The first laparoscopic splenectomy was performed by Delaitre and Maignen in 1991. In 1992, Carrol, Philips, Semal, Fellas and Morgenstern of Cedars-Sinai medical center reported three cases of successful laparoscopic splenectomy.
Laparoscopic cholecystectomy is the gold standard for the treatment of gallstone disease. The operation is routinely performed using four or three ports of entry into the abdomen. At laparoscopy hospital, we frequently perform cholecystectomy by two-port method using modified extracorporeal knot.
Ureteral injury is one of the most serious complications of gynecologic surgery. Ureteral injury during laparoscopic surgery has become more common as a result of the increased number of laparoscopic hysterectomies and retroperitoneal procedures that are being performed.
One of the limitations of minimal access surgery is difficulty in retrieval of tissue. Previously, surgeons were reluctant to perform many of the advanced surgical procedure due to this difficult procedure.
On July 11, 2000, the Food and Drug Administration (FDA) approved the first completely robotic surgery device, the da Vinci surgical system from Intuitive Surgical (Mountain View, CA).
Since the advent of laparoscopic surgery in the 1980s, laparoscopic surgery has been popularized by surgeons throughout the world. However, routine laparoscopic surgery has been slow to catch the pregnant patient.
Laparoscopic sterilization was the first popular minimal access surgical procedure ever performed. Laparoscopic sterilization is very straightforward procedure. Worldwide laparoscopic sterilization is now the most commonly applied method for family planning
Laparoscopic cholecystectomy is the gold standard for the treatment of gallstone disease. The operation is routinely performed using four or three ports of entry into the abdomen. At laparoscopy hospital, we frequently perform cholecystectomy by two-port method using modified extracorporeal knot.
Ureteral injury is one of the most serious complications of gynecologic surgery. Ureteral injury during laparoscopic surgery has become more common as a result of the increased number of laparoscopic hysterectomies and retroperitoneal procedures that are being performed.
One of the limitations of minimal access surgery is difficulty in retrieval of tissue. Previously, surgeons were reluctant to perform many of the advanced surgical procedure due to this difficult procedure.
On July 11, 2000, the Food and Drug Administration (FDA) approved the first completely robotic surgery device, the da Vinci surgical system from Intuitive Surgical (Mountain View, CA).
Since the advent of laparoscopic surgery in the 1980s, laparoscopic surgery has been popularized by surgeons throughout the world. However, routine laparoscopic surgery has been slow to catch the pregnant patient.
Laparoscopic sterilization was the first popular minimal access surgical procedure ever performed. Laparoscopic sterilization is very straightforward procedure. Worldwide laparoscopic sterilization is now the most commonly applied method for family planning
The esophageal hiatus is an elliptical opening in the diaphragmatic muscular portion. The crura of diaphragm originate from the anterior surface of the first four lumbar vertebrae on the right and L2–L3 on the left to insert anteriorly into the transverse ligament of the central portion of diaphragm.
The document discusses trocar site herniation (TSH), a complication of minimal access surgery where abdominal contents protrude through incisions made for laparoscopic ports. TSH requires emergency repair and can lead to bowel complications if left untreated. The literature recommends preventative measures like fascial closure of port sites ≥10 mm to prevent TSH. Additional risk factors include port location, obesity, extensive port manipulation, and poor port closure technique. Proper closure of fascial defects at port sites is emphasized as the most important preventative factor against TSH. Various port closure instruments and techniques are described, including the use of a Veress needle which allows port closure to be performed internally under vision. Meticulous port closure can
Laparoscopic ovarian surgery can be used to manage most ovarian abnormalities. Key steps in laparoscopic ovarian cystectomy include aspirating cyst contents, stripping the cyst capsule from the ovarian cortex, and extracting the capsule. It is important to avoid injury to nearby structures like the ureter and completely remove the cyst to evaluate for early carcinoma. Outcomes are better when the ovary can be preserved through cystectomy rather than full oophorectomy. Teratomas require especially careful removal of all contents to prevent chemical peritonitis.
