Name: application of laparoscopic partial splenectomy with total blood flow occlusion in benign splenic lesions
Uploaded: 2024-12-20T12:00:00.000+00:00
Duration: 2 min 9 s
Description: Laparoscopic partial splenectomy (LPS) is gradually becoming the preferred method for treating benign splenic lesions. However, due to the abundant blood ...

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
<ol>
	<li>Apply this surgical method in the following cases:
	<ol>
		<li>Include patients experiencing abdominal pain or discomfort, coupled with radiological examinations confirming the presence of benign lesions.</li>
		<li>Do not impose specific restrictions on tumor size, but maintain a residual spleen volume exceeding 25%.</li>
		<li>Ensure patients exhibit normal levels of AFP, CEA, and CA-199 or confirm the absence of malignancy.</li>
		<li>Consider obesity, which results in increased visceral fat potentially affecting intraoperative anatomy, but does not view it as an absolute limitation.</li>
	</ol>
	</li>
	<li>Exclude patients from this surgery in the following conditions:
	<ol>
		<li>Exclude if the patient is highly suspected of splenic metastasis from malignant tumors.</li>
		<li>Exclude patients with splenomegaly resulting from hematologic diseases or lymphoma.</li>
		<li>Exclude patients with splenomegaly secondary to liver cirrhosis.</li>
		<li>Exclude patients having life-threatening traumatic spleen rupture.</li>
		<li>Exclude patients who have poor overall health and inability to withstand surgery.</li>
	</ol>
	</li>
</ol>
2. Surgical technique
<ol>
	<li>Set up for the operation.
	<ol>
		<li>Position the patient under general anesthesia in a reverse Trendelenburg posture with the left side of the body inclined approximately 10-30&#176;. 
		NOTE: Make adjustments in position as needed throughout the surgical procedure.</li>
		<li>Position the first surgeon and the assistant with the laparoscope on the patient&#39;s right side and the first assistant on the patient&#39;s left side.</li>
		<li>Establish and maintain pneumoperitoneum at 12-14 mmHg.</li>
		<li>Install four ports on the abdominal wall with the assistance of laparoscopic visualization, as depicted in Figure 1.</li>
	</ol>
	</li>
	<li>Examine the peritoneal cavity under laparoscopy to confirm the absence of malignancies.</li>
	<li>Perform temporary occlusion of the splenic artery.
	<ol>
		<li>Use a vessel sealing system to dissect the gastrosplenic ligament along the greater curvature of the stomach,entering the lesser sac.</li>
		<li>Grasp the stomach and move it to the upper right for better exposure to the surgical field.</li>
		<li>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.</li>
	</ol>
	</li>
	<li>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).</li>
	<li>Perform temporary occlusion of the splenic hilum.
	<ol>
		<li>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.</li>
		<li>Following this step, conduct a thorough reassessment of the spleen&#39;s color, size, and texture.</li>
	</ol>
	</li>
	<li>Perform intraoperative ultrasound for lesion boundary identification.
	<ol>
		<li>Use intraoperative ultrasound to identify the boundary of the lesion during surgery.</li>
		<li>Apply electrocautery to mark the demarcation line at least 1 cm away from the lesion boundary.</li>
	</ol>
	</li>
	<li>Perform spleen parenchyma dissection.
	<ol>
		<li>Insert a bipolar radiofrequency device into the splenic parenchyma along the demarcation line for coagulation and ablation, setting the radiofrequency energy at 80 W.</li>
		<li>Use an ultrasonic scalpel to dissect the splenic parenchyma in the necrotic coagulation zone.</li>
		<li>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</li>
	</ol>
	</li>
	<li>Remove the specimen.
	<ol>
		<li>Release the bulldog clip, ensuring no bleeding from the splenic cut edge, and confirm adequate blood supply to the remnant spleen.</li>
		<li>Use bipolar electrocautery to cauterize the splenic cut edge and apply absorbable hemostatic agents over it.</li>
		<li>Position a drain tube in the splenic fossa.</li>
		<li>Place the specimen into a specimen bag, fragment it with oval forceps, and remove it through the enlarged port.</li>
		<li>Release the pneumoperitoneum and suture the puncture wounds.</li>
	</ol>
	</li>
</ol>
3. Postoperative details
<ol>
	<li>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.</li>
	<li>Administer antibiotics (cefuroxime sodium, 1.5 g every 12 h) and proton pump inhibitors routinely following the surgery.</li>
	<li>Remove the gastric tube on the second postoperative day and allow the patient a full liquid diet.</li>
	<li>Remove the abdominal drain tube when the drainage output is less than 100 mL/24 h.</li>
	<li>Schedule a follow-up abdominal CT scan 2 months after the surgery to assess the abdominal condition.</li>
</ol>

