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158
6.1 Splenectomy
1
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.
2
3
.
.
.
.
.
.
4
Fig. 6.1.7 Splenectomy. Topography of the hilus of the spleen.
Precise knowledge of the splenic anatomy is essential to avoid complica-
tions when dissecting the hilus of the spleen. The hilus itself is covered by
the gastrosplenic ligament containing the short gastric arteries and veins.
These are branches of the splenic artery and vein, which fan out from the
left gastroepiploic vessels. To expose the hilus of the spleen itself with the
splenic artery and vein and their branches, one must first open the omental bursa by gradually dissecting the gastrosplenic ligament close to the
spleen. Only then will you expose the anterior aspect of the tail of the pancreas; generally you will find the splenic artery and vein and their branches
on its superior margin.
1 Short gastric arteries and veins
2 Splenic artery and vein
3 Gastrosplenic ligament
4 Splenorenal ligament
T4
T4
Fig. 6.1.8 Splenectomy. Transecting the gastrosplenic ligament.
Using curved laparoscopic scissors inserted under the gastrosplenic ligament, lift the individual short gastric arteries and veins one pair at a time
and ligate them with clips. Place two clips each on the stomach and
spleen sides of the respective vascular structures to avoid intraoperative
bleeding. Then transect the vessels between the clips (insert). Accessory
spleens are most often found on the posterior aspect of the gastrosplenic
ligament. These should be removed as well (see Fig. 6.1.3 for key to instrument numbers).
T4
T2
T4
Bibliography
159
T3
Fig. 6.1.9 Splenectomy. Dividing the splenic artery and vein.
By transecting the gastrosplenic ligament containing the short gastric ar-
teries and veins, the hilus of the spleen is exposed. This brings into view
the area where the splenic artery and vein fan out along the superior margin of the tail of the pancreas. For safety reasons, these major vessels
should be divided using a multifire vascular stapler. Place the stapler carefully to avoid injury to the pancreas.
Fig. 6.1.10 Splenectomy. Extracting the spleen from the abdominal cavity.
After ligating and dividing the hilar vessels, dissect off any remaining ligamentous adhesions. Now place the spleen in a sterile specimen bag. Use
an impermeable waterproof bag strong enough to permit breaking up the
spleen in the bag.
Bibliography
Caroll BJ, Phillips EH, Semel CJ, Fallas M, Morgenstern L. Laparoscopic
splenectomy. Surg. Endosc. 1992; 6:183.
Delaitre B, Maignien B. Laparoscopic splenectomy—technical aspects. Surg.
Endosc. 1992; 6:305.
Delaitre B, Phillips EH. Laparoskopische Splenektomie. In Brune IB, Schönle-
ben K. Laparo-endoskopische Chirurgie, p. 273. München: Marseille; 1993.
Flowers JL. Laparoscopic Splenectomy. In Zucker AK, Bailey RW, Reddick EJ.
Surgical Laparoscopy Update. p. 357. St. Louis: Quality Medical Publishing;
1993.
Gastinger I, Köckerling F, Schneider B, Krause W, Reck T. Die laparoskopische
Splenektomie. MIC 1993; 3:87.
Hellrieger KP, Gharib M, Helbig D, Gross R. Indikationen zur Splenektomie
im Kindes- und Erwachsenenalter. Chirurg 1979; 50:472.
Phillips EH. Laparoscopic Splenectomy. In Hunter JG, Sackier JM. Minimally
Invasive Surgery. p. 309. New York: McGraw-Hill; 1993.
Poulin EC, Thibault C. The anatomical basis for laparoscopic splenectomy.
Canad. J. Surg. 1993; 484.
Zornig C, Emmermann A, Peiper M, Zschaber R, Broelsch CE. La-
paroskopische Splenektomie. Chirurg 1993; 64:314.
Fig. 6.1.11 Splenectomy. Extracting the spleen.
After closing the pursestring suture on the sterile bag, pull the bag into
the extractor trocar and withdraw the trocar from the abdomen. With the
opening of the bag outside the abdomen, insert a finger into the bag and
further break up the spleen. Then extract the bag. Now control any bleeding, irrigate the surgical site, and place an aspiration drain through the left
lateral instrument trocar. This completes the procedure.
