Final Steps of the Procedure

The ports are replaced. The area of the spleen is carefully checked for hemostasis. A drain is very rarely needed. This depends on the surgeon’s experience and in particular on the degree of trauma to the tail of the pancreas during the dissection. If a drain is used, it should be taken out through a separate incision to avoid herniation of the small bowel while removing the drain through a large port site.

 Posterior Approach. Laparoscopic splenectomy can also be performed via a posterior approach.The benefit of this approach is improved exposure of the hilar vessels compared to the anterior approach; however,in the anterior approach,the hilar vessels are controlled earlier in the procedure, which reduces the risk of uncontrollable bleeding later in the procedure.

The procedure follows these key steps:

Division of the splenocolic ligament.

Division of the inferior pole vessels.

Division of the phrenic attachments.

Exposure and division of the hilar vessels.

Division of the short gastric vessels.

Extraction of the spleen in a bag.

The surgeon begins the procedure by taking down the inferior pole vessels,as described for the anterior approach.After division of these vessels,the spleen is gently retracted medially and the splenophrenic ligament is divided using the harmonic shears (Fig. 12.14). This dissection continues superiorly until the short gastric vessels are encountered. Careful dissection of the splenorenal ligament is done at this point, with extreme attention given to avoid injury to the left adrenal gland. Next, the short gastric vessels are divided using the harmonic shears and clips as needed. The hilar vessels will now be in view, and can be dissected with a right angle dissector before being divided separately or together with a vascular endo cutter (Fig. 12.15). Next, the short gastric vessels are divided using the harmonic shears. The rest of the operation is performed as described in anterior approach.

 Post Operative Course. The postoperative course following laparoscopic splenectomy is straightforward.Amylase and lipase levels should be checked on the first postoperative day to ensure there has been no pancreatic injury during the operation. A clear liquid diet is initiated if the levels are normal, and the patient can be discharged home once the diet has been tolerated.

 Management of Complications. Bleeding constitutes a major problem. Two etiologies are possible:

Bleeding from an unnamed vessel, such as a short gastric vessel or a branch of the inferior or superior pole vessels.

Bleeding from a major vessel such as the splenic artery or vein.

Bleeding from a splenic injury.

Abdominal wall

Splenophrenic attachments

Spleen

Fig. 12.14   Posterior approach for laparoscopic splenectomy; initial division of the splenophrenic ligament

Diaphragm

Liver

Hilar vessels

Fig. 12.15   Posterior approach; division of the pedicle with a stapler using the white vascular 

load

Control of an Unnamed Vessel

Control of an unnamed vessel should always be attempted and is usually successful. The first step is to pull back on the scope to protect the lens from blood. The vessel is then clamped using an atraumatic grasper. The grasper should be long and flat without teeth. Irrigation and aspiration of the surgical site should follow to evaluate the rate of bleeding. If the bleeding has been controlled, clips are placed appropriately. Sometimes, electrocautery will control the situation and allow safe placement of the clips. Compression using a laparoscopic 2 × 2 cm gauze can control the bleeding, allowing the operative site to be cleaned in preparation for hemostasis.

Control of a Major Vessel

The situation is different when a major vessel is injured. Examples are the splenic vein or artery, or the direct terminal branches of the main trunk. Flow is usually very high in these vessels, and blood reaching the left upper quadrant of the abdomen will obscure the view. In these circumstances, one can try to control the bleeding using the steps described previously, using a larger atraumatic instrument such as a bowel clamp to grasp the whole hilum. If this is not successful, it is usually wise to convert the patient rapidly through an open left subcostal incision.

Splenic Injury

Another possibility is an injury to the spleen itself during the dissection. A forceful retraction, for example, can tear the capsule. Although resultant bleeding may obscure the dissection, simple compression with a 2 × 2-cm surgical gauze together with appropriate electrocautery should control bleeding. If a combination of bleeding from the spleen and a minor vessel occurs, it is not possible to control both at the same time. It is recommended to either grab the bleeding vessel with a grasper while cauterizing the capsule, or control the capsular bleeding with a 2 × 2 gauze and compression while the bleeding vessel is clipped.

Maneuver of Last Resort During Bleeding of the Hilar Vessels

In the event of a splenic injury in traditional open surgery, the surgeon rapidly mobilizes the splenic attachments after inserting a large piece of gauze to compress the hilum. The surgeon’s left hand retracts the splenic handle and the right hand clamps the vessels “en bloc” using large and long Kelly clamps. The same maneuvers can be realized laparoscopically if the surgeon and assistant have very good laparoscopic skills.

The hilum is compressed using a large 4 × 4 gauze and the bleeding controlled. As the short gastric vessels and the inferior attachments are already divided, the surgeon should promptly divide the phrenic attachments to mobilize the spleen. Once the spleen is mobilized, the assistant can retract the whole spleen superiorly with an open fan retractor, and the surgeon fires one or two shots of a linear cutter with vascular staples.