When widespread use of laparoscopy and thoracoscopy in adult patients occurred in the first part of the 1990s, it did not transfer into widespread application in the pediatric population for a number of reasons.
The indications and preparation for laparoscopic liver surgery remain the same as in open hepatic surgery. Visualization is excellent with the laparoscope, and the addition of laparoscopic ultrasound has been shown to help intraoperative plans in 66% of cases when compared to laparoscopic exploration alone.
Gastroesophageal reflux disease (GERD) is defined as the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus. It is a condition which develops when the reflux of stomach contents causes troublesome symptoms and complications.
It is well-known that laparoscopy is the consequence of advances made in the field of medical engineering. Each surgical specialty has different requirement of instruments. Laparoscopy was initially criticized owing to the cost of specialized instruments and possible complications due to these sharp long instruments.
Laparoscopic hysterectomy is a minimally invasive surgical procedure to remove the uterus through small incisions in the abdomen using laparoscopic instruments and visualization. There are several types of laparoscopic hysterectomy depending on the extent of the procedure and whether it is assisted vaginally. Key advantages over traditional abdominal hysterectomy include less postoperative pain, shorter hospital stay, and faster recovery time. Important anatomical structures like the ureters must be carefully identified and protected during the procedure.
Dissection is defined as the separation of tissues with hemostasis. It consists of a sensory visual and tactile component, an access component involving tissue manipulation, and instrument maneuverability.
Laparoscopic exploration of the common bile duct (CBD) is performed either for the diagnosis or the treatment of CBD stones. CBD stones demonstrated by laparoscopic intraoperative cholangiography (IOC) or laparoscopic ultrasonography (LUS) are extracted either through the cystic duct or through choledochotomy.
Laparoscopic colon resections are being performed with increasing frequency all over the world. However, the use of minimal access surgery in colorectal surgery has lagged behind its application in other surgical fields.
Appendicitis was first recognized as a disease entity in the 16th century and was called perityphlitis. McBurney first described its clinical findings in 1889.
This document discusses peritoneal adhesions and laparoscopic adhesiolysis. It begins by introducing peritoneal adhesions as a common cause of bowel obstruction, pelvic pain, and infertility. Adhesions form following abdominal or pelvic surgery as a normal response to peritoneal injury, but can cause morbidity. Laparoscopic adhesiolysis offers advantages over open surgery such as less pain, reduced hernia risk, and shorter recovery. The document then discusses the technique of laparoscopic adhesiolysis in detail, including port placement, dissection methods, and measures to prevent readhesion. Key aspects of pathogenesis and preventing adhesion formation are also reviewed.
Laparoscopic surgery has undergone rapid development in recent years. Laparoscopic cholecystectomy was first performed in 1985. Since the introduction of laparoscopic cholecystectomy into general practice in 1990, it has rapidly become the dominant procedure for gallbladder surgery.
The future laparoscopic technology includes threedimensional virtual reality and expands the scanning rate from 525 lines of resolution to 1,000 or 1,200 lines per frame and the quality of picture would be twice better than existing system.
Hysteroscopy is a procedure used to view the inside of the uterus through a telescope-like device called a hysteroscope. Hysteroscopy offers a valuable extension to the gynecologist’s armamentarium.
Diagnostic laparoscopy allows direct visual examination of intra-abdominal organs through minimally invasive surgery. It can detect pathology, obtain biopsies and cultures, and diagnose conditions like appendicitis, diverticulitis, ovarian cysts, and ectopic pregnancy. Key advantages are that it is safe, well-tolerated, and has replaced more invasive exploratory laparotomy. Diagnostic laparoscopy provides accurate diagnosis of conditions presenting with abdominal pain or ascites, correcting clinical diagnoses in some cases. It allows evaluation of conditions affecting female fertility through examination of pelvic organs and tubal patency assessment.