Optimized Hemorrhage Control Method for Laparoscopic Partial Splenectomy

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J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+spleen+in+local+and+systemic+regulation+of+immunity.">The spleen in local and systemic regulation of immunity.</a> Immunity. 39 (5), 806-818 (2013).</li><li>Christo, M. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Partial+regulated+splenectomies.+Preliminary+note+on+the+first+3+cases+operated+on.">Partial regulated splenectomies. Preliminary note on the first 3 cases operated on.</a> Hospital (Rio J). 56, 645-650 (1959).</li><li>Redmond, H. P., Redmond, J. M., Rooney, B. P., Duignan, J. P., Bouchier-Hayes, D. 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M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Splenectomy+leads+to+a+persistent+hypercoagulable+state+after+trauma.">Splenectomy leads to a persistent hypercoagulable state after trauma.</a> Am J Surg. 199 (5), 646-651 (2010).</li><li>Poulin, E. C., Thibault, C., DesC&#244;teaux, J. G., C&#244;t&#233;, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Partial+laparoscopic+splenectomy+for+trauma:+technique+and+case+report.">Partial laparoscopic splenectomy for trauma: technique and case report.</a> Surg Laparosc Endosc. 5 (4), 306-310 (1995).</li><li>Ignjatovic, D., Stimec, B., Zivanovic, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+basis+for+splenic+segmental+dearterialization:+a+post-mortem+study.">The basis for splenic segmental dearterialization: a post-mortem study.</a> Surg Radiol Anat. 27 (1), 15-18 (2005).</li><li>Costi, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Partial+splenectomy:+Who,+when+and+how.+A+systematic+review+of+the+2130+published+cases.">Partial splenectomy: Who, when and how. A systematic review of the 2130 published cases.</a> J Pediatr Surg. 54 (8), 1527-1538 (2019).</li><li>Borie, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+partial+splenectomy:+Surgical+technique.">Laparoscopic partial splenectomy: Surgical technique.</a> J Visc Surg. 153 (5), 371-376 (2016).</li><li>Ouyang, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+partial+splenectomy+with+temporary+occlusion+of+the+trunk+of+the+splenic+artery+in+fifty-one+cases:+experience+at+a+single+center.">Laparoscopic partial splenectomy with temporary occlusion of the trunk of the splenic artery in fifty-one cases: experience at a single center.</a> Surg Endosc. 35 (1), 367-373 (2021).</li><li>Mignon, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preoperative+selective+embolization+allowing+a+partial+splenectomy+for+splenic+hamartoma.">Preoperative selective embolization allowing a partial splenectomy for splenic hamartoma.</a> Ann Chir. 128 (2), 112-116 (2003).</li><li>Zheng, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+of+hemangioma+of+the+spleen+by+preoperative+partial+splenic+embolization+plus+laparoscopic+partial+splenectomy:+A+case+report.">Treatment of hemangioma of the spleen by preoperative partial splenic embolization plus laparoscopic partial splenectomy: A case report.</a> Medicine (Baltimore). 97 (17), e0498 (2018).</li><li>Vasilescu, C., Stanciulea, O., Tudor, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+robotic+subtotal+splenectomy+in+hereditary+spherocytosis.+Potential+advantages+and+limits+of+an+expensive+approach.">Laparoscopic versus robotic subtotal splenectomy in hereditary spherocytosis. 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A., Bouhanna, P., Bar-Zakai, B., Briennon, X., Gayet, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+partial+splenectomy+using+radiofrequency+ablation.">Laparoscopic partial splenectomy using radiofrequency ablation.</a> J Laparoendosc Adv Surg Tech A. 18 (4), 611-613 (2008).</li><li>Liu, G., Fan, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Feasibility+and+safety+of+laparoscopic+partial+splenectomy:+A+systematic+review.">Feasibility and safety of laparoscopic partial splenectomy: A systematic review.</a> World J Surg. 43 (6), 1505-1518 (2019).</li><li>Teperman, S. 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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%9. This heightened risk of bacterial infections in splenectomized patients is attributed to the role of IgM memory B cells in the spleen's marginal zone, which is crucial for clearing encapsulated bacteria10,11. Furthermore, postoperative complications such as portal thrombosis, caval system thrombosis, and pulmonary embolism need to be noted. Patients with cirrhosis who undergo splenectomy have a higher incidence of portal thrombosis12, possibly related to a hypercoagulable state13. PS can achieve therapeutic effects while preserving spleen function. Therefore, for eligible patients, PS has become a preferred alternative. Laparoscopic surgery, offering benefits such as minimal trauma, aesthetic outcomes, and shorter postoperative stays, has been widely used in PS in recent years.
LPS was first reported by Poulin in 199514. LPS involves selective vascular occlusion of specific spleen segments, followed by resection along the demarcation line. Typically, the terminal branches of the splenic artery divide into 2-3 branches before entering distinct spleen segments. Each segment is separated by relatively avascular regions15. However, the application of LPS is challenging due to uncontrolled intraoperative hemorrhage. Renato reviewed 344 cases of LPS surgery performed between 1960 and July 2017, indicating that the average intraoperative blood loss ranged from 0 to 1200 cc. Among the cases, 6.4% (22/344) required conversion to laparotomy, and 14 cases underwent total splenectomy due to intraoperative hemorrhage16. Based on our experience, the main reasons are as follows: (i) The spleen possesses a rich blood supply, and its delicate texture makes it prone to injury during surgery, rendering hemostasis challenging. (ii) Insufficient perisplenic ligament dissection complicates the mobilization of the spleen, leading to splenic parenchymal tears. (iii) Dissecting the branches of the splenic artery poses significant difficulty and carries the potential risk of damaging adjacent abdominal structures.
