Surgical workshop Br. J. Surg. 1992, Vol. 79, December, 1334
Laparoscopic splenectomy B. Delaitre, B. Maignien and Ph. lcard Department of Surgery, Hijpital Cochin, 27 Rue du Faubourg St Jacques, Paris 14, France Correspondence to: Professor B. Delaitre
New laparoscopic procedures continue t o be d e ~ c r i b e d 'as ~~ instruments such as the Endo-GIA stapler (Auto Suture, Lyons, France) allow intestinal a n d vascular transection a nd closure. Laparoscopic splenectomy, including a method for extracting the spleen, is described below.
Surgical technique Splenectomy was carried out in a 17-year-old female patient with autoimmune thrombocytopenic purpura in September 1991. The disease was corticosteroid dependent with enhanced platelet destruction. Following the administration of 100mg prednisone daily, the platelet count rose from 20 x 109/1to 145 x 109/1the day before surgery. The surgeon stood between the patient's legs, the first assistant on the left side and the second on the right. The laparoscope with videocamera was inserted in the upper part of the umbilicus. Four other cannulas were inserted (Figure I ) . The stomach was retracted to the right with an atraumatic forceps and the splenogastric ligament exposed. Inferior polar splenic vessels and inferior short gastric vessels were divided between clips. The inferior part of the splenogastric ligament was opened using electrocoagulation and clips. When the lower part of the spleen was free, it was gently raised, revealing the splenic vessels and tail of the pancreas. An Endo-CIA stapler was placed around these vessels and three staples were used to divide the hilum. The upper short gastric vessels were divided between clips; the posterior peritoneal attachments were cut using electrocoagulation. The free spleen was placed in a plastic bag inserted via the left 12-mm cannula. The opening of the bag was pulled out through the left abdominal skin incision after removal of the cannula. The spleen was cut into fragments inside the bag, with standard scissors and forceps, and the fragments removed through the opening of the bag. The procedure took 5 h. No blood or platelet transfusion was required. The patient was discharged 6 days after operation with a platelet count of 1100 x 109/l. This procedure has since been repeated in a second patient, with an uneventful postoperative course.
/ Figure 1 Positions of ports for laparoscopic splenectomy. A , 10-mm cannula ,for monocular endoscope with uideocamera; B, 10-mm cannula .for atraumotic grasping forceps to hold the stomach; C, 5-mm cannula for aspiration-irrigation instrument; D, 5-mm cannula for utraumatic forceps; E, 12-mm cannula,for Endo-GIA stapler
associated with operative problems an d the surgeon should be experienced in endoscopic an d abdominal surgery. T he operation should probably also be restricted t o patients with haematological disease not associated with splenomegaly (i.e. idiopathic thrombocytopenic purpura). A reduced incidence of subphrenic and wound abscesses o r wound dehiscence is a potential advantage of the endoscopic method. Cosmetic advantages, faster recovery with less postoperative pain, an d reduced hospital stay an d costs are also expected.
References 1.
2. 3. 4.
Discussion
5.
Dubois F, Icard Ph, Berthelot C , Levard H. Coelioscopic cholecystectomy. Ann Surg 1990; 211: 6@2. Leahy PF. Technique of laparoscopic appendicectomy. Br J Surg 1989; 76: 616. Mouret P, Francois Y, Viguel J, Barth X, Lombard-Platet R. Laparoscopic treatment of perforated peptic ulcer. Br J Surg 1990; 77: 1006. Paterson-Brown S, Garden OJ. Laser-assisted laparoscopic excision of liver cyst. Br J Surg 1991; 78: 1047. Nathanson LK, Shimi S, Cuschieri A. Laparoscopic ligamentum teres (round ligament) cardiopexy. Br J Surg 1991; 78: 947-51.