Initial development of “minimal access surgery” began in the animal laboratory and was later studied in selected academic centers. It was imported to the community hospitals only when its benefits and safety were established.
The esophageal hiatus is an elliptical opening in the diaphragmatic muscular portion. The crura of diaphragm originate from the anterior surface of the first four lumbar vertebrae on the right and L2–L3 on the left to insert anteriorly into the transverse ligament of the central portion of diaphragm.
The document discusses trocar site herniation (TSH), a complication of minimal access surgery where abdominal contents protrude through incisions made for laparoscopic ports. TSH requires emergency repair and can lead to bowel complications if left untreated. The literature recommends preventative measures like fascial closure of port sites ≥10 mm to prevent TSH. Additional risk factors include port location, obesity, extensive port manipulation, and poor port closure technique. Proper closure of fascial defects at port sites is emphasized as the most important preventative factor against TSH. Various port closure instruments and techniques are described, including the use of a Veress needle which allows port closure to be performed internally under vision. Meticulous port closure can
Laparoscopic ovarian surgery can be used to manage most ovarian abnormalities. Key steps in laparoscopic ovarian cystectomy include aspirating cyst contents, stripping the cyst capsule from the ovarian cortex, and extracting the capsule. It is important to avoid injury to nearby structures like the ureter and completely remove the cyst to evaluate for early carcinoma. Outcomes are better when the ovary can be preserved through cystectomy rather than full oophorectomy. Teratomas require especially careful removal of all contents to prevent chemical peritonitis.
When widespread use of laparoscopy and thoracoscopy in adult patients occurred in the first part of the 1990s, it did not transfer into widespread application in the pediatric population for a number of reasons.
The indications and preparation for laparoscopic liver surgery remain the same as in open hepatic surgery. Visualization is excellent with the laparoscope, and the addition of laparoscopic ultrasound has been shown to help intraoperative plans in 66% of cases when compared to laparoscopic exploration alone.
Gastroesophageal reflux disease (GERD) is defined as the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus. It is a condition which develops when the reflux of stomach contents causes troublesome symptoms and complications.
It is well-known that laparoscopy is the consequence of advances made in the field of medical engineering. Each surgical specialty has different requirement of instruments. Laparoscopy was initially criticized owing to the cost of specialized instruments and possible complications due to these sharp long instruments.
Laparoscopic hysterectomy is a minimally invasive surgical procedure to remove the uterus through small incisions in the abdomen using laparoscopic instruments and visualization. There are several types of laparoscopic hysterectomy depending on the extent of the procedure and whether it is assisted vaginally. Key advantages over traditional abdominal hysterectomy include less postoperative pain, shorter hospital stay, and faster recovery time. Important anatomical structures like the ureters must be carefully identified and protected during the procedure.
Dissection is defined as the separation of tissues with hemostasis. It consists of a sensory visual and tactile component, an access component involving tissue manipulation, and instrument maneuverability.
Laparoscopic exploration of the common bile duct (CBD) is performed either for the diagnosis or the treatment of CBD stones. CBD stones demonstrated by laparoscopic intraoperative cholangiography (IOC) or laparoscopic ultrasonography (LUS) are extracted either through the cystic duct or through choledochotomy.
Laparoscopic colon resections are being performed with increasing frequency all over the world. However, the use of minimal access surgery in colorectal surgery has lagged behind its application in other surgical fields.
Appendicitis was first recognized as a disease entity in the 16th century and was called perityphlitis. McBurney first described its clinical findings in 1889.
This document discusses peritoneal adhesions and laparoscopic adhesiolysis. It begins by introducing peritoneal adhesions as a common cause of bowel obstruction, pelvic pain, and infertility. Adhesions form following abdominal or pelvic surgery as a normal response to peritoneal injury, but can cause morbidity. Laparoscopic adhesiolysis offers advantages over open surgery such as less pain, reduced hernia risk, and shorter recovery. The document then discusses the technique of laparoscopic adhesiolysis in detail, including port placement, dissection methods, and measures to prevent readhesion. Key aspects of pathogenesis and preventing adhesion formation are also reviewed.