Numerous studies have reported methods to reduce intraoperative hemorrhage during LPS. There are mainly three main methods: occlusion of splenic blood supply, the use of radiofrequency devices, and robotic assistance. Borie reported the temporary occlusion of the splenic artery using a loop clamp to control intraoperative hemorrhage during LPS17. In Peng's study18, 46 patients underwent LPS with temporary occlusion of the splenic artery. They temporarily blocked the main splenic artery with a bulldog clip before dissecting the corresponding branches of the splenic artery. Unlike us, this study only included tumors located at the upper and lower poles of the spleen, with spleen sizes less than 20 cm. Preoperative vascular embolization has also been attempted for controlling hemorrhage in LPS19,20, demonstrating satisfactory clinical outcomes. Catalin et al.21 reviewed 10 cases of robotic-assisted PS, which had less intraoperative hemorrhage and shorter postoperative stays compared to LPS. However, its high cost limits its widespread use. Our center was the first to apply the radiofrequency device Habibi4X for splenectomy22. It creates a coagulative necrotic area through radiofrequency, allowing for bloodless splenectomy. It has become a standardized method at the center with consistent clinical effectiveness.
Considering the limitations of the above methods and the unique experience of our center, we attempted to use a bulldog clip for temporary occlusion of the splenic artery and hilum, performing LPS under complete splenic ischemia. The study reported that 95% of the main splenic artery trunk runs at the superior edge of the pancreas23. Temporary occlusion using a bulldog clip after intraoperative localization and isolation is easily feasible. However, it is essential to highlight that the dissection of the splenic hilum requires considerable laparoscopic surgical experience. The complexity of this procedure is influenced by factors such as a high BMI, a lesion located near the splenic hilum, a large lesion volume, and a history of abdominal surgery. Precise surgical technique is required to prevent injury to the pancreatic tail and short gastric vessels. A complete blockade of splenic blood flow can ensure the desired splenic ischemic effect, particularly when dealing with cases of variant blood vessels.
Radiofrequency devices demonstrate excellent performance in hemostasis24,25. We routinely use radiofrequency devices to insert into the splenic parenchyma along the pre-cut edge for coagulation, forming a coagulative necrotic area. Subsequently, we use an ultrasonic scalpel to dissect the splenic parenchyma, achieving bloodless partial splenectomy. In this study, we performed a large splenic lesion resection assisted with radiofrequency. The intraoperative blood loss was 30 mL, and the operative time was 102 min, with no conversion to open surgery. The patient was discharged 7 days after surgery without postoperative complications, which was significantly better than most other studies16,26. Upper abdominal CT follow-up at 2 months after the operation showed no thrombosis, and the remnant spleen had good blood supply, demonstrating a satisfactory therapeutic effect.
Teperman et al. indicate that the safe, warm ischemic time for the human spleen is 1 h27. Based on extensive surgical experience, we can complete the dissection of the splenic parenchyma within a safe time. Furthermore, postoperative abdominal CT scans have consistently shown no thrombosis or splenic infarction. This confirms the safety of LPS under complete splenic blood flow occlusion. However, we recommend that during the initial learning curve, challenging cases should be avoided, including those with BMI &gt; 25 kg/m&#178;, a history of abdominal surgery, and oversized or near-splenic hilum lesions, to prevent prolonged ischemic time that may damage splenic function. The method described in this study is not applicable to lesions located at the splenic hilum. Postoperative monitoring is also equally important for detecting potential adverse events.
Compared to total splenectomy, PS offers the advantage of preserving the spleen's physiological function while achieving therapeutic efficacy and reducing long-term complication rates2. It is generally recommended that the remnant spleen volume should exceed 25% to effectively preserve splenic function. To assess the remnant spleen volume, we employ preoperative CT-3D reconstruction technology. In cases involving massive splenic lesions, the conventional approach of identifying and occluding corresponding splenic artery branches poses challenges in preserving sufficient splenic parenchyma. In this study, by combining preoperative CT-3D reconstruction and intraoperative ultrasound assessment, we optimized the approach to LPS to maximize the preservation of normal spleen tissue. Approximately 65% of the spleen was resected, which can achieve both therapeutic goals and maintaining splenic function.
In order to ensure the safety of this method, we recommend performing preoperative abdominal CT scans to clarify the relationship between the lesion, splenic vessels, and important abdominal structures, as well as the presence of variant blood vessels. If possible, CT-3D reconstruction can further enhance preoperative assessment. It is important to note that this method is suitable for patients with trauma confined to one side of the spleen, and we do not advise employing this method in cases of life-threatening traumatic splenic rupture or for patients with hematologic disorders. The former may pose a risk of unnecessary splenic preservation leading to death. For patients undergoing PS due to hematologic disorders, long-term follow-up has shown a high risk of recurrence and subsequent conversion to total splenectomy2. The ideal indication for this method is benign lesions of the spleen. This method does not require the dissection of splenic artery branches, thereby somewhat simplifying the learning curve for LPS. However, caution should be taken when selecting patients during the initial learning phase.
In conclusion, LPS under total splenic blood flow occlusion is a safe, feasible, and reproducible method that yields satisfactory results. However, further extensive research is still needed to assess its safety and effectiveness comprehensively.