160
6.2 Comments on Laparoscopic Splenectomy
6.2 Comments on Laparoscopic Splenectomy
J. J. Jakimowicz
Only a limited experience with laparoscopic splenectomy (LS)
has been accumulated and published worldwide so far. The
available data indicate that this procedure is feasible in experienced hands and can be safely accomplished in 90% of attempted cases and the morbidity is low, 8% (Graham et al.,
1996). The benefits of a minimal access approach are preserved
and good therapeutic end-result can be achieved. Chapter 6.1
provides a clear and comprehensive review of the technique of
this procedure.
Benign hematologic conditions represent the main indication in
about 78% of the patients undergoing LS. Laparoscopic
splenectomy should not be attempted in patients with
splenomegaly. The authors indicate that spleens heavier than
500 gram should not be approached by LS, but the way of estimating the weight as proposed by the authors makes this calculation rather difficult. Actually when the spleen is palpable it is
usually large to the point where it should not be removed by laparoscopy. The longitudinal axis of the spleen measured by ultrasound and exceeding 20 cm is, according to different authors,
a contraindication for LC. A CT-scanwith volumetric assessment
of the spleen provides reliable information on size and weight
of the organ, but the final decision to proceed with LS is undoubtedly taken during diagnostic laparoscopy.
In the section of the chapter dealing with special preparations,
the recommendation to administer polyvalent meningococcal
vaccine and Hemophilus influenzae type B conjugated vaccine
should be stressed. Also patients with ITP and critically low
platelet counts should receive preoperative IgG infusions to
transiently raise platelet levels to a safe range. Patients treated
with corticosteroids should receive stress doses of i.v. cortico-
steroids imme diately prior to operation. Antibiotic prophylaxis
is recommended. In patients with some degree of splenomegaly
where LS has been chosen, preoperative splenic artery embolization should be considered to diminish the risk of major bleeding and achieve some reduction of spleen volume. This intervention however induced morbidity of ± 50% and should be
used only selectively (Cuschieri et al., 1992).
The authors advocate LS in lateral position. In the majority of
the published reports, as in our practice, patients are positioned
in a supine position with the left side slightly tillted up to
25 degrees, using a soft roll placed under the left flank. Positioning on the table in reversed Trendelenburg is often helpful to
enhance exposure.
The success of a complex procedure such as LS depends very
much on the appropriate instruments. In our experience a sideviewing 30° laparoscope is essential for satisfactory visualization.
The use of disposable trocars, 5−12 mm, (Versaport
the passage of instruments of different size without the use of
converter tubes may shorten operating time. A strong and safe
retrieval bag is important to perform safe break-up of the spleen
and assure its removal (Coock urological).
The authors provide a clear description of the different steps of
the procedure and their drawings are helpful in memorizing
these steps. However, it should be stressed that the most important step of the procedure is early ligation or clipping of the
splenic artery. After exploration of the peritoneal cavity we
open the gastrosplenic ligament and selectively ligate the
TM
), allowing
splenic artery. This reduces the chance for major bleeding and
results in a reduction of the volume of the spleen.
Despite encouraging results reported by different investigators,
LS does not gain popularity. In The Netherlands only a limited
number of cases in a few centers are reported and there is no increase in the number of such operations performed from 1995
to 1996.
LS is a technically demanding procedure. The main drawbacks
are: complex instrumentation and the need to have the required expertise. The long duration of the procedure from
1
2
/2/31/2 hours to 51/4 hours (Glasgow et al., 1997), the relatively
high cost generated by the use of specific instrumentation, such
as clipping and stapling devices are reported to have a negative
impact. Last but not least, the lack of tactile feedback and the
danger of massive bleeding holds many surgeons back from
performing laparoscopic LS.
Recently a new type of procedure has been developed to solve
these problems. This hybrid of laparoscopic operation is called
“hand-assisted laparoscopic surgery” (HALS), using a pneumo
sleeve device (dexterity
hand of the surgeon is introduced through a small muscle splitting incision into the abdomen and assists in the laparoscopic
procedure while the pneumoperitoneum is maintained. This
abdominal access sleeve functions similar to a trocar cannula
and provides access to the abdominal cavity, without leakage.