Laparoscopic surgery has undergone rapid development in recent years. Laparoscopic cholecystectomy was first performed in 1985. Since the introduction of laparoscopic cholecystectomy into general practice in 1990, it has rapidly become the dominant procedure for gallbladder surgery.
The future laparoscopic technology includes threedimensional virtual reality and expands the scanning rate from 525 lines of resolution to 1,000 or 1,200 lines per frame and the quality of picture would be twice better than existing system.
Hysteroscopy is a procedure used to view the inside of the uterus through a telescope-like device called a hysteroscope. Hysteroscopy offers a valuable extension to the gynecologist’s armamentarium.
Diagnostic laparoscopy allows direct visual examination of intra-abdominal organs through minimally invasive surgery. It can detect pathology, obtain biopsies and cultures, and diagnose conditions like appendicitis, diverticulitis, ovarian cysts, and ectopic pregnancy. Key advantages are that it is safe, well-tolerated, and has replaced more invasive exploratory laparotomy. Diagnostic laparoscopy provides accurate diagnosis of conditions presenting with abdominal pain or ascites, correcting clinical diagnoses in some cases. It allows evaluation of conditions affecting female fertility through examination of pelvic organs and tubal patency assessment.
Initial development of “minimal access surgery” began in the animal laboratory and was later studied in selected academic centers. It was imported to the community hospitals only when its benefits and safety were established.
Congestive Heart failure is caused by low cardiac output and high sympathetic discharge. Diuretics reduce preload, ACE inhibitors lower afterload, beta blockers reduce sympathetic activity, and digitalis has inotropic effects. Newer medications target vasodilation and myosin activation to improve heart efficiency while lowering energy requirements. Combination therapy, following an assessment of cardiac function and volume status, is the most effective strategy to heart failure care.
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)GeorgeKieling1
Home
Organization
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
About AOMA: The Academy of Oriental Medicine at Austin offers a masters-level graduate program in acupuncture and Oriental medicine, preparing its students for careers as skilled, professional practitioners. AOMA is known for its internationally recognized faculty, award-winning student clinical internship program, and herbal medicine program. Since its founding in 1993, AOMA has grown rapidly in size and reputation, drawing students from around the nation and faculty from around the world. AOMA also conducts more than 20,000 patient visits annually in its student and professional clinics. AOMA collaborates with Western healthcare institutions including the Seton Family of Hospitals, and gives back to the community through partnerships with nonprofit organizations and by providing free and reduced price treatments to people who cannot afford them. The Academy of Oriental Medicine at Austin is located at 2700 West Anderson Lane. AOMA also serves patients and retail customers at its south Austin location, 4701 West Gate Blvd. For more information see www.aoma.edu or call 512-492-303434.
The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
Applications of NMR in Protein Structure Prediction.pptxAnagha R Anil
This presentation explores the pivotal role of Nuclear Magnetic Resonance (NMR) spectroscopy in predicting protein structures. It delves into the methodologies, advancements, and applications of NMR in determining the three-dimensional configurations of proteins, which is crucial for understanding their function and interactions.
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14...Donc Test
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition (Hinkle, 2017) Verified Chapter's 1 - 73 Complete.pdf
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition (Hinkle, 2017) Verified Chapter's 1 - 73 Complete.pdf
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition (Hinkle, 2017) Verified Chapter's 1 - 73 Complete.pdf
Receptor Discordance in Breast Carcinoma During the Course of Life
Definition:
Receptor discordance refers to changes in the status of hormone receptors (estrogen receptor ERα, progesterone receptor PgR, and HER2) in breast cancer tumors over time or between primary and metastatic sites.
Causes:
Tumor Evolution:
Genetic and epigenetic changes during tumor progression can lead to alterations in receptor status.