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 practice2,3. 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 &plusmn; 43.7 min, and demonstrated that about 3.9% of patients required conversion due to hemorrhage, and the average postoperative stay is 4.9 &plusmn; 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.

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

application of laparoscopic partial splenectomy with total blood flow occlusion in benign splenic lesions

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.

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 the large size of the lesion, after full discussion, LPS with complete spleen blood flow occlusion was attempted. Representative intraoperative laparoscopic images are shown in Figure 3.
The operative time was 102 min, with an intraoperative blood loss of 30 mL, and approximately 65% of the spleen was resected. No intraoperative complications occurred, and there was no conversion to laparotomy. Intraoperative blood transfusion was not required. The abdominal drain was removed 4 days postoperatively, and the patient was discharged on the 7th day after the surgery. There were no postoperative complications, including postoperative pancreatic fistula, intraperitoneal infection, hemorrhage, portal thrombosis, or splenic infarction. Specific details can be seen in Table 1. The pathological diagnosis was hemangioma. The follow-up abdominal CT after 2 months showed that the remnant spleen had good blood supply, and no recurrence was observed.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/66254/66254fig01.jpg" /> 
Figure 1: Distribution of trocars. Place a 10 mm trocar beneath the umbilicus as an observation port. The other two 10 mm trocars are inserted, one at the midpoint between the umbilicus and xiphoid process and the other on the left anterior axillary line, parallel to the umbilicus, both serving as the main operating ports. Then, the 5 mm trocar was inserted along the midline of the left clavicle at the level of the umbilicus as the assisted operating port. <a href="https://www.jove.com/files/ftp_upload/66254/66254fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/66254/66254fig02.jpg" /> 
Figure 2: Contrast-enhanced CT and CT-3D reconstruction. Abdominal contrast-enhanced CT and CT-3D reconstruction show a massive lesion located in the upper middle pole of the spleen. <a href="https://www.jove.com/files/ftp_upload/66254/66254fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/66254/66254fig03.jpg" /> 
Figure 3: Intraoperative laparoscopic images. (A,B) Representative intraoperative laparoscopic images of the surgical procedure. <a href="https://www.jove.com/files/ftp_upload/66254/66254fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Items</td>
			<td>Outcome</td>
		</tr>
		<tr>
			<td>Operative time (min)</td>
			<td>102</td>
		</tr>
		<tr>
			<td>Intraoperative blood loss (mL)</td>
			<td>30</td>
		</tr>
		<tr>
			<td>Conversion to laparotomy</td>
			<td>No</td>
		</tr>
		<tr>
			<td>Intraoperative blood transfusion</td>
			<td>No</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay (days)</td>
			<td>7</td>
		</tr>
		<tr>
			<td>Postoperative complications</td>
			<td>No</td>
		</tr>
	</tbody>
</table>
Table 1: Operative and postoperative details of LPS.

