Laparoscopic Splenectomy

Anatomical clues
No two spleens have same anatomy
Size of spleen does not determine number of arteries
Notches and tubercles correlates with greater number of entering arteries
Splenic artery tends to be more tortuous with age and may arise from aorta, SMA, middle colic, left gastric and others
Arteries outside spleen are divided into first second and third terminal divisions, most spleens have 2-3 terminal branches entering hilum. The arteries are true terminal arteries, meaning there is an avascular plane between them in the spleen
Veins are usually posterior to arteries
Search for accessory spleens should occur at the start of the operation, most are found at the hilum and distal pancreas
Tail of pancreas is within 1cm of spleen in 70% patients
Tail of pancreas is in contact with spleen in 30%

Two arterial patterns (see photos) distributed 70% (short splenic trunk with long branches) and bundled 30%

Normal spleen <11cm, moderate splenomegaly 11-20cm

Therefore: a notched spleen with a wide hilum will have a complicated vascular anatomy

Ligaments
Gastrosplenic contains short gastrics and gastroepiploics
Lienorenal ligament contains hilar vessels and tail of pancreas
Other ligaments are avascular except in portal hypertension

Indication
Usually ITP with moderately enlarged spleens

1.Right lateral position with the table broken and bean bag
2.Surgeon stands to the patient’s right with the Tower to the patients left.
3.Hassan cutdown in subcostal position at the anterior axillary line with 10mm camera, one 10mm for endoGIA and remaining 5mm ports (i.e. may need an additional port for retraction (working, Hasson, working, retractor from anterior to posterior as for left adrenal)
Open the 'splenic tent' by opening lesser sac to identify anatomy (between gastrosplenic and lienorenal ligaments)
4.Using a Lap Ligasure or harmonic scalpel mobilize the splenic flexure.
5.Dissect medially by dividing the gastro-splenic ligament and ligating the left gastroepiploic and short gastric vessels to visualize the hilum. Identify the splenic artery, vein and tail of pancreas. Some authors suggest ligating the artery first to minimize risk of bleeding and diminish its size.
6.Divide the lienorenal ligament but not all attachments as they help secure the spleen.
7.Use an EndoGIA Roticulator stapler with white cartridges over the vessels completely, avoiding the tail of pancreas. You may need 2-3 cartridges
8.Once the hilum is secured, divide any remaining attachments to the diaphragm.
9.Deliver the spleen into an EndoCatch apparatus (10 or 15mm but will require removal of port if 15mm used and blunt insertion). Try and deliver the spleen intact if for malignancy by enlarging the most posterior/retracting port or it can be morcellated if for ITP.
10.Lavage and close in layers.


Morcellation and extract in bag, avoid spillage to avoid splenic rests

HALS if spleen more than 20cm in length

Complications
Portal vein thrombosis: suspect where unexplained fever or ongoing abdominal symptoms
Accessory spleens
10% patients
Around splenic hilum, greater omentum, mesentery, pelvis
CT and Nuclear med scan to localise