The dexterity pneumo sleeve
wound retractor placed into a 7 to 9 cm muscle splitting incision. It enables the surgeon to perform a splenectomy according
to the principles of an open operation using only one trocar
cannula for the laparoscope and one 12 mm cannula for instrumentation. The experience gained with the device in other
areas of application such as colonic surgery in a randomized
multicenter trial indicates that there is no difference in mortality or morbidity between laparoscopic colon resection and
HALS colon resection (Meyer and Bannenberg, 1996). The
advantages of laparoscopic surgery such as short hospital stay
and fast return to normal activity are preserved with the HALS
approach. It appears also to be more cost-effective. From a recent feasibility study in which HALS splenectomy was compared to historical literature data, it became clear that the average hospitalization is shorter after HALS than after open operation. Median operating time was reduced to less than 1
(45 to 120 minutes), the median blood loss was 123 ml, and the
mean hospital stay was 3.9 days (Meyer et al., 1998). HALS
splenectomy combines the advantages of both open and laparoscopic surgery. Patients return faster to normal activity. Using
the HALS technique, tactile feedback is restored, the lack of 3D
viewing is compensated, the handling of the tissues is gentle,
and the control of bleeding is enhanced. The removal of the
spleen through the small utility incision avoids the need for
morcellation and prevents spillage of splenic tissue during extraction.
The steps of the hand-assisted laparoscopic splenectomy are actually the same as in the laparoscopic procedure with the exception that after preparation and draping of the abdomen, and
after performing diagnostic laparoscopy the pneumo-sleeve
device is placed and the surgeon’s hand introduced into the peritoneum.
TM
Pilling-Weck). The non-dominant
TM
is placed over the top ring of a
1
/2 hour
Results and Conclusions
161
Bibliography
Cuschieri A, Shimi S, Banting S, vander Velpen G. Technical aspects of laparo-
scopic splenectomy: hilar segmental devascularization and instrumentation. Journal of the Royal College of Surgeons of Edinburgh 1992; 37:414.
Glasgow RE, Lee LF, Mulvihill SJ. Laparoscopic splenectomy. Surgical Endos-
copy 1997; 11:108−112.
Graham SM, Soriano JA, Flowers JL. Laparoscopic splenectomy. Endosurgery,
Churchill Livingstone 1996; 613−621.
Meyer DW, Bannenberg JJG. Dexterity Pneumosleeve and Protactor retractor
trial, Interim report of randomised prospective multicenter center, 510-K
application. FDA; May 1996.
Meyer DW, Gossot D, Jakimowicz JJ, de Wit LT, Bannenberg JJG, Gouma DJ,
Splenectomy Revised-Manually Assisted Splenectomy with the Dexterity
Device, a feasibility study in 22 patients, submitted to the British Journal
of Surgery.
6.3 Comments on Laparoscopic Splenectomy
R. J. Rosenthal
In 1826 Quittenbaum of Rostock performed the first undisputed
splenectomy described in the world literature. The patient died
six hours later. At autopsy the ligature of the splenic artery was
intact, however the liver was small, hard and cirrhotic. This was
a case of secondary hypersplenism due to portal hypertension
(Wells, 1866). The second splenectomy (again fatal) was per-
formed by Kuchler of Darmstadt. This patient died two hours
after operation because of hemorrhage from the splenic artery
(Wells, 1866). In 1865, Sir Spencer Wells reported the third case
of splenectomy in the world literature also with a fatal out-
come; 158 hours after performing splenectomy for an abdominal tumor an autopsy showed that the patient died because of
septicemia (Wells, 1866). It was not until 1867 that Jules Pean
reported the first successful splenectomy. The patient, a woman
of 20, had a painful abdominal mass thought to be an ovarian
tumor. On exploration a splenic cyst was found, the spleen was
removed and the patient recovered (Pean, 1867). In 1888 Wells
reported this case and multicenter results on 52 splenectomies
with a mortality rate of 63% (Wells, 1888). By 1908, the intro-
duction of anesthesia and antiseptic precautions as well as the
refinement of surgical technique decreased the mortality rate of
this operation to 20% (Johnston, 1908). The development of
blood banks and the understanding of the immunological role
of the spleen continued decreasing mortality to under 10%
(Wintrobe, 1933; King and Schumaker, 1952). Finally, the intro-
duction and rapid development of advanced minimal access
surgical techniques towards the end of this century has led in-
evitably to the development of laparoscopic techniques for
splenectomy. Mortality rates in elective cases are as low as 1%.
In fact, this overview demonstrates that splenectomy has
evolved from decades of surgical experience. It has become an
operation routinely performed with low morbidity and mortality rates in elective cases. This chapter highlights and masters
the major features of laparoscopic splenectomy with special
emphasis on the surgical approach.
