Single port access: a feasible alternative to conventional laparoscopic splenectomy

Laparoscopic splenectomy (LS) is the gold standard approach for normal spleens. Conventional LS requires 3 to 5 large bore trocars and enlargement of one trocar for bag insertion and spleen morcellation. There is a trend to reduce invasiveness of minimally invasive procedures with NOTES, hybrid NOTES and single incision surgery, but it has not yet been applied to the spleen. This video demonstrates the technical details to perform single port access laparoscopic splenectomy.

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Single port access: a feasible alternative to conventional laparoscopic splenectomy

Authors

EM Targarona, J Marescaux

Abstract

Laparoscopic splenectomy (LS) is the gold standard approach for normal spleens. Conventional LS requires 3 to 5 large bore trocars and enlargement of one trocar for bag insertion and spleen morcellation. There is a trend to reduce invasiveness of minimally invasive procedures with NOTES, hybrid NOTES and single incision surgery, but it has not yet been applied to the spleen. This video demonstrates the technical details to perform single port access laparoscopic splenectomy.

Classification

new techniques, single port

Keywords

Single port access, laparoscopic splenectomy

Media type

Surgical video

Duration

06'32''

Publication

2009-05

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Subtitles

E-publication

WeBSurg.com, May 2009;9(05).
URL: http://www.websurg.com/doi-vd01en2642.htm

Single port access: a feasible alternative to conventional laparoscopic splenectomy

1. Introduction 00'00''

Laparoscopic splenectomy (LS) is the gold standard approach for normal spleens. Conventional LS requires 3 to 5 large bore trocars and enlargement of one trocar for bag insertion and spleen morcellation. There is a trend to reduce invasiveness of minimally invasive procedures with NOTES, hybrid NOTES and single incision surgery, but it has not yet been applied to the spleen.

2. Clinical case presentation 00'23''

This video shows a single port access laparoscopic splenectomy in a 25-year-old male patient diagnosed with idiopathic thrombocytopenic purpura (ITP).

3. Patient positioning 00'31''

The patient was placed in the standard right decubitus position for LS with the table flexed at the flank, leaving the umbilical area free of draping.

4. Trocars introduction 00'41''

A 15mm peri-umbilical incision was made and a flexible tip 10mm HD scope inserted in a 12mm bladeless trocar was bluntly introduced in the abdomen under optic control, and the pneumoperitoneum was established. After exploration of the abdominal cavity, a 5mm trocar with a flexible corrugated shaft was inserted to the left of the 12mm trocar and another 5mm trocar with a small head was inserted to the right.

5. Splenic flexure mobilization 01'41''

The tip of the flexible scope was placed in front of the spleen. A 5mm curved grasper was placed through the left trocar and a conventional 5mm Ultracision was introduced on the right. Using this approach, it was possible to mobilize the splenic flexure and to reach the lower pole of the spleen.

6. Lesser sac opening 02'32''

The next step was to access the lesser sac and divide the short vessels, reaching the upper pole of the spleen.

7. Retrosplenic area exposure and division of the splenorenal attachments 02'48''

The instruments were moved to the posterior face of the spleen and the table was tilted to the left to take advantage of gravity and obtain exposure of the retrosplenic area. The posterior splenorenal attachments were freed. When the spleen was completely mobile, it was turned to the left to lie on the stomach.

8. Stapler and division of the spleen hilum 03'12''

Once the spleen was completely mobile, the flexible scope was retrieved and intra-abdominal visual control was changed to a 5mm scope. A flexible probe inserted through the left 5mm trocar raised the splenic hilum, providing sufficient space for the smooth application of the stapler. A stapler with a 6cm white cartridge was inserted through the 12mm trocar and advanced to the splenic fossa, and the stapler was applied several times to divide the splenic hilum.

9. Accessory spleen excision 04'42''

Prior to the splenic extraction, the accessory spleen was excised.

10. Endobag introduction 04'51''

Once the spleen was completely free and after checking for hemostasis, a 15mm Endobag was inserted, replacing the 12mm trocar. The spleen was grasped with a 5mm instrument and suspended in the splenic fossa. The bag was deployed underneath the organ and the spleen was introduced.

11. Spleen morcellation and extraction 05'51''

The bag was pulled to the umbilical incision and the spleen was morcellated. Postoperative outcome was uneventful, and the patient was discharged 48 hours later. The mean operative time was 90 min and blood loss was minimal. Spleen weight was 200g.

12. Final external view 06'08''

The cosmetic result was perfect.

13. Conclusion 06'11''

Single incision trans-umbilical access can be safely used for operative visualization, hilum transection and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, cosmetic, and functional advantages require further analysis.