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

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

Laparoscopic partial splenectomy (LPS) is gradually becoming the preferred method for treating benign splenic lesions. However, due to the abundant blood ...

application-laparoscopic-partial-splenectomy-with-total-blood-flow

Universidad San Sebastian

Research

JoVE Journal

Medicine

149 Views.  First People's Hospital of Shunde. In this study, we describe an intraoperative hemorrhage control technique for laparoscopic partial splenectomy, improving spleen resection's safety and precision.

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

Visualization and Analysis of Blood Flow and Oxygen Consumption in Hepatic Microcirculation: Application to an Acute Hepatitis Model

There is a considerable discrepancy between oxygen supply and demand in the liver because hepatic oxygen consumption is relatively high but about 70% of the hepatic blood supply is poorly oxygenated portal vein blood derived from the gastrointestinal tract and spleen. Oxygen is delivered to hepatocytes by blood flowing from a terminal branch of the portal vein to a central venule via sinusoids, and this makes an oxygen gradient in hepatic lobules. The oxygen gradient is an important physical parameter that involves the expression of enzymes upstream and downstream in hepatic microcirculation, but the lack of techniques for measuring oxygen consumption in the hepatic microcirculation has delayed the elucidation of mechanisms relating to oxygen metabolism in liver. We therefore used FITC-labeled erythrocytes to visualize the hepatic microcirculation and used laser-assisted phosphorimetry to measure the partial pressure of oxygen in the microvessels there. Noncontact and continuous optical measurement can quantify blood flow velocities, vessel diameters, and oxygen gradients related to oxygen consumption in the liver. In an acute hepatitis model we made by administering acetaminophen to mice we observed increased oxygen pressure in both portal and central venules but a decreased oxygen gradient in the sinusoids, indicating that hepatocyte necrosis in the pericentral zone could shift the oxygen pressure up and affect enzyme expression in the periportal zone. In conclusion, our optical methods for measuring hepatic hemodynamics and oxygen consumption can reveal mechanisms related to hepatic disease.

An optical system was developed to visualize hepatic microcirculation with FITC-labeled erythrocytes and to measure the partial pressure of oxygen in the microvessels with laser-assisted phosphorimetry. This method can be used to investigate physiological and pathological mechanisms by analyzing microvascular structure, diameter, blood flow velocity, and oxygen tension.

There is a considerable discrepancy between oxygen supply and demand in the liver because hepatic oxygen consumption is relatively high but about 70% of ...

Embolic Middle Cerebral Artery Occlusion (MCAO) for Ischemic Stroke with Homologous Blood Clots in Rats

Clinically, thrombolytic therapy with use of recombinant tissue plasminogen activator (tPA) remains the most effective treatment for acute ischemic stroke. However, the use of tPA is limited by its narrow therapeutic window and by increased risk of hemorrhagic transformation. There is an urgent need to develop suitable stroke models to study new thrombolytic agents and strategies for treatment of ischemic stroke. At present, two major types of ischemic stroke models have been developed in rats and mice: intraluminal suture MCAO and embolic MCAO. Although MCAO models via the intraluminal suture technique have been widely used in mechanism-driven stroke research, these suture models do not mimic the clinical situation and are not suitable for thrombolytic studies. Among these models, the embolic MCAO model closely mimics human ischemic stroke and is suitable for preclinical investigation of thrombolytic therapy. This embolic model was first developed in rats by Overgaard et al.1 in 1992 and further characterized by Zhang et al. in 19972. Although embolic MCAO has gained increasing attention, there are technical problems faced by many laboratories. To meet increasing needs for thrombolytic research, we present a highly reproducible model of embolic MCAO in the rat, which can develop a predictable infarct volume within the MCA territory. In brief, a modified PE-50 tube is gently advanced from the external carotid artery (ECA) into the lumen of the internal carotid artery (ICA) until the tip of the catheter reaches the origin of the MCA. Through the catheter, a single homologous blood clot is placed at the origin of the MCA. To identify the success of MCA occlusion, regional cerebral blood flow was monitored, neurological deficits and infarct volumes were measured. The techniques presented in this paper should help investigators to overcome technical problems for establishing this model for stroke research.