Indications: In our experience the main indications for laparoscopic splenectomy are diseases in which the spleen is normal
or minimally enlarged, such as idiopathic thrombocytopenic
purpura or hemolytic anemias (sometimes related to AIDS). In
the case of splenic tumors, it is important to distinguish be-
tween benign and malignant disease. While benign tumors can
be operated totally laparoscopically, malignant ones are often
associated with significant splenomegaly and require incisions
for specimen removal and isolation. Staging operations for
Hodgkin’s disease although ideal because of the small size of the
spleen are still controversial from the oncological point of view.
Salvage therapy is considered as a valid option to adequate staging. However, when discussing our cases with the oncologist, it
should be emphasized that 6% of patients treated with radiation
and chemotherapy will get leukemia or lymphoma on average
20 years later. Additionally, 10 to 12% of treated patients will
get second tumors such as melanoma, breast cancer and sarcomas (Meadows, 1989). The extremely low morbidity and
mortality achieved with the laparoscopic approach should
renew the interest of oncologists in performing staging operations before beginning their therapy.
Preoperative phase. Patients should receive immunization with
a pneumococcal vaccine such as Pneumovax in order to avoid
septicemia from encapsulated organisms. Autologous blood is
held ready for elective cases. Preoperative splenic artery embolization (same day of procedure) is helpful in reducing the
size of the spleen and decreasing operative time and bleeding.
Indications: Splenomegaly, surgeons inexperience, obesity, and
AIDS.
Technique: Patients are positioned on an electric table and secured on a beanbag for easier position change during operation.
The right lateral decubitus also called the ”double access” position is the most convenient. It allows easier access to the
spleno-renal ligament and spleno-phrenic attachements. We
begin the operation by occluding the splenic artery in the lesser
sac. However, many authors argue that the splenic artery has
anatomical variants which make this step unnecessary and
there is an increased risk of pancreatitis if the pancreas capsule
suffers injuries. As mentioned in this chapter it is crucial to
divide the splenocolic, splenorenal, and splenophrenic attachments first. This will enable the surgeon to better expose the
hilar vessels and control unexpected bleeding. The hilar vessels
can be sequentially isolated, ligated, and divided or taken ”en
block” with the endovascular stapler. After the spleen has been
isolated from its vessels and attachments it is extracted by morcellation. In cases of Hodgkin’s disease or other tumors that require careful pathological analysis, the specimen can be removed intact via a lower abdominal incision.
Results and Conclusions
Analysis of reported series of laparoscopic splenectomy for ITP
shows that the procedure may be completed in 90% of properly
selected patients. In 49 patients that underwent laparoscopic
splenectomy for ITP at Cedars Sinai Medical Center major and
minor complications were 3.4% each, with no mortality. Acces-
162
6.4 Fenestration of Large Splenic Cysts
sory spleens were encountered in 21% of the patients while
platelet response was seen in 93% (Fiedman et al., 1996; Phillisp
and Rosenthal, 1995). These results compare very favorably
with open splenectomy. Morbidity rates ranging from 7 to 22%
and mortality rates of 2 to 3% are reported for open splenectomy
(Musser et al., 1984).
Laparoscopic splenectomy has become the golden standard for
ITP and other hematologic diseases without massive
splenomegaly. It offers the avoidance of an upper abdominal in-
cision lowering the incidence of pulmonary, thromboembolic,
and wound complications associated with open procedures.
With continuous improvement in instrumentation, proper
patient selection, careful technique, good surgical judgment,
and experience in advanced procedures it may also become a
standard procedure for removal of neoplastic and enlarged
spleens in the future.
Bibliography
Fiedman RI, Fallas MJ, Carroll BJ, Hiatt JR, Phillips EH. Laparoscopic
splenectomy for ITP. The Gold Standard. Surg. Endosc. 1996; 10:991−995.
Johnston GB. Splenectomy with a review of six cases. Johns. Hopk. Hosp.
Bull. 1908; 19:178−179.
King and Schumaker HB. Splenic studies. I. Suceptibility to infection after
splenectomy performed in infancy. Ann. Surg. 1952; 136:239.
Meadows AT. Second malignant neoplasms following childhood Hodgkin’s
disease: treatment and splenectomy risk factors. Med. Ped. Oncol. 1989;
17:477−484.
Musser G, Lazar G, Hocking W, Busutill RW. Splenectomy for hematologic
disease: The UCLA experience with 306 patients. Ann. Surg. 1984; 200:40−
45.
