Тотальная спленэктомия

Gastric bypass for morbid obesity is a well standardized procedure but in case of previous surgery, perioperative challenging complications may occur. This is the case of a female patient who benefited from a gastric band removal 2 months ago because of band’s failure. The video shows the management of a splenic injury.

Laparoscopic spleno-pancreatic resection performed for adenocarcinoma in the tail of the pancreas. This case demonstrates how a complex resection can be undertaken laparoscopically using a stepwise approach. Difficulty was encountered with division of the pancreas and the management of this problem is discussed.

The surgeon stands between the patient's legs with the table in the reverse Trendelenburg position. The authors place three 10-mm ports across the upper abdomen with additional 5-mm ports in the left subcostal epigastric area. The camera is placed in the supraumbilical port. The laparascopic approach provides superior visualization, and tactile assessment of the pancreas. Mobility of the tumor is important to determine feasibility of resection. Laparoscopic ultrasound can delineate the tumor and surrounding structures.

Soper et al. in 1994 were able to establish the safety and efficacy of laparoscopic distal pancreatectomy in an animal model, with no evidence of pancreatic leaks or fistulas. Later, in 1996, Cuschieri et al. described the technique they used to perform laparoscopic distal 70–80% pancreatectomy with en-bloc splenectomy in a group of five patients with intractable pain due to chronic pancreatitis. The authors demonstrated that this operation can be performed laparoscopically within an acceptable operating time and without major complications with advantages that include smaller incisions, less pain, and shorter postoperative recovery.
Identification of anatomical landmarks is crucial for this kind of procedure expecially when treating cancer. Augmented reality is a new tool to improve oncological safety, confirming the ideal dissection plane and anatomical landmarks, and to maximize functional preservation. The objective of this video is to demonstrate