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Laparoscopic Splenectomy and Cholecystectomy for Spherocytosis
Chapter 1 of 6 · Case-Based Learning
Case & positioning
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What the experts said
The patient is a 17 year old boy with hereditary spherocytosis with moderate, relatively asymptomatic anemia and chronic left upper quadrant discomfort interfering with lifestyle.
Ultrasound revealed a very large spleen, greater than 18 centimeters in longest diameter, as well as cholelithiasis.
For laparoscopic splenectomy, the patient is placed on a beanbag in the right lateral decubitus position with a slight tilt posteriorly.
Tilting the table to the right and left allows for appropriate displacement of the spleen medially and laterally at different points in the dissection.
The left lower quadrant 12 millimeter port is a versatile port that allows for use of a 10 millimeter ligature device or 12 millimeter endo GIA stapler.
The camera can be switched to either of the epigastric 5 millimeter ports as needed.
Most of the vascular dissection is completed in a direction parallel to the spleen and perpendicular to the splenic hilum, starting at the inferior pole.
The splenic flexure of the colon is separated from the spleen by taking the intervening vessels.
The peritoneal attachments and smaller vessels are divided with a hook cautery.
In this case, the colon is quite tethered to the spleen and has to be carefully mobilized.
The vessels are carefully delineated and skeletonized before attempting to divide them, in order to prevent vessel injury.
Placing a sponge at the hilum to soak up blood during dissection helps maintain visibility.
Use of the suction device as a retractor helps maintain visibility in the dissection field.
Dissection of the hilum proceeds in small increments.
The ligature is used to divide the hilar vessels one pedicle at a time.
In this case, the pancreatic tail is quite adherent to the splenic hilum and has to be separated following division of the hilar vessels.
This dissection leaves a thin rim of pancreatic tissue on the splenic surface.
The ligature should adequately seal the divided pancreatic tissue.
In this case, there were no short gastric vessels.
For cholecystectomy, the fundus is retracted cephalad and the neck laterally to obtain the critical view.
The peritoneum overlying the cystic duct and artery is divided on both sides to allow retraction of the neck and clear visualization of the duct and artery.
The cystic duct is clipped twice on the patient's side and once on the gallbladder side.
The cystic artery is clipped and both structures are then sharply divided.
The gallbladder is separated from the liver bed using a hook cautery, starting with the peritoneal attachments and proceeding to the deep surface.
The spleen is morcellized and removed in pieces through an endobag inserted through the left lower quadrant port.
Fibrin sealant was sprayed over the pancreatic tail surface and a sheet of Surgicel was left in the splenic bed.
No drains were placed.