Laparoscopic Partial Splenectomy for Splenic Cyst

This video will demonstrate a laparoscopic partial splenectomy for a very large epidermoid cyst of the spleen. The cyst was seen on an ultrasound performed for abdominal pain in a 14 year old girl. A CT scan showed a giant cyst measuring more than 10 centimeters in greatest diameter in the upper pole of the spleen. 25 millimeter ports and 210 millimeter ports are placed as shown here. The camera is placed at the umbilicus, and the superiormost epigastric port is used for retraction. The mid epigastric and left lower quadrant ports are used for the working instruments. The use of 210 millimeter ports allows for a 10 millimeter energy device to be deployed parallel or perpendicular to the splenic axis as needed. All 3 midline port incisions are oriented vertically so that they can be included in a midline incision if conversion is necessary. The patient is positioned on a bean bag in a partial left lateral decubitus position, as is used for a laparoscopic splenectomy. The relationship of the cyst to the liver and stomach can be seen. The left lobe of the liver is elevated by the cyst. The dissection starts by dividing the adhesions between the cyst and the left lobe of the liver. The mental adhesions to the cyst are divided using a ligature device. The short gastric vessels are divided in order to devascularize the superior pole of the spleen containing the cyst. As this continues superiorly, the lesser sac is entered, and the posterior wall of the stomach can be clearly seen. This process is continued until the stomach is completely detached from the superior pole of the spleen. The cyst closely approaches the hilum. A hilar branch vessel is therefore also divided. Once devascularization of the involved splenic segment is complete, transsection of the spleen is started. I prefer to use the 10 millimeter ligature device, as I find that it compresses the tissues more securely. And is less likely to simply fracture the spleen. Notice the difference between the well vascularized spleen to the right and the devascularized spleen to the left. Despite devascularization and despite using an energy device, a fair amount of bleeding should be expected during transaction. A suction device should be used to evacuate the blood intermittently as the transaction progresses. Once the transaction is complete, the posterolateral peritoneal attachments to the diaphragm and kidney are divided. This results in complete detachment of the superior pole of the spleen containing the cyst. The raw surface of the spleen is then cauterized using spray coagulation set at 30 to 40. The bed of the resected splenic segment is irrigated and suction to confirm hemostasis. It is important to confirm complete hemostasis of the splenic surface. A large sheet of surgicel is then brought into the abdomen and draped over the raw surface of the spleen. An omental pedicle is also brought to the vicinity of the same surface. The partial splenectomy specimen with the cyst is then placed in a specimen retrieval bag for removal.