Treatment Effects:
Therapies, especially endocrine and targeted therapies, can selectively pressure tumor cells, causing shifts in receptor expression.
Heterogeneity:
Inherent heterogeneity within the tumor can result in subpopulations of cells with different receptor statuses.
Impact on Treatment:
Therapeutic Resistance:
Loss of ERα or PgR can lead to resistance to endocrine therapies.
HER2 discordance affects the efficacy of HER2-targeted treatments.
Treatment Adjustment:
Regular reassessment of receptor status may be necessary to adjust treatment strategies appropriately.
Clinical Implications:
Prognosis:
Receptor discordance is often associated with a poorer prognosis.
Biopsies:
Obtaining biopsies from metastatic sites is crucial for accurate receptor status assessment and effective treatment planning.
Monitoring:
Continuous monitoring of receptor status throughout the disease course can guide personalized therapy adjustments.
Understanding and managing receptor discordance is essential for optimizing treatment outcomes and improving the prognosis for breast cancer patients.
Can Traditional Chinese Medicine Treat Blocked Fallopian Tubes.pptxFFragrant
There are many traditional Chinese medicine therapies to treat blocked fallopian tubes. And herbal medicine Fuyan Pill is one of the more effective choices.
Can Traditional Chinese Medicine Treat Blocked Fallopian Tubes.pptx
Laparoscopic Splenectomy
1. Fig. 1A: Splenic anatomy.
Laparoscopic Splenectomy
adjacent organs. The spleen being a reticuloendothelial
organ is soft, friable and deserves careful handling by the
surgeon as well as the assistants. Despite the fragility of
the splenic parenchyma, its capsule is solid and can be
manipulated without rupture if handled with care. Capsular
tears can lead to bleeding, splenosis, and conversion into
open.
Two types of splenic blood supply exist around spleen
are magistral and distributed. Transverse anastomosis
existsbetweenthesplenicarterybranches.Thegastrosplenic
ligament contains short gastric and gastroepiploic vessels.
The lienorenal ligament contains the hilar vessels and the tail
of the pancreas. Other suspensory ligaments are avascular,
except in portal hypertension and myeloid metaplasia. The
tail of the pancreas lies within 1 cm of the inner surface of the
spleen in 73% of patients. The tail of the pancreas is in direct
contact with the spleen in 30% of patients. The size of the
spleen does not determine the number of entering arteries.
The spleen has in essence a double blood supply: short
gastric vessels and a main hilar vascular trunk. Although
highly variable, splenic artery anatomy has been classified
more simply into two patterns: (1) magistral and (2)
distributed. The more common distributed type found in
around 70% of the dissections and the magistral type found
in the rest. By definition, in the distributed type, the trunk
is short and many long branches enter over three-fourths
the medial surface of the spleen. The branches originate
3–13 cm from the hilum. There are also accessory polar
INTRODUCTION
ThefirstlaparoscopicsplenectomywasperformedbyDelaitre
and Maignen in 1991. In 1992, Carrol, Philips, Semal, Fellas
and Morgenstern of Cedars-Sinai medical center reported
three cases of successful laparoscopic splenectomy. The
first laparoscopic splenectomy in children was performed
in 1993 by Tulman. Laparoscopic splenectomy first started
in early 90s, but due to very high conversion rate it was not
accepted by most of the laparoscopic surgeons. Now due to
increased proficiency in the performance of laparoscopic
procedures, conversion rate is now inexistent even with large
spleens. To date, this procedure continues to be associated
with a steep learning curve but remains very rewarding,
elegant procedure. The indications for this procedure have
broadened and are now the same as with open procedures.
They range from idiopathic thrombocytopenic purpura,
unresponsive hemolytic anemia to staging procedures and
to primary splenic cysts.
Laparoscopic splenectomy can be safely performed to
treatcertainconditionssuchashereditaryhemolyticanemias,
autoimmune cytopenias, or symptomatic splenomegaly.
