Application of Laparoscopic Partial Splenectomy with Total Blood Flow Occlusion in Benign Splenic Lesions

Podsumowanie

In this study, we describe an intraoperative hemorrhage control technique for laparoscopic partial splenectomy, improving spleen resection's safety and precision.

Streszczenie

Laparoscopic partial splenectomy (LPS) is gradually becoming the preferred method for treating benign splenic lesions. However, due to the abundant blood supply and its soft, fragile tissue texture, especially when the lesion is located near the splenic hilum or is particularly large, performing partial splenectomy (PS) in clinical practice is extremely challenging. Therefore, we have been continuously exploring and optimizing hemorrhage control methods during PS, and we here propose a method to perform LPS with complete spleen blood flow occlusion.

This study describes an optimized approach to control intraoperative hemorrhage during LPS. First, it involves the thorough dissection of the splenic ligaments and careful separation of the pancreatic tail from the spleen. With complete exposure to the splenic hilum, we temporarily occlude the entire blood supply of the spleen using a laparoscopic bulldog clip. Subsequently, we employ intraoperative ultrasound to identify the boundary of the lesion and resect the corresponding portion of the spleen under complete blood flow control. This approach embodies the essence of 'spleen preservation' through effective hemorrhage control and precise resection. It is particularly suitable for laparoscopic surgery and deserves further clinical promotion.

Wprowadzenie

With a profound understanding of the physiological functions of the spleen, the research underscores its pivotal role in the body's immune response, hematopoiesis, and clearance of red blood cells¹. Complications following splenectomy, such as overwhelming post-splenectomy infections (OPSIs), pulmonary hypertension, and thromboembolism, significantly influence the choice of surgical methods in clinical practice^2,3. According to the literature, patients after total splenectomy exhibit a decreased capacity to clear malaria-parasitized RBCs and a higher risk of developing meningitis and sepsis following infections with Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type B⁴. PS preserves splenic function while ensuring treatment effectiveness, making it widely applied in clinical practice.

In 1959, the first successful PS was reported by Cristo⁵. The spleen is a fragile organ comprising well-defined splenic segments, each with its distinctive arterial and venous supply, demarcated by relatively avascular regions⁶. These factors collectively establish the anatomical foundation for PS. However, conventional open surgery carries inherent drawbacks, including significant trauma, cosmetic disadvantages, and postoperative pain. In recent years, alongside the maturation of laparoscopic instruments and techniques, LPS has emerged as the preferred therapeutic modality for benign splenic lesions. Nonetheless, due to the spleen's rich blood supply, substantial intraoperative hemorrhage during laparoscopy may cause a conversion to open surgery. Romboli et al. reviewed 457 cases of LPS, revealing an average operative time of approximately 128 ± 43.7 min, and demonstrated that about 3.9% of patients required conversion due to hemorrhage, and the average postoperative stay is 4.9 ± 3.8 days⁷. Comprehensive knowledge of splenic anatomy and meticulous surgical skills have hindered the broad clinical application of LPS.

To mitigate the risk of intraoperative hemorrhage and expedite the learning curve, we try to perform LPS with complete blood flow occlusion. In this study, we present a 72-year-old female patient with a massive splenic vascular tumor located in the upper middle pole of the spleen and adjacent to the splenic hilum. This novel technique excels in effective hemorrhage control and ensures safety, efficacy, and a high level of reproducibility.

Protokół

This study follows the guidelines of the Ethics Committee of Shunde Hospital of Southern Medical University. Informed consent was obtained from the patient before the surgery for the data and video.

1. Patient selection

1. Apply this surgical method in the following cases:
   1. Include patients experiencing abdominal pain or discomfort, coupled with radiological examinations confirming the presence of benign lesions.
   2. Do not impose specific restrictions on tumor size, but maintain a residual spleen volume exceeding 25%.
   3. Ensure patients exhibit normal levels of AFP, CEA, and CA-199 or confirm the absence of malignancy.
   4. Consider obesity, which results in increased visceral fat potentially affecting intraoperative anatomy, but does not view it as an absolute limitation.
2. Exclude patients from this surgery in the following conditions:
   1. Exclude if the patient is highly suspected of splenic metastasis from malignant tumors.
   2. Exclude patients with splenomegaly resulting from hematologic diseases or lymphoma.
   3. Exclude patients with splenomegaly secondary to liver cirrhosis.
   4. Exclude patients having life-threatening traumatic spleen rupture.
   5. Exclude patients who have poor overall health and inability to withstand surgery.

