dissection to show you that the left flexure of the colon is clearly behind the lower part of the spleen, and here we can very easily understand the danger of a left colectomy.
Concerning the management of platelets, we know that at the beginning of the procedure there is no request for platelets. So we avoid any early transfusion and convince the anesthesiologist to wait for platelet transfusion if possible until the end of the procedure.

To perform this surgery, we will use the Ligasure™ device, probably a very effective method in this case. Very frequently, we like to use a hook but here, due to bleeding risks, we prefer to start with the dissector.
03'10'' Inferior dissection of spleen
So the inferior attachment of the spleen will be freed first in order to lower the colon and to be able to lift the spleen. The objective is to have a totally bloodless dissection in order to very clearly identify the vessels with the intent to control the splenic pedicle, artery and vein, if possible separately using clips or if necessary a GIA™ linear stapler. The objective is not to dissect the colon but really to lower it in order to find our landmarks. The risk at this level would clearly be an injury of the left colonic flexure so every application of Ligasure™ is completed by a control of what we have there.

So we will do a posterior inferior mobilization of the spleen trying to get access to the vessels from the lower part. The second objective is to avoid any injury to the capsule of the spleen to avoid any recurrence of the disease later on. So all the dissection will be performed by keeping a safety distance with the spleen’s parenchyma.
04'48'' Dissection of splenic flexure
So first the dissection is done to open the peritoneal reflection to be in the fat and you can see that it will give us access to the mobilization of the colon, and we will be able to progressively lower the left colonic flexure and to take it out of the operative field. So the omentum at the inferior part of the spleen is going to be free so the first step is as follows: the inferior angle of the spleen is mobilized. It will be possible to progressively go below the spleen.
05'36'' Identification of pancreas
The second element that can be risky during this dissection is the identification of the pancreas because we know that regarding the size of the pancreas, there is a risk of injury to the tail of the pancreas during a splenectomy. So you don’t have the CT image of this patient but we have carefully evaluated the pancreas and we have probably a distance of 2cm in the hilum between the tail of the pancreas and the hilum of the spleen. So here I mobilize posteriorly the attachment but I will not go too high at the beginning because I want to keep the spleen attached to the diaphragm to prevent it from falling down into the operative field.
The pancreas should be identified somewhere here. That is the second interest of the lowering of the left colonic flexure: it is to have access to the inferior border of the pancreas. So here we have a little artery that is certainly a direct artery between the pedicle of the spleen and the pancreas, and this is the vascularity of the inferior short gastric. We should find the place of the pedicle after a short while and get access to the lesser sac. The second interest of this progressive dissection is that we should find and identify the position of the vessels and as closer to the vessels we will be, and as early as we can apply a clip on the splenic artery, but the second objective—if we have an identification of the pedicle, if we have any bleeding, we can perform what I call a salvage procedure, which is a global control of the pedicle either with the Ligasure™ device or with an application of the GIA™ linear stapler. But for the moment, I just open the peritoneal reflection. The increased size of the spleen has also to be considered as an advantage because it has lengthened all the ligaments including the vessels. Here, you can see some omentum on the stomach and here you can see the stomach.
08'38'' Inferior polar artery of spleen
This is the inferior polar artery and here you can see the beginning of change of color of the edge of the spleen so it is really an inferior polar artery that was just cut so we are in a good plane close to the spleen, no identification of the pancreas yet.
09'01'' Identification of vein
There’s something bigger here, this can be a splenic vein. As I have little space here, I will use the hook just to cut 1 or 2cm away from the spleen. That’s the inferior mobilization of the spleen. I think it’s not necessary to see the pancreatic tail. You have to know where it is, and if you have any doubt with your landmarks, you must identify it. Here, I know it’s somewhere here but for me it’s not important. I have the vein here. I know that the dissection area will be here so if I go in this direction, the danger is to go this way, and here to have an injury to the pancreatic tail.

But I agree, if you have freed the posterior attachment, if you have sufficiently opened the anterior attachment of the stomach, you will have a good view on the hilum and vascular pedicle.