Embolic Middle Cerebral Artery Occlusion MCAO for Ischemic Stroke with Homologous Blood Clots in Rats

In this paper, we demonstrate a standard method for producing an embolic middle cerebral artery occlusion with homologous blood clots (fibrin-rich) in adult rat. This model closely mimics human ischemic stroke and is suitable for preclinical study of thrombolytic therapy for ischemic stroke.

Clinically, thrombolytic therapy with use of recombinant tissue plasminogen activator (tPA) remains the most effective treatment for acute ischemic ...

Complete and Partial Aortic Occlusion for the Treatment of Hemorrhagic Shock in Swine

Hemorrhage remains the leading cause of preventable deaths in trauma. Endovascular management of non-compressible torso hemorrhage has been at the forefront of trauma care in recent years. Since complete aortic occlusion presents serious concerns, the concept of partial aortic occlusion has gained a growing attention. Here, we present a large animal model of hemorrhagic shock to investigate the effects of a novel partial aortic balloon occlusion catheter and compare it with a catheter that works on the principles of complete aortic occlusion. Swine are anesthetized and instrumented in order to conduct controlled fixed-volume hemorrhage, and hemodynamic and physiological parameters are monitored. Following hemorrhage, aortic balloon occlusion catheters are inserted and inflated in the supraceliac aorta for 60 min, during which the animals receive whole-blood resuscitation as 20% of the total blood volume (TBV). Following balloon deflation, the animals are monitored in a critical care setting for 4 h, during which they receive fluid resuscitation and vasopressors as needed. The partial aortic balloon occlusion demonstrated improved distal mean arterial pressures (MAPs) during the balloon inflation, decreased markers of ischemia, and decreased fluid resuscitation and vasopressor use. As swine physiology and homeostatic responses following hemorrhage have been well-documented and are like those in humans, a swine hemorrhagic shock model can be used to test various treatment strategies. In addition to treating hemorrhage, aortic balloon occlusion catheters have become popular for their role in cardiac arrest, cardiac and vascular surgery, and other high-risk elective surgical procedures.

Here, we present a protocol demonstrating a hemorrhagic shock model in swine that uses aortic occlusion as a bridge to definitive care in trauma. This model has application in testing a wide range of surgical and pharmacological therapeutic strategies.

Hemorrhage remains the leading cause of preventable deaths in trauma. Endovascular management of non-compressible torso hemorrhage has been at the ...

Quantitative Analysis of Cellular Composition in Advanced Atherosclerotic Lesions of Smooth Muscle Cell Lineage-Tracing Mice

Atherosclerosis remains the leading cause of death worldwide and, despite countless preclinical studies describing promising therapeutic targets, novel interventions have remained elusive. This is likely due, in part, to a reliance on preclinical prevention models investigating the effects of genetic manipulations or pharmacological treatments on atherosclerosis development rather than the established disease. Also, results of these studies are often confounding because of the use of superficial lesion analyses and a lack of characterization of lesion cell populations. To help overcome these translational hurdles, we propose an increased reliance on intervention models that employ investigation of changes in cellular composition at a single cell level by immunofluorescent staining and confocal microscopy. To this end, we describe a protocol for testing a putative therapeutic agent in a murine intervention model including a systematic approach for animal dissection, embedding, sectioning, staining, and quantification of brachiocephalic artery lesions. In addition, due to the phenotypic diversity of cells within late-stage atherosclerotic lesions, we describe the importance of using cell-specific, inducible lineage tracing mouse systems and how this can be leveraged for unbiased characterization of atherosclerotic lesion cell populations. Together, these strategies may assist vascular biologists to more accurately model therapeutic interventions and analyze atherosclerotic disease and will hopefully translate into a higher rate of success in clinical trials.

We propose a standardized protocol to characterize the cellular composition of late-stage murine atherosclerotic lesions including systematic methods of animal dissection, tissue embedding, sectioning, staining, and analysis of brachiocephalic arteries from atheroprone smooth muscle cell lineage tracing mice.

Atherosclerosis remains the leading cause of death worldwide and, despite countless preclinical studies describing promising therapeutic targets, novel ...