2. Surgical technique

1. Set up for the operation.
   1. Position the patient under general anesthesia in a reverse Trendelenburg posture with the left side of the body inclined approximately 10-30°.
      NOTE: Make adjustments in position as needed throughout the surgical procedure.
   2. Position the first surgeon and the assistant with the laparoscope on the patient's right side and the first assistant on the patient's left side.
   3. Establish and maintain pneumoperitoneum at 12-14 mmHg.
   4. Install four ports on the abdominal wall with the assistance of laparoscopic visualization, as depicted in Figure 1.
2. Examine the peritoneal cavity under laparoscopy to confirm the absence of malignancies.
3. Perform temporary occlusion of the splenic artery.
   1. Use a vessel sealing system to dissect the gastrosplenic ligament along the greater curvature of the stomach,entering the lesser sac.
   2. Grasp the stomach and move it to the upper right for better exposure to the surgical field.
   3. Meticulously dissect the main trunk of the splenic artery at the superior edge of the pancreas and temporarily occlude it with a bulldog clip.
      NOTE: Following the occlusion of blood flow, the spleen exhibits a decrease in volume and a softer texture, which will provide adequate surgical space.
4. Dissect the perisplenic ligaments, including the splenocolic, splenorenal, and splenophrenic ligaments.
   NOTE: Caution must be taken when separating the pancreatic tail from the spleen, particularly in cases of splenomegaly or massive splenic lesions, to prevent uncontrolled hemorrhage and the occurrence of postoperative pancreatic fistula (POPF).
5. Perform temporary occlusion of the splenic hilum.
   1. Expose the splenic hilum by resecting the attachments around it with an ultrasonic scalpel, then implement a temporary occlusion of the splenic hilum with a bulldog clip.
      NOTE: In cases with variations in splenic blood vessels, merely occluding the splenic artery may not achieve the desired splenic ischemic changes.
   2. Following this step, conduct a thorough reassessment of the spleen's color, size, and texture.
6. Perform intraoperative ultrasound for lesion boundary identification.
   1. Use intraoperative ultrasound to identify the boundary of the lesion during surgery.
   2. Apply electrocautery to mark the demarcation line at least 1 cm away from the lesion boundary.
7. Perform spleen parenchyma dissection.
   1. Insert a bipolar radiofrequency device into the splenic parenchyma along the demarcation line for coagulation and ablation, setting the radiofrequency energy at 80 W.
   2. Use an ultrasonic scalpel to dissect the splenic parenchyma in the necrotic coagulation zone.
   3. Securely clamp thick ducts using Hem-o-lok vascular clips and then carefully cut, ensuring a safe resection of the upper spleen containing the lesion.
      NOTE:Vessels supplying the removed portion of the spleen need to be carefully ligated and transected
8. Remove the specimen.
   1. Release the bulldog clip, ensuring no bleeding from the splenic cut edge, and confirm adequate blood supply to the remnant spleen.
   2. Use bipolar electrocautery to cauterize the splenic cut edge and apply absorbable hemostatic agents over it.
   3. Position a drain tube in the splenic fossa.
   4. Place the specimen into a specimen bag, fragment it with oval forceps, and remove it through the enlarged port.
   5. Release the pneumoperitoneum and suture the puncture wounds.

3. Postoperative details

1. Perform continuous electrocardiography for 24 h postoperatively. Monitor essential signs, including heart rate, blood pressure, respiration, oxygen saturation, central venous pressure, pupillary response, and level of consciousness, todetect early postoperative complications in a timely manner.
2. Administer antibiotics (cefuroxime sodium, 1.5 g every 12 h) and proton pump inhibitors routinely following the surgery.
3. Remove the gastric tube on the second postoperative day and allow the patient a full liquid diet.
4. Remove the abdominal drain tube when the drainage output is less than 100 mL/24 h.
5. Schedule a follow-up abdominal CT scan 2 months after the surgery to assess the abdominal condition.

Wyniki

In this case, a 72-year-old female patient was admitted for a massive splenic lesion found on a routine examination at a local hospital. She had a history of previous abdominal surgery. Her medical history was unremarkable, and her BMI was normal (20.1 kg/m²). Abdominal contrast-enhanced CT showed a massive lesion located in the upper middle pole of the spleen, with a diameter of approximately 15 cm (Figure 2). Preoperative assessments revealed no evidence of malignancy. Due to th...

Dyskusje

For years, total splenectomy was the primary treatment for splenic tumors, splenomegaly, and hematological disorders. However, with extensive cases followed up, complications after total splenectomy, including infectious complications and thromboembolic complications, have gradually aroused attention⁸. Overwhelming post-splenectomy infections (OPSIs) are the most severe complication after splenectomy, characterized by rapid disease progression with a mortality rate of approximately 50%

Materiały

Name	Company	Catalog Number	Comments
Absorbable hemostat	Ethicon, LLC	W1913T
Disposable trocar	Kangji Medical	101Y.307,101Y.311
Endo bag	Medtronic	https://www.medtronic.com/covidien/en-us/search.html#q=endo%20bag	specimen bag
Jaw sealer/divider	Covidien Medical	LF1737
Laparoscopic radiofrequency device	AngioDynamics, Inc	Rita 700-103659
Laparoscopic system	Olympus	WM-NP2 L-RECORDOR-01
LigaSure	Medtronic	https://www.medtronic.com/covidien/en-us/products/vessel-sealing/ligasure-technology.html	vessel sealing system
Ligation clips (Hem-o-lok)	Teleflex Medical	544240,544230,544220
Ultrasonic scalpel	ETHICON Medical	HAR36