The Endo-GIA stapler allows intestinal and vascular transection and closure. Th e plastic bag method avoids intra-abdominal loss of spleen fragments. Laparoscopic splenectomy may be
Paper accepted 30 April 1992
1334
0007-1323,92/!2133C01
~
(
1992 Butterworth-Heinernann Ltd
Laparoscopic splenectomy B. Delaitre, B. Maignien and Ph. lcard Department of Surgery, Hijpital Cochin, 27 Rue du Faubourg St Jacques, Paris 14, France Correspondence to: Professor B. Delaitre
New laparoscopic procedures continue t o be d e ~ c r i b e d 'as ~~ instruments such as the Endo-GIA stapler (Auto Suture, Lyons, France) allow intestinal a n d vascular transection a nd closure. Laparoscopic splenectomy, including a method for extracting the spleen, is described below.
Surgical technique Splenectomy was carried out in a 17-year-old female patient with autoimmune thrombocytopenic purpura in September 1991. The disease was corticosteroid dependent with enhanced platelet destruction. Following the administration of 100mg prednisone daily, the platelet count rose from 20 x 109/1to 145 x 109/1the day before surgery. The surgeon stood between the patient's legs, the first assistant on the left side and the second on the right. The laparoscope with videocamera was inserted in the upper part of the umbilicus. Four other cannulas were inserted (Figure I ) . The stomach was retracted to the right with an atraumatic forceps and the splenogastric ligament exposed. Inferior polar splenic vessels and inferior short gastric vessels were divided between clips. The inferior part of the splenogastric ligament was opened using electrocoagulation and clips. When the lower part of the spleen was free, it was gently raised, revealing the splenic vessels and tail of the pancreas. An Endo-CIA stapler was placed around these vessels and three staples were used to divide the hilum. The upper short gastric vessels were divided between clips; the posterior peritoneal attachments were cut using electrocoagulation. The free spleen was placed in a plastic bag inserted via the left 12-mm cannula. The opening of the bag was pulled out through the left abdominal skin incision after removal of the cannula. The spleen was cut into fragments inside the bag, with standard scissors and forceps, and the fragments removed through the opening of the bag. The procedure took 5 h. No blood or platelet transfusion was required. The patient was discharged 6 days after operation with a platelet count of 1100 x 109/l. This procedure has since been repeated in a second patient, with an uneventful postoperative course.
/ Figure 1 Positions of ports for laparoscopic splenectomy. A , 10-mm cannula ,for monocular endoscope with uideocamera; B, 10-mm cannula .for atraumotic grasping forceps to hold the stomach; C, 5-mm cannula for aspiration-irrigation instrument; D, 5-mm cannula for utraumatic forceps; E, 12-mm cannula,for Endo-GIA stapler
associated with operative problems an d the surgeon should be experienced in endoscopic an d abdominal surgery. T he operation should probably also be restricted t o patients with haematological disease not associated with splenomegaly (i.e. idiopathic thrombocytopenic purpura). A reduced incidence of subphrenic and wound abscesses o r wound dehiscence is a potential advantage of the endoscopic method. Cosmetic advantages, faster recovery with less postoperative pain, an d reduced hospital stay an d costs are also expected.
References 1.
2. 3. 4.
Discussion
5.
Dubois F, Icard Ph, Berthelot C , Levard H. Coelioscopic cholecystectomy. Ann Surg 1990; 211: 6@2. Leahy PF. Technique of laparoscopic appendicectomy. Br J Surg 1989; 76: 616. Mouret P, Francois Y, Viguel J, Barth X, Lombard-Platet R. Laparoscopic treatment of perforated peptic ulcer. Br J Surg 1990; 77: 1006. Paterson-Brown S, Garden OJ. Laser-assisted laparoscopic excision of liver cyst. Br J Surg 1991; 78: 1047. Nathanson LK, Shimi S, Cuschieri A. Laparoscopic ligamentum teres (round ligament) cardiopexy. Br J Surg 1991; 78: 947-51.
The Endo-GIA stapler allows intestinal and vascular transection and closure. Th e plastic bag method avoids intra-abdominal loss of spleen fragments. Laparoscopic splenectomy may be
Paper accepted 30 April 1992
1334
0007-1323,92/!2133C01
~
(
1992 Butterworth-Heinernann Ltd