Hemocompatibility Testing of Blood-Contacting Implants in a Flow Loop Model Mimicking Human Blood Flow

The growing use of medical devices (e.g., vascular grafts, stents, and cardiac catheters) for temporary or permanent purposes that remain in the body&#39;s circulatory system demands a reliable and multiparametric approach that evaluates the possible hematologic complications caused by these devices (i.e., activation and destruction of blood components). Comprehensive in vitro hemocompatibility testing of blood-contacting implants is the first step towards successful in vivo implementation. Therefore, extensive analysis according to the International Organization for Standardization 10993-4 (ISO 10993-4) is mandatory prior to clinical application. The presented flow loop describes a sensitive model to analyze the hemostatic performance of stents (in this case, neurovascular) and reveal adverse effects. The use of fresh human whole blood and gentle blood sampling are essential to avoid the preactivation of blood. The blood is perfused through a heparinized tubing containing the test specimen by using a peristaltic pump at a rate of 150 mL/min at 37 &#176;C for 60 min. Before and after perfusion, hematologic markers (i.e., blood cell count, hemoglobin, hematocrit, and plasmatic markers) indicating the activation of leukocytes (polymorphonuclear [PMN]-elastase), platelets (&#946;-thromboglobulin [&#946;-TG]), the coagulation system (thombin-antithrombin III [TAT]), and the complement cascade (SC5b-9) are analyzed. In conclusion, we present an essential and reliable model for extensive hemocompatibility testing of stents and other blood-contacting devices prior to clinical application.

This protocol describes a comprehensive hemocompatibility evaluation of blood-contacting devices using laser-cut neurovascular implants. A flow loop model with fresh, heparinized human blood is applied to mimic blood flow. After perfusion, various hematologic markers are analyzed and compared to the values gained directly after blood collection for hemocompatibility evaluation of the tested devices.

The growing use of medical devices (e.g., vascular grafts, stents, and cardiac catheters) for temporary or permanent purposes that remain in the ...

Technical Modification of the Terminal Ureter During Total Transperitoneal Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) accounts for 5%&ndash;10% of all urothelial tumors. Radical nephroureterectomy is the standard treatment procedure. At present, different choices still exist for treating the ureteral end during laparoscopic ureteral bladder sleeve resection. Our center has adopted a new method for treating the ureteral end. This new method can increase the operating space and reduce the difficulty of the surgery compared with current methods.

Here, we present a protocol to increase the surgical field of view and reduce the difficulty of total transperitoneal laparoscopic nephroureterectomy surgery by precutting the umbilical ligament before treating the terminal ureter.

Upper tract urothelial carcinoma (UTUC) accounts for 5%&ndash;10% of all urothelial tumors. Radical nephroureterectomy is the standard treatment ...

Bloodless Laparoscopic Partial Splenectomy Assisted by Bipolar Radiofrequency Excision Hemostatic Device

Among the lymphatic system in the human body, the spleen is the most extensive one and has hematopoietic, hemofiltration, blood storage, and immune functions. As a new method of preserving the spleen, laparoscopic partial splenectomy (LPS) has been increasingly applied in clinical practice with people&#39;s deeper insights into minimally invasive treatment and the development of technical equipment. Compared with conventional open splenectomy, LPS can preserve normal spleen tissue as much as possible, decrease the occurrence of complications after total splenectomy, and reduce postoperative hospital stay. The bipolar radiofrequency excision hemostatic device used for LPS can solidify the splenic tissue and close the small blood vessels, which reduces the hemorrhage of the spleen cross-section and clears the operative field, thus achieving the ideal effect of &#34;bloodless partial splenectomy&#34;. Therefore, under the premise of strictly mastering the indications and fully understanding the vascular anatomy of the spleen, the application of the bipolar radiofrequency excision hemostatic&#160;device in LPS is worthy of clinical promotion.

The present protocol describes that bipolar radiofrequency device-assisted laparoscopic partial splenectomy (LPS) is safe and effective. A bipolar radiofrequency device in LPS can reduce intraoperative bleeding and achieve the clinical effect of a "bloodless spleen incision", which is worthy of clinical application.

Among the lymphatic system in the human body, the spleen is the most extensive one and has hematopoietic, hemofiltration, blood storage, and immune ...

