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| The initial position is supine for induction of endotracheal anesthesia and the placement of a foley catheter. Next, the patient is turned left side up at 30 to 45 degrees. The kidney rest is positioned just above the iliac crests, and a roll, wedge or bean bag is employed to maintain this position. The dependent axilla is padded, and the left arm is placed on an elevated arm board, or taped across the chest. The table is broken slightly, and the kidney rest raised. The skin preparation is carried beyond the left posterior axillary line. The table is then rotated to the left, flattening the patient for the camera insertion cut down. |
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| The camera is placed by cut down, in the midline at a point approximately 1/3 of the distance from the umbilicus to the xiphus. After the abdomen is explored the table is rotated to flat, giving the patient the original position of 45 degrees left side up. The assistant places two 5 mm. ports in the midline to his/her left of the camera. The first is positioned just inferior to the xiphus and the other is placed to split the difference between the sub-xiphoid port and the camera. A 10/12 mm. trocar is placed near the left mid axillary line for the surgeons right hand. This port is placed by guidance of the intra-abdominal location of the inferior pole of the spleen. An adequate working distance of 8 to 10 cm. is ideal. The Surgeon's left hand port is 5mm in size, and splits the difference between the mid-axillary port and the camera site. These locations are based on average body habitus. Variations are the norm, and flexibility with respect to port placement is advantageous. Short, wide torsos are best approached by moving the camera to the patients left of the Hassan midline port as shown in the inset. And in thin patients the camera and assistants ports may be situated to the right of the midline. |
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Head up positioning(anti-Trendelenburg) facilitates the
removal of the greater omentum from the left upper quadrant, and weights
the stomach away from the spleen. The field is then set up by the assistant,
using the left hand to elevate the spleen by placing the body of a blunt
grasper across the inferior pole, and gently lifting.
The right hand is used to depress the gastrosplenic ligament. Splenocolic and phrenocolic ligaments which obstruct access to the lower pole of the spleen are addressed first. Lower pole attachments are dissected , and any vessels are ligated with clips. As the inferior pole is freed the assistant gradually moves the propping (left hand) grasper more cranial. Thus, the spleen is step wise dissected, and elevated, starting at the lower pole and working toward the hilar vessels. The phrenosplenic ligaments are addressed by elevating the lower pole while dissecting lateral to the spleen. Proper camera position is attained by placing the light cord at 3 O'clock and advancing the 30 degree scope. As the spleen is freed, the assistant increases the level of elevation, applying tension and exposeing new tissue planes. |
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The dissection of the main vascular pedicle is directed approximately
3 to 4 cm. away from the splenic hilum. This distance is chosen because
the splenic vein and artery usually arborize to form 5 to 6 branches prior
to penetrating the splenic parenchyma.
Operating too close to the hilum will bring the dissection across these multiple small branches, while selecting a plane 3 to 4 cm away affords a greater opportunity of only having to manage a single artery and vein. After the major pedicle is visualized, peritoneal and fibrous attachments are removed with scissors and electrocautery. A circumferential plane is established and widened with a right angle dissector. The surgeon then passes a 0-0, 36 cm silk ligature from a left hand grasper to the (righthand)right angle, and the silk is pulled around the vessel. Ample ligature is fed into the abdomen prior to advancing the ligature around the pedicle, as pulling a silk ligature under tension around the pedicle can lacerate or cause evulsion of the vessels. The passed tail is then exits via the same 5mm port (surgeon's left hand) through which it was introduced. Extra-corporeal knots are advanced with an endoscopic pusher, and knot friction is diminished with a water soluble lubricant. This initial ligature is placed on the patent's side of the pedicle, as the organ side of the pedicle can often be controlled with clips alone. |
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The short gastric vessels are either individually isolated and clipped, or taken with the ultrasonic dissector. After complete ligation of the splenic blood vessels supply, the splenic ligamentous attachments to the diaphragm remain at the superior pole and posterior-lateral surfaces. To free these attachments the spleen is elevated with the edge of one or two blunt graspers and the diaphragm and other foreground is pushed posterior or posterior-superior to expose and divide the upper pole phrenosplenic ligaments. |
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A nylon reinforced retreval bag with drawstring is used to remove the dissected spleen from the abdomen. The spleen is grabbed by it's pedicle and flipped onto its back so that the pedicle is facing up. This places the smooth surface onto the bowel and locates the pedicle facing up to be used as a handle. Using this handle and repositioning the table the spleen it retracted into the mid abdomen. The bag rolled up and inserted closed end first through the 12 mm mid- axillary port using a Kelly clamp. The assistant pulls the bag into the abdomen, and places the closed end into the left upper quadrant, above the recently moved spleen. The bag opening is triangulated, this helps to maximize the receptacle area. The assistant used two hands, one as the close base of the triangle and the other as the point. The surgeon used the right hand to form the other base point of the triangle and the left hand to grasp the hilum and introduce the spleen into the bag. |
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Once in the bag the draw string is tightened and used to withdraw the entire mouth of the bag through the lateral most (mid-axillary, 12 mm) port. A finger is used to fragment the spleen, and a ring forceps is employed to remove the pieces and place them into a specimen container, until the bag can be pulled through the port site. The abdomen is then reexplored, with attention to the pedicle vessels, short gastrics, and diaphragmatic bed. Accessory spleen are searched for by inspecting the gastrosplenic ligament, greater omentum, and gastrocolic ligament. The operative field is irrigated, and all port sites greater than 5mm are closed. |
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