Here again, I have probably a little artery. It’s the inferior polar one probably. I will take the Ligasure™ device to control this second little vein. It’s a 10mm device is good because you see the large sealing. We could put clips, but with clips, I think it’s also dangerous, particularly if it’s not perfectly closed. I agree, in this case, I will not use clips for many reasons, and one of these reasons is if I have to do an emergency application of any other device, I would not be able due to the presence of the clips. And now we begin to guess the position of the vein. I really only use the hook for the opening of the peritoneum and I use the Ligasure™ device for all major vessels.
When you apply the Ligasure™ device, you have to reduce traction to avoid cutting the vessels too rapidly. So if you reduce traction, you have less risk.
So I ask my assistant to release the tension.

Now we can see that we are very close into the spleen and certainly I’ve got the splenic artery after their division. See the spleen has changed in color completely now. The spleen is ischemic—we don’t see the change any longer. Now there’s something interesting: the patient has no arterial alimentation of the spleen but the vein is still connected. This means that there are certainly some platelets from the spleen moving back. The hook I use (from Karl Storz) is totally isolated. This part of the hook is isolated. I will mobilize the spleen a little more posteriorly if I can because I will lengthen the vein a little bit. I can again cut posterior attachments here because I have freed a lot in front. This will again lengthen the vein.
The white part is totally isolated and the interest when you compare with the standard hook, I will say the quality of isolation is the same but due to the heat, if it’s plastic, it’s very quickly destroyed after some use. I will check if I surround the vein or not. See I have the anterior dissection here, the posterior dissection there, and perhaps I have something left, I don’t know.
13'45'' Control of splenic vein
Certainly I have the division of the vein here, and I have to go close to the vein here. The idea is not to make a performance in patients by carrying out intracorporeal sutures. I don’t trust the Ligasure™ device for this size of vein. See I put some tension here, and so when I put clips, I clip. Always the first clip on the place that will be the last one. And so you see that I can put some tension and control exactly what I have clipped.

Now the pedicle is probably completed. We know that some bleeding is coming back, probably the upper clip was not perfectly placed and I have some blood coming out into the pedicle.

Now we will complete the dissection and probably there is here a little arterial branch. I will try to avoid putting the Ligasure™ device on clips otherwise it will not work. We know that the final part of the fibrous part of the splenic hilum is always an avascular one with dense nodes, that is the area where when you do a gastrectomy you must absolutely complete your lymph node dissection, but here it is a very safe place when you have lowered the vessels. Now we will change the position of our assistant. Again you see that we really try to avoid too much tension on the spleen. I keep the posterior attachment here, that was helping me a lot.
16'25'' Short gastric vessels
Now access to the stomach. Here I have the nasogastric tube. Here you see the vascularization of the upper pole of the spleen so there is certainly one more big vessel here for the vascularization of the upper pole of the spleen. So I will just put my assistant like that, this patient has certainly a big upper pole artery, so here we are down in the lesser sac. You see the posterior area.

For the dissection of this area, you see that the Ligasure™ device is very effective. You see immediately if you don\'t have complete control, there is some oozing but it will be very easy to control after removal of the spleen.
18'07'' Posterior dissection
Here, we have the posterior attachment. Anterior freeing and certainly the short gastrics are completely open. I think we will now have the possibility to have a final posterior mobilization. Here you see it is free here, here we are in the spleen, so it\'s completely free. Here also, there are some attachments here, but there is usually no vessels at this level, so there is oozing coming from here, it\'s not a problem. I will change the orientation, you see it\'s only the final and upper attachment of the spleen that is fixed posteriorly, you see the length of the spleen, so I will go back, and let the spleen fall down in the right part of the abdomen. Thanks to this, now we see the access from the inferior part. At this place, there should be no vessels but I still prefer to coagulate with the Ligasure™ device. You see the spleen is self-retracted by its posterior attachment, the posterior reflection of lienorenal ligament. Again you see the interest of using the Ligasure™ device and this little bit blind posterior area, it allows to grasp the remaining. Is it free or not? Not free? OK. Here it\'s free.
20'17'' Extraction of spleen
The spleen is free in the abdomen. The splenectomy is completed. The objective is achieved to perform a complete splenectomy without any tear of the capsule, which is very important in this patient because you must avoid postoperative splenosis. Now as everything is free and dissected the objective of the platelets will be to complete hemostasis. And again this insertion must be done without injury, that\\'s why I do it very gently at the skin. The patient will be suctioned permanently. I will extract the spleen by morcellation, I have no morcellator, I will certainly enlarge 1cm and extract the spleen.
It takes ten minutes to do that. Thank you.
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Didier Mutter 

Jacques Marescaux