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to the anatomical characteristics of the liver, with intraoperative hemorrhage being a primary concern. Intraoperative blood loss is the leading cause of conversion to open surgery; therefore, effective management of bleeding and hemostasis is crucial for a successful LAH.
The two-surgeon technique is proposed as an alternative to the traditional single-surgeon approach, with potential benefits in reducing intraoperative bleeding during laparoscopic hepatectomy. However, there remains a lack of evidence to determine which mode of the two-surgeon technique yields superior patient outcomes. Besides, to our knowledge, the LAH technique, which involves the use of a cavitron ultrasonic surgical aspirator (CUSA) by the primary surgeon while an ultrasonic dissector by the second surgeon, has been rarely reported before.
Herein, we present a modified, two-surgeon LAH technique, wherein one surgeon employs a CUSA while the other uses an ultrasonic dissector. This technique is combined with a simple extracorporeal Pringle maneuver and low central venous pressure (CVP) approach. In this modified technique, the primary and secondary surgeons utilize a laparoscopic CUSA and an ultrasonic dissectorconcurrently to achieve precise and expeditious hepatectomy. A simple extracorporeal Pringle maneuver, combined with the maintenance of low CVP, is employed to regulate the hepatic inflow and outflow in order to minimize intraoperative bleeding. This approach facilitates the attainment of a dry and clean operative field, which allows for the precise ligation and dissection of blood vessels and bile ducts. The modified LAH procedure is simpler and safer due to its effective control over bleeding as well as the seamless transition between the roles of primary and secondary surgeons. It holds great promise for future clinical applications.

Here, we present a protocol to perform a modified laparoscopic anatomic hepatectomy using improved techniques and instruments.

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to ...

Reducing Bleeding in Laparoscopic Partial Splenectomy with Microwave Ablation

Application of Microwave Ablation in Laparoscopic Partial Splenectomy

Splenic hemangioma is the most common pathological classification of splenic tumors, and its surgical indication and treatment have been controversial. Before, open splenectomy was usually used to treat splenic hemangioma. Following the rapid development of laparoscopic techniques, people's requirements for minimally invasive treatment have gradually increased, and laparoscopic splenectomy has gradually become the main treatment method. However, through the deeper study of spleen function, it was found that partial splenectomy can cut down the incidence of postoperative thrombocythemia and decrease side effects on the physiological function of the body, so laparoscopic partial splenectomy came into being. However, due to the special anatomical structure, the incidence of hemorrhage during partial splenectomy is greater. Therefore, during the operation, we removed part of the splenic blood vessels, combined with microwave ablation, which perfectly solved the problem of intraoperative bleeding. Laparoscopic partial splenectomy combined with microwave ablation not only achieves the requirements of minimally invasive treatment but also reduces the risk of intraoperative bleeding, meriting clinical application and promotion.

The use of laparoscopic partial splenectomy has been limited due to the high risk of bleeding during surgery. Therefore, we introduce a laparoscopic method combined with microwave ablation to solve the problem of intraoperative bleeding.

Splenic hemangioma is the most common pathological classification of splenic tumors, and its surgical indication and treatment have been controversial. ...

Laparoscopic Splenectomy with Pericardial Devascularization for Hypersplenism and Esophageal Variceal Hemorrhage Due to Portal Hypertension

Hypersplenism and esophageal variceal hemorrhage caused by portal hypertension are common and serious complications of decompensated cirrhosis. In recent years, with the widespread application of various therapeutic methods such as drugs, endoscopy, splenic artery embolization, transjugular intrahepatic portal shunt, and liver transplantation, the role of surgery in the treatment of portal hypertension has gradually diminished, and the indications for surgical treatment have become more strictly defined. However, according to the clinical practice in China, surgical treatment of portal hypertension still holds an important role that other treatments cannot fully replace. In fact, surgical treatment of portal hypertension is widely performed in hospitals at all levels in China, saving numerous lives. Splenectomy combined with pericardial devascularization (SPD) is the most common surgical method for treating hypersplenism and esophageal variceal hemorrhage caused by portal hypertension. Long-term clinical practice has proven that SPD is a safe and effective treatment for hypersplenism and esophageal variceal rupture and hemorrhage due to portal hypertension. With the rapid development of laparoscopic techniques, the minimally invasive advantages of laparoscopic splenectomy combined with pericardial devascularization (LSPD) have become increasingly evident. However, the successful performance of LSPD mainly depends on the skill and proficiency of the surgeon. In this context, this article presents detailed techniques for LSPD.

With the rapid advancement of laparoscopic techniques, the minimally invasive benefits of laparoscopic splenectomy combined with pericardial devascularization have become increasingly evident. In this context, we present a protocol for performing laparoscopic splenectomy alongside pericardial devascularization to treat hypersplenism and esophageal variceal hemorrhage resulting from portal hypertension.

Hypersplenism and esophageal variceal hemorrhage caused by portal hypertension are common and serious complications of decompensated cirrhosis. In recent ...