Pean J. Opération de splenotomie (ablation d’un cyste splénique et extirpa-
tion complète de la rate hypertrophée) guersion. L’union méd. 1867;
4:340−344, 373−377.
Phillips EH, Rosenthal RJ. Laparoscopic Splenectomy. In Phillips EH, Rosen-
thal RJ (eds.) Operative Strategies in Laparoscopic Surgery, pp. 167−172.
Germany: Springer; 1995.
Wells S. On excision of enlarged spleen, with a case in which the operation
was performed. Med. Times & Gaz 1866; 1:2−5.
Wells TS. Remarks on splenectomy with a report of a successful case. Proc. R.
Med. Chir. Soc. Lond. 1888; 2:36 8.
Wintrobe MM. Clinical Hematology, 9
1993.
th
edn. Lea and Febiger, Philadelphia;
6.4 F enestr ation of Large Splenic Cysts
F. Köckerling, A. Emmermann
Goals and Methods
Splenic cysts are rare. We differentiate between cysts and pseu-
docysts. Cysts consist of an enclosed hollow space lined with
endothelium or epithelium. Cysts are either congenital (espe-
cially epidermoid cysts, foliate cysts, or dysplasia of lymph vessels), neoplastic (cystic lymphangiomas and hemangiomas), or
parasitic (Echinococcus). Congenital splenic cysts can occur in
conjunction with congenital renal and hepatic cysts. In pseudo-
cysts, the cystic wall consists of a layer of connective tissue
without an epithelial covering. Detection of an endothelial layer
is not a definite criterion for differentiation, since the en-
dothelium may recede in congenital cysts and develop in ac-
quired cysts.
Acquired cysts are generally traumatic in origin and result from
parenchymal subcapsular bleeding. The patient may have
suffered trauma decades previously and no longer remember it.
The intrasplenic hematoma becomes encapsulated and is absorbed. This results in the development of a thick-walled pseu-
docyst of connective tissue. Secondary calcification of the walls
may also occur. This calcification does not aid in the differential
diagnosis of the origin of the cyst. Published studies cite Echino-
coccus infestation of the spleen as the world’s most common
cause of splenic cysts. However in non-endemic areas, parasitic
splenic cysts are rare. In Europe and North America, the surgeon
most often encounters nonparasitic congenital and posttrau-
matic splenic cysts.
About 30% of all splenic cysts are asymptomatic. Symptoms
occur with larger cysts. So-called giant cysts may contain
several liters of fluid. They produce displacement symptoms of
pain and pressure sensations, and cause atrophic changes in the
splenic parenchyma accompanied by partial impairment of
splenic function. Ureteral colic from displacement of the kidney
and hypertension from compression of the renal vascular
pedicle have been reported. More frequent symptoms include
left-side chest and shoulder pain and respiratory problems as a
result of a displaced diaphragm or reactive pleural effusion.
Small splenic cysts are generally asymptomatic incidental findings. The most important complications include empyema formation, for example in conjunction with infectious disorders
(infectious splenic disease), and bleeding following rupture.
Bleeding may vary in intensity and may occur repeatedly, either
spontaneously or following an injury. Intense abdominal pain
occurs which can simulate the clinical picture of an acute abdomen with peritonitis. Bleeding into the cystic cavity can lead to
acute expansion with the attendant symptoms.
A certain and simple method of managing congenital or posttraumatic cysts is to resect a portion of the cystic wall to create a
permanent opening into the peritoneum. Experience with this
technique in open operation has been favorable with respect to
the incidence of recurrence. Laparoscopic management should
provide the same degree of effectiveness combined with the
advantages that minimally invasive surgery offers the patient,
i. e., reduced postoperative pain and a shorter period of hospitalization. To reduce the risk of recurrence, the surgeon should
remove a sufficiently large section of the cystic wall and fix a
fold of the omentum over the resulting parenchymal defect.
Indications
Laparoscopic fenestration (or unroofing) may be indicated in
the presence of large symptomatic congenital or acquired
splenic cysts. Splenic cysts are generally observed b etween the
ages of 20 and 40, i. e., in patients whose age does not contraindicate establishing a pneumoperitoneum.
Positioning
163
Contraindications
쐌 Bleeding.
쐌 Infection (abscess).
