Laparoscopic Splenectomy and Cholecystectomy for Spherocytosis

This video will demonstrate laparoscopic splenectomy and cholecystectomy for spherocytosis. The patient is a 17 year old boy with hereditary spherocytosis. He had moderate, relatively asymptomatic anemia. However, he complained of chronic left upper quadrant discomfort that was interfering with his lifestyle. An ultrasound revealed a very large spleen, greater than 18 centimeters in longest diameter, as well as cholelithiasis. The positioning for a laparoscopic splenectomy is shown. The patient is placed on a beanbag in the right lateral decubiris 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 locations of the trocars are shown here. 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 splenichylum. This starts at the inferior pole, where 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. During this dissection, an atraumatic grasper in the highest epigastric port retracts the inferior pole laterally and superiorly. In this case, the colon is quite tethered to the spleen and has to be carefully mobilized. This dissection will lead to the splenichylum. In this case, branches of the hilar vessels are encountered relatively early in the dissection. The tail of the pancreas can also be seen. The vessels are carefully delineated and skeletonized before attempting to divide them, in order to prevent vessel injury. The ligature is again used to divide the skeletonized vessels. Blood collecting at the hylum is suctioned. Excellent visibility has to be maintained. Placing a sponge at the hylum to soak up blood during dissection helps maintain visibility. The main hilar vessels are now skeletonized close to the border of the spleen. The tail of the pancreas can be clearly seen during the dissection. Use of the suction device as a retractor helps maintain visibility in the dissection field. Dissection of the hylum proceeds in small increments. The ligature is again used to divide the hilar vessels one pedicle at a time. The superiormost branches of the hilar vessels are now divided. In this case, the pancreatic tail is quite adherent to the splenichylum 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. Normally the short gastric vessels would be divided next. However, in this case, there were no short gastric vessels. Attention is thus turned to dividing the peritoneal attachments, starting with the most inferior ones to the kidney and diaphragm. The dissection is continued cephalad, allowing the spleen to fall superiorly and further reveal its attachments. All attachments have been divided and the spleen is now free. Attention is now turned to the gallbladder. 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 and artery are then dissected and skeletonized. The cystic duct is clipped twice on the patient's side and once on the gallbladder side. The cystic artery is likewise clipped. Both structures are then sharply divided. The gallbladder is then separated from the liver bed, using a hook cautery, starting with the peritoneal attachments and proceeding to the deep surface. Towards the end of the dissection, the gallbladder is suspended like a hammock in order to divide its last attachments. It is removed immediately through the left lower quadrant port. The left lower quadrant wound is slightly spread, and an endocach2 bag is inserted directly through the abdominal wall to scoop the spleen using ring forceps and yunker suction. The spleen is morselized and removed in pieces. The pneumoperitoneum is re-established and hemostasis of the splenic bed is confirmed. In this case, fibrine sealant was sprayed over the pancreatic tail surface. A sheet of surgicel was also left in the splenic bed. Excellent hemostasis can be seen at the end of the case. No drains were placed.