One of the most common uses of elective splenectomy is
for treatment of idiopathic thrombocytopenic purpura with
severe thrombocytopenia that does not respond to a course
of glucocorticoids.
Only contraindication of laparoscopic splenectomy
is excessively large spleens with weight over 1,000 g. We
personally believe that the maneuvers used to remove such
large spleens do not warrant these procedures. One should
always remember that by laparoscopic approach, the spleen
cannot be removed in its integral anatomical form and is
usually shredded. If there is any need to preserve splenic
integrity, then laparoscopic approach is not indicated.
ANATOMY OF SPLENIC
VASCULATURE (FIG. 1A)
For successful laparoscopic splenectomy, the surgeon
should be familiar with the three-dimensional relations of
the spleen and be conversant with the variations of the blood
supply. The important anatomical aspects of the spleen are
its vascularization and its great number of relationships with
Prof. Dr. R. K. Mishra
2. 303
CHAPTER 22: Laparoscopic Splenectomy
vessels and anastomoses with gastroepiploic vessels. These
anatomic details require that the surgeon be completely
familiar with variable and anomalous extrasplenic vascular
anatomy. The more the number of notches on the spleen,
the more is a segmental distributed pattern of blood supply
likely. Accessory spleens are more likely with this pattern of
blood supply.
ADVANTAGES OF LAPAROSCOPIC
SPLENECTOMY
Reasons to prefer laparoscopic splenectomy include the
following:
■ Lower surgical mortality: In a systematic review
that included over 6,000 splenectomies for immune
thrombocytopenia, laparoscopic splenectomy was
associated with a mortality of 0.2% (3 of 1,301 patients)
whereas laparotomy with an open procedure was
associatedwithamortalityof1%(48of4,955individuals).
■ Shorter hospitalization and faster recovery: One of the
reviews from the National Surgical Quality Improvement
Program (NSQIP) also evaluated length of hospital stay
and found that this was approximately 2 days shorter
with the laparoscopic procedures.
■ Reduced complications: Long-term complications such
as infection and venous thromboembolism (VTE)
appear similar with open and laparoscopic splenectomy.
In the perioperative period, individuals undergoing
laparoscopic rather than open splenectomy have been
reported to receive fewer transfusions. In a report from
a high-volume center, the median blood loss was only
50 mL (interquartile range, 20–150 mL).
DISADVANTAGES OF LAPAROSCOPIC
APPROACH
Settings in which an open procedure may be preferred
include the following:
■ Massive splenomegaly with concern about the ability to
remove the spleen via a laparoscopic procedure.
■ Local expertise favoring an open procedure or lack of
support or equipment for laparoscopy.
■ Abilitytosearchmorethoroughlyforanaccessoryspleen.
■ Cancer surgery or adhesion of the spleen to adjacent
organs requiring laparotomy.
In some cases, laparoscopic splenectomy may need to
be converted to an open procedure. The likelihood of this
happening has been estimated to be in the range of 3–10%.
Reasons for conversion included excess bleeding, technical
problems, splenic size, and other abnormalities such as
friability or infiltration of surrounding structures.
VACCINATION
Patients undergoing laparoscopic splenectomy should
receive vaccinations against encapsulated organisms
(Haemophilus influenzae, Pneumococcus, Meningococcus
species) in order to prevent overwhelming postsplenectomy
infection (OPSI). Optimally, vaccinations should be
administered 2 weeks prior to surgery. However, in emergent
cases, vaccinations can be postponed until 1–2 weeks
postoperatively.
OPERATING ROOM SETUP AND
PATIENT POSITION
Patient is placed in supine and semi-right lateral position
on the table although laparoscopic splenectomy can be
performedeitherinthesupineorrightsemi-lateraldecubitus
position. Surgeon stands to the right of patient (Fig. 1B).
Operating table is flexed at approximately 30 degrees to
increase space between the costal margin and iliac crest, and
the patient is placed in semi-lateral position.