쐌 Demonstrated or suspected parasitic or neoplastic cyst. Ul-
trasound, CT angiography with density measuring, and the
obligatory serum diagnostic studies for Echinococcus (com-
plement bond reaction and indirect hemoagglutination test)
should be sufficient to differentiate between parasitic or
neoplastic cysts and congenital or posttraumatic cysts.
쐌 Perisplenitis or other disorders with extensive, broad adhe-
sions.
Note: When in doubt, conventional laparotomy is indicated.
Surgical Risks and Patient Information
The patient should be informed of typical complications that
may occur during splenic surgery and complications specific to
laparoscopy. These include injuries to major vascular structures
or hollow organs caused by insertion of the Veress needle and
laparoscope/camera trocar. Complications that require conversion to open laparotomy include bleeding and injury to adjacent
organs. Also inform the patient about possible loss of the spleen
and the risks this entails.
Special Preparations
Place a nasogastric tube and indwelling urinary catheter. Be-
cause of the proximity to the left colon flexure, we recommend
a preoperative oral large-bowel preparation.
Positioning
Rightlateraldecubituspositioningis best for laparoscopic splenic
surgery (Fig. 6.4.1). This provides good exposure of the spleen,
the left colon flexure, the stomach, and the left hepatic lobe.
The patient can be repositioned during the operation to achieve
optimumexposureofthesurface of thespleen.Thepositioningof
the patient determines the location of the equipment and position of the operating team (Fig. 6.4.2). An alternative is to place
the patient supine with the left side slightly elevated. Such positioning facilitates conversion to an open procedure, in case of an
intraoperative emergency.
Fig. 6.4.1 Fenestration of large splenic cysts. Right lateral decubitus
position of the patient.
Monitor
Anesthesia
General anesthesia.
Fig. 6.4.2 Fenestration of large splenic cysts. Equipment and position of the operating team.
The surgeon stands to the right of the patient and
manipulates the instruments through the instrument
trocars with both hands. The assistant holding the la-
paroscope also stands to the right of the patient, guiding
the laparoscope beneath the surgeon’s right arm. If a
third instrument trocar is required, the instrument or
swab inserted through it is manipulated by a second assistant. The monitor and insufflator are located behind
the left side of the head of the operating table so that the
entire operating team looks past the surgical site to the
monitor. The operating room nurse and the instrument
table are to the left of the patient opposite the surgeon.
The electrocautery unit and aspirator/irrigator can be
positioned more or less as desired.
st
surgeon
1
Assistant holding
laparoscope
Electrocautery
unit
Insufflator
Instrument
table
nd
surgeon
2
Aspirator/irrigator set
164
6.4 Fenestration of Large Splenic Cysts
T3
T4
Complications
Intraoperative Complications
쐌 Perforation of hollow organs when establishing the
pneumoperitoneum.
쐌 Bleeding from a major vessel caused by puncture from the
Veress needle or laparoscope/camera trocar.
쐌 Thermal damage to the intestine from electrocautery.
쐌 Bleeding from the spleen.
쐌 Subcutaneous emphysema.
Corrective action: If one of these complications occurs, immediate conversion to open laparotomy is indicated.
Postoperative Complications
쐌 Postoperative bleeding.
쐌 Wound infection.
쐌 Undetected injury to the colon accompanied by abscess and
peritonitis.
쐌 Thrombosis or embolism.
Corrective action: If one of these complications occurs, immediate conversion to laparotomy is generally indicated.
T2
T1
Fig. 6.4.3 Fenestration of large splenic cysts. Trocar placement.
T1 10-mm laparoscope/camera trocar inserted in the left lower abdo-
men, left of and lateral to the rectus abdominis and inferior to the
umbilicus.
T2 12-mm instrument trocar inserted in the left flank in the posterior ax-
illary line.
T3 12-mm instrument trocar inserted in the left upper abdomen at
about the midclavicular line.
T4 5-mm additional instrument trocar inserted about midway between
the medial and lateral instrument trocars.
Trocar Placement
(Fig. 6.4.3).
In many instances, fenestration of a splenic cyst will only require two instrument trocars. If a third instrument trocar is required, it is placed between the first two to form a semicircle.
Open trocar placement is an alternative (see chapter 2.2).
Step-by-Step Procedure
1. Insert trocars under laparoscopic visualization.
2. Explore the peritoneal cavity, make diagnosis, and define indication.
3. Lyse any adhesions between the splenic cyst and the left he-
patic lobe or greater omentum.
