Severe intra-operative bleeding has limited the application of complex laparoscopic splenectomy (LS), including laparoscopic total splenectomy (LTS) and laparoscopic partial splenectomy (LPS). Therefore, reducing bleeding risk in complex LS has become a subject of major interest [Supplementary Figure 1, https://links.lww.com/CM9/B377].
Through spleen computed tomography (CT), multi-slice spiral CT angiography of the splenic artery, magnetic resonance angiography, three-dimensional reconstruction of the spleen, splenic artery angiography, and visual artificial simulation splenectomy, the anatomy of the splenic artery can be defined. Gastroscopy, ultrasound, and CT can be used to evaluate spleen size and the conditions of esophageal and gastric varices.
In LTS for splenomegaly and hypersplenism secondary to portal hypertension, the splenic artery can be ligated with a titanium clip or a Hem-o-lock clip to render the spleen smaller, softer, and easier to operate on. However, in patients with severe local edema or unclear blood vessel exposure, the splenic artery should not be forcibly separated to prevent uncontrollable massive bleeding [Figure 1A].
Regarding LTS for splenomegaly and hypersplenism secondary to portal hypertension, we used iodized oil and gelfoam particles to embolize the entire spleen parenchyma and the distal portion of the splenic artery and then used coils to embolize the main splenic artery. LTS was performed approximately 1 h after embolization. Regarding LPS for benign splenic tumors, we proposed a scheme including ultraselective intubation of the branch arteries of the partial spleen to be resected, embolization of the splenic parenchyma and the distal portion of the splenic artery with iodized oil and gelfoam particles, and embolization of the branch arteries of the spleen with appropriate coils. LPS was performed approximately 1 h after embolization [Figure 1B and 1C]. The results showed that the above procedures are safe and effective.[1,2]
The structure and function of the spleen will not be damaged by surgery if the duration of splenic pedicle occlusion is within 2 h. The anatomical space between the pancreatic tail and the retroperitoneum, which is called the retropancreatic tunnel, is loose. An occlusion belt can be inserted through this tunnel to bind the total splenic artery and vein and pancreatic tail, which blocks the splenic artery and vein at the same time. Studies have shown that occlusion of the blood flow through the spleen is simple, safe, and feasible. For LPS, the occlusion belt can also be pre-introduced in the retropancreatic tunnel.
The main splenic artery can be temporarily blocked to control intra-operative bleeding during LPS. After the main splenic artery is blocked, the blood flow into the spleen at the resection site can be well controlled. After transection of the blood vessel branches at the target site, the warm ischemia time of the spleen can be controlled within 1 h, and the spleen parenchyma can be transected. After transection, the main splenic artery can be opened, and the blood supply of the remaining spleen parenchyma can be restored without irreversible ischemic injury [Figure 1D].
Ligament transection should follow the principles of “simple ligament before complex ligament,” “proximal ligament before distal ligament,” and “easy operation before difficult operation.” The order of separation and transection should be determined individually according to the patient's body position, spleen size, and surrounding adhesions to achieve in situ splenectomy to the greatest extent possible. An ultrasonic scalpel and LigaSure can be used to separate and transect the middle and lower parts of the gastrosplenic ligaments and then transect thesplenocolic ligaments, the splenorenal ligaments, and the splenophrenic ligaments. When pushing and turning the spleen, an instrument rod or holding a small piece of gauze with non-invasive forceps should be used for gentle operation. Manipulations such as violently pulling the ligament around the spleen, pushing the tip of the operating forceps, or pressing on the spleen should be avoided to prevent the operating forceps from penetrating the spleen parenchyma and causing bleeding. When the gastrosplenic ligaments at the upper pole of the spleen are fully exposed, an ultrasonic scalpel or LigaSure should be used to transect the thick and short ligaments and their vascular tissues. When separating the gastrosplenic ligaments, the operation should remain close to the spleen to avoid damaging the gastric serosa and causing bleeding. Variant arteries in the lower pole of the spleen, short gastric vessels in the upper pole, and small blood vessels attached to the tail of the pancreas are common bleeding sites that should be carefully dissected.
Transection of the splenic pedicle is usually performed with a linear stapler [Figure 1E]. Multiple cuttings can be performed if the splenic pedicle is wide, but the splenic pedicle vessels should be completely clamped and transected to prevent massive bleeding caused by partial transection of the splenic pedicle vessels. During transection of the secondary splenic pedicle, the splenic artery and vein branches should be individually clamped and transected with titanium clips or Hem-o-lock clips, respectively, and care should be taken to ensure that they are securely clamped to avoid large ligations and the ligation of clusters. The stump of the splenic pedicle should be carefully evaluated, and pulsatile bleeding can be stopped with titanium clips or sutures. If the bleeding site is not easy to clamp or suture, laparotomy or small-incision surgery should be performed to help stop the bleeding.
Splenic parenchyma transection along the vasculature-free plane can not only reduce bleeding but can also reduce the possibility of spleen ischemic necrosis. After the branch of splenic blood vessels is transected, obvious ischemic zones can appear on the spleen surface, and the splenic parenchyma can be transected within approximately 0.5 cm of the ischemic line [Figure 1F]. Skeletonization of the splenic vessels is not necessary.
An ultrasonic scalpel is usually used for splenic parenchyma transection, and the technique of “walking in small steps” can be used to actively identify small blood vessels in the splenic parenchyma. Additionally, ultrasonic scalpel use can be combined with an Argon beam coagulator, bipolar electrocoagulation, and LigaSure [Figure 1G and 1H].
Radiofrequency technology has been widely used in LPS and has shown good results for splenic bleeding prevention. However, spleen tissues are sensitive to radiofrequency, and the energy should be well controlled to prevent damage.
In LPS, when the spleen parenchyma is fully separated and compressed, it can be transected using a surgical stapler.
After complete transection, bleeding at the spleen section can be stopped by applying pressure with hot saline gauze, electrocoagulation, and argon beam coagulation. After ensuring the absence of active bleeding, the spleen section can be covered with hemostats. If bleeding that is difficult to treat with electrosurgery occurs, an appropriate vascular suture can be selected for hemostasis. The length of the suture should be appropriate, preferably approximately 12 cm. Non-invasive forceps can be used for knotting to reduce the degree of wear on the suture and ensure secure knotting.
The surgeon should comprehensively consider the equipment, technical and specific disease conditions, and other factors while selecting the most suitable methods; master the anatomical basis of splenectomy; understand the surgical indications; and operate carefully. Additionally, the application of new technology and equipment is the key to control bleeding during complex LS.
The study was approved by the Ethics Committee of the Second Affiliated Hospital of Third Military Medical University (Army Medical University). Informed consent was obtained from individual participants included in the study.
This study was supported by the Basic Science and Frontier Technology Research Project of Chongqing Science and Technology Commission (No. cstc2017jcyjAX0348).
Conflicts of interest
1. Li J, You N, Deng C, Wu K, Wang L, Huang X, et al. Use of iodized oil and gelatin sponge embolization in splenic artery coiling reduces bleeding from laparoscopic splenectomy for cirrhotic portal hypertension patients with complicating hypersplenic splenomegaly: a comparative study. J Laparoendosc Adv Surg Tech A 2018;28:713–720. doi: 10.1089/lap.2017.0596.
2. Zheng L, Deng C, Li J, Wang L, You N, Wu K, et al. Treatment of hemangioma of the spleen by preoperative partial splenic embolization plus laparoscopic partial splenectomy: a case report. Medicine 2018;97:e0498. doi: 10.1097/MD.0000000000010498.
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