Semilateral position allows the spleen to hang by
its diaphragmatic attachments, thus acting as a natural
counter traction while gravity retracts the stomach,
transverse colon, and greater omentum inferiorly, and
places the hilum of the spleen under tension. Bean bag is
used to secure patient position and all pressure points are
padded. Camera operator stands to right side of the patient
next to the surgeon toward right hand side of surgeon.
Monitor is placed left to the patient and Mayo’s stand
is placed near the feet of the patient (Figs. 2A and B).
Various steps of splenectomy shown in (Fig. 3).
Port Position
Port position should be decided according to baseball
diamond concept depending on the size of spleen.
Operative Procedure
Laparoscopic splenectomy can be described in five steps:
Step 1: Dissection of the inferior aspect of the spleen.
Step 2: Dissection of the lateral and retroperitoneal
attachments.
Step 3: Transection of the splenic hilum.
A 10-mm fan retractor is inserted and will lift the inferior
aspect spleen superiorly. The tail of the pancreas should be
identified. The splenorenal and colosplenic ligaments are
divided with sharp dissection. The splenorenal ligament
should be divided without Gerota’s fascia. The gastrosplenic
ligament containing the short gastric vessels are divided with
an energy device. The dissection is continued superior and
lateral to mobilize the entire spleen (Figs. 4 and 5). Search
for accessory spleens is traditionally performed at the onset
of the procedure. Common locations include the splenic
hilum, gastrosplenic ligament, splenorenal ligament, and
greater omentum. Accessory spleens can also be embedded
in the pancreas.
3. 304 SECTION 2: Laparoscopic General Surgical Procedures
Fig. 1B: Position of surgical team.
Fig. 3: Various steps of splenectomy.
Figs. 2A and B: Position of patient in laparoscopic splenectomy.
A B
It is essential to continue our dissection posterior and
inferior to the spleen as far as possible. Its purpose is to
sufficiently expose the posterior aspect of the splenic hilum
(Fig. 6). The entire anterior aspect of the hilum should also
be well-visualized (Figs. 7A to D).
Occasionally, the short gastric vessels will have to be
first transected to gain additional exposure. While the
assistant elevates and retracts the spleen, the hilum should
be distinguished from the tail of the pancreas and an
endoscopic linear stapler with vascular load should be used
to divide the vessels.
Stapler is inserted and each jaw should be positioned
anterior and posterior to the splenic vessels (Figs. 8A to F).
Advances in linear stapling devices have enhanced
laparoscopic splenectomy. In general, 2.5-mm vascular
loads are sufficient for hemostasis, but 2.0-mm staple loads
are used for thin pedicles and skeletonized vessels. A large
spleen dictates an approach to the hilum through less than
optimal port placement. The tail of the pancreas should
be well visualized to avoid inadvertent injury at the time of
firing stapler.
Step 4: Dissection of the short gastric vessels.
4. 306 SECTION 2: Laparoscopic General Surgical Procedures
Figs. 7A to D: Dissection of splenic hilum.
A B
C D
which can develop as a complication of chronic hemolysis,
such as with an inherited hemolytic anemia.
COMPLICATIONS OF LAPAROSCOPIC
SPLENECTOMY
Surgical complications of laparoscopic splenectomy are
similar to those for the open splenectomy.
Early complications include:
■ Bleeding
■ Pneumonia
■ Left pleural effusions
■ Atelectasis
■ Injury to colon, small bowel, stomach, liver, and pancreas
Late complications include:
■ Subphrenic abscess
■ Splenic or portal vein thrombosis (or both)
■ Failure of the procedure to control the primary disease
■ Recurrent disease as a result of accessory spleens
■ Overwhelming postsplenectomy infection
Independent of any complications inherent to
laparoscopic surgery (LS) in general (e.g., related to
pneumoperitoneum injuries from trocars), LS is associated
with several potential perioperative complications that the
surgeon should be aware of and be able to treat. The greatest
potential problem is hemorrhage. Hemorrhage from a larger
vessel may be an indication for immediate conversion to
laparotomy. The best means for its prevention is delicate
dissection of the artery and vein to prevent rupture of smaller
splenic and pancreatic blood vessels. The dissected artery
and vein should then be clipped prior to any movement of
the spleen. Injury to these vessels can occur simply due to the
rigidityoftheclampinginstruments.Hemorrhageoriginating
in the parenchyma is less dangerous and can be managed
by clamping the artery or by applying slight pressure with
gauze, as well as by the use of electrocoagulation.