4. Aspirate the cyst.
5. Resect the wall of the cyst circumferentially at its junction with
the splenic parenchyma.
6. Pull a fold of the omentum into the cyst and maintain it in place
with metal clips.
7. Place a suction drain close to the operative site.
8. Remove the trocars under laparoscopic visualization.
Bibliography
Bähr R, Reifferscheid P, Kummer D. Nichtparasitäre Milzcysten. Chirurg
1980; 51:175.
Ehrlich P, Jamieson CG. Nonparasitic splenic cysts. A case report and review.
Canad. J. Surg. 1990; 306.
Musy PA, Roche B, Belli D, Bugmann P, Nussle D, le Coultre C. Splenic cysts in
pediatric patients—a report on 8 cases and review of the literature. Eur. J.
Pediatr. Surg. 1992; 2:137.
Reck T, Köckerling F, Gastinger I, Schneider B, Schneider I, Gall FP. Die la-
paroskopische Resektion großer Milzzysten. MIC 1992; 1:106.
Treutner KH, Truong S, Schumpelick V. Die Milzcyste. Chirurg 1988; 59:478.
Wolters U, Keller HW, Lorenz R, Pichlmaier H. Milzzysten: Indikation zur
Operation und operatives Vorgehen. Langenbecks Arch. Chir. 1990;
375:231.
Operative Technique
T3
T4
T3
Bibliography
165
Fig. 6.4.4 Fenestration of large splenic cysts. Lysis of omental adhesions.
The right lateral decubitus position facilitates exposure of the spleen. The
full extent of the splenic cyst is visible. Bluntly dissect adhesions to the left
hepatic lobe and the greater omentum with a swab. You can also use a
swab to palpate where the cyst wall joins the splenic parenchyma. Expose
as much of the splenic cyst as possible to permit adequate fenestration
(see Fig. 6.4.3 for key to instrument numbers).
T3
Fig. 6.4.5 Fenestration of large splenic cysts. Aspirating the cyst.
After exposing the wall of the cyst, aspirate it. A cyst can contain several
hundred milliliters of clear fluid. Decompressing the cyst causes the wall
to collapse and permits the demonstration of the border between the cyst
and the splenic parenchyma (see Fig. 6.4.3 for key to instrument numbers).
T4
T4
Fig. 6.4.6 Fenestration of large splenic cysts. Partial resection of the cyst.
Incise the cyst wall at the junction with the splenic parenchyma using elec-
trocautery (hooked electrode or scissors). Control any bleeding immediately to preventtheoperativesitefrom becoming obscured.Resectthe free
cyst wall as completely as possible to reduce the risk of a recurrent cyst.
However, be careful not to dissect into the splenic parenchyma, because
this may cause laparoscopically uncontrollable bleeding (see Fig. 6.4.3 for
key to instrument numbers).
Fig. 6.4.7 Fenestration of large splenic cysts. Placement and maintenance of an omental fold.
After completely exposing the splenic cyst and resecting the cyst wall,
verify hemostasis in the remaining cystic cavity. Now place a fold of the
omentum into the remaining cyst, and attach it to the bottom and edges
of the cyst with metal clips. The omental fold helps to reduce the risk of a
recurrent cyst. Place a suction drain at the operative site (see Fig. 6.4.3 for
key to instrument numbers).
166
6.5 Fenestration of Hepatic Cysts
6.5 F enestr ation of Hepatic Cysts
F. Köckerling, A. Emmermann
Goal and Methods
Congenital and acquired cysts can occur in the liver. One cause
of genuine congenital cysts is polycystic disease in early childhood associated with simultaneous life-threatening polycystic
disease of the kidneys and, later in childhood, with portal hypertension. In these patients, the disorder may become clinically significant only years later. The pathological condition re-
sults from cystic proliferation, continuous secretion from the
inner epithelial lining, possible infection, progressive portal hypertension, and simultaneous kidney failure. Isolated congenital hepatic cysts and clinically significant small groups of congenital cysts require surgical treatment.
Specific diagnostic studies are required to differentiate these
cystic tissue changes from other types of hepatic cysts, i. e., infected inflammatory cysts, proliferative (Meyenburg’s complex)
and posttraumatic cysts, parasitic cysts, and benign and malignant cystadenomas.
The procedure of choice is to resect the dome covering isolated
cysts, usually the remnants of congenital cysts or acquired cysts.