Another potential complication of LS is injury to the
tail of the pancreas. Proper dissection and placement of
the endostapler can avoid this problem. A further possible
complication of LS is perforation of the diaphragm during
dissection of the superior pole of the spleen. A small
puncture may be quickly amplified by the presence of
pneumoperitoneum, causing a pneumothorax. This can be
controlled laparoscopically and by the use of a pleural drain.
Other complications reported with LS include deep vein
thrombosis, pulmonary embolus, and wound.
Rapid advances in minimal access surgery technology
and improvement in noninvasive imaging tests, laparoscopic
splenectomy is now being advocated for most of the
patient. It has shorter operative time and recovery period
and excellent cosmetic results as compared to the open
splenectomy. Laparoscopic splenectomy though has a
5. 307
CHAPTER 22: Laparoscopic Splenectomy
Figs. 8A to F: Use of endo-gastrointestinal (GI) linear stapler or vascular stapler can make the laparoscopic splenectomy easy but many surgeon use
extracorporeal knot as their main skill to secure splenic umenti.
A
C
E
B
D
F
Figs. 9A and B: Manual morcellation of the spleen inside endobag.
A B
6. 308 SECTION 2: Laparoscopic General Surgical Procedures
definite learning curve is not difficult if one has experience
in open splenectomy. Advanced laparoscopic instruments
such as harmonic scalpel, endoscopic vascular stapler,
LigaSure™, and good quality endobag aid the surgeons in
removing spleen.
BIBLIOGRAPHY
1. Baccarani U, Carroll BJ, Hiatt JR, Donini A, Terrosu G, Robert
Decker, et al. Comparison of laparoscopic and open staging in
Hodgkin disease. Arch Surg. 1998;133:517-22.
2. BaccaraniU,TerrosuG,DoniniA,ZajaF,BresadolaF,BaccaraniM.
Splenectomy in hematology: current practice and new
perspectives. Haematologica. 1999;84:431-6.
3. Bell RL, Reinhardt KE, Cho E, Flowers JL. A ten-year, single
institution experience with laparoscopic splenectomy. JSLS.
2005;9:163-8.
4. Berends FJ, Schep N, Cuesta MA, Bonjer HJ, Kappers-Klunne MC,
Huijgens P, et al. Hematological long-term results of laparoscopic
splenectomy for patients with idiopathic thrombocytopenic
purpura: a case-control study. Surg Endosc. 2004;18:766-70.
5. Brunt LM, Langer JC, Quasebarth MA, Whitman ED. Comparative
analysis of laparoscopic versus open splenectomy. Am J Surg.
1996;172:596-9; discussion 599-601.
6. Casaccia M, Torelli P, Squarcia S, Sormani MP, Savelli A, Troilo
B, et al. Laparoscopic splenectomy for hematologic diseases:
a preliminary analysis performed on the Italian Registry of
Laparoscopic Surgery of the Spleen (IRLSS). Surg Endosc.
2006;20:1214-20.
7. Casaccia M, Torelli P, Squarcia S, Sormani MP, Savelli A, Troilo
BM, et al. The Italian Registry of Laparoscopic Surgery of the
Spleen (IRLSS): a retrospective review of 379 patients undergoing
laparoscopic splenectomy. Chir Ital. 2006;58:697-707.
8. Cordera F, Long KH, Nagorney DM, McMurtry EK, Schleck
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