Superficial hepatic cysts in which at least one-third of the roof is
accessible may be managed laparoscopically. Here, the patient
can benefit from the reduced surgical access, preservation of
most of the host organ, and diminished risk of recurrence equal
to that of the open procedure.
Indications
The typical indication is an isolated symptomatic cyst. Surgical
treatment of polycystic disorders (see above) tends to be palliative at best.
Anesthesia
General anesthesia.
Positioning
(Fig. 6.5.1).
Trocar Placement
(Fig. 6.5.2).
Complications
Intraoperative Complications
쐌 Bleeding or perforation of hollow organs when placing the
trocars.
쐌 Bleeding or bile leakage from the site of the resection.
쐌 Bleeding from the hepatic parenchyma.
쐌 Major bile leakage within the cyst wall (see above).
Corrective action: If one of these surgical complications occurs,
immediate conversion to laparotomy is indicated.
Postoperative Complications
쐌 Bleeding from the resection site.
쐌 Bile leakage from the resection site or from within the cyst
wall (see above).
Corrective action: If one of these surgical complications occurs,
immediate conversion to laparotomy is indicated.
쐌 Recurrence of the cyst.
Corrective action: Remedial laparotomy.
Contraindications
쐌 Parasitic cysts (Echinococcus granularis and Echinococcus
alveolaris) demonstrated by serum diagnostic studies and CT
scan.
쐌 Suspected or confirmed cystadenomas and cystadenocarci-
nomas based on CT scans and needle biopsies.
쐌 In the presence of cystic complications such as rupture,
bleeding, jaundice, or infection, open laparotomy is indicated.
쐌 In the presence of traumatic hepatic cysts, communication
with the bile ducts must be excluded by endoscopic retrograde cholangiography (ERC).
Surgical Risks and Patient Information
The patient should be informed of typical risks of laparoscopic
surgery such as injuries to hollow organs and bleeding. Typical
complications of fenestration include bleeding at the site of re-
section and fistulas. Technical difficulties or complications can
require conversion to open laparotomy, as can misinterpretation of the findings, i. e., findings indicative of a parasitic disorder or tumor.
Step-by-Step Procedure
1. Insert trocars under laparoscopic visualization.
2. Explore the peritoneal cavity, make diagnosis, and confirm indication.
3. Aspirate the cyst and remove the contents with suction.
4. Open the cyst where it joins the hepatic parenchyma.
5. Resect the free wall of the cyst.
6. Remove the resected cyst wall through the right lateral trocar.
7. Inspect the inner cyst wall for bile leakage.
8. Cauterize seeping areas in the resection site, placing sutures if
necessary.
9. Pull a fold of the omentum into the cyst and maintain it in
place with metal clips.
10. Place a suction drain at the lowest portion of the cyst.
11. Remove the instruments and trocars under laparoscopic visualization.
Fig. 6.5.1 Fenestration of hepatic cysts.
Surgeon
Monitor
Assistant
Assistant
holding
laparoscope
Instrument
table
Positioning of the patient, equipment, and
operating team.
The patient is placed supine in a reverse
Trendelenburg position with the table inclined about 20−30° to the left as for laparoscopic cholecystectomy. The surgeon and the
assistant holding the laparoscope stand to
the left of the patient. Depending on the situation, the surgeon operates with one or
both hands. The assistant holds the laparo-
scope below the surgeon’s left arm. A second
assistant stands to the right of the patient
and turns away from the operating table to
watch the operation on the monitor. The
monitor, insufflator, and light source are lo-
cated to the right of the patient’s head so
that the operating team looks past the surgi-
cal site to the monitor. The operating room
nurse and the instrument table are at the
patient’s feet. The electrocautery unit and
aspirator/irrigator set can be positioned more
or less as desired.
Complications
167
Fig. 6.5.2 Fenestration of hepatic cysts. Trocar placement.
T1 10/12-mm laparoscope/camera trocar inserted through the inferior
margin of the umbilicus.
T2 10/12-mm instrument trocar inserted to the right of and lateral to the
midline and inferior to the xiphoid process.
T3 7-mm instrument trocar inserted inferior to the right costal arch in
the midclavicular line.
T4 10/12-mm trocar inserted inferior to the right costal arch as far lateral
as possible at about the anterior axillary line.
Alternative: Open trocar placement, see chapter 2.2.
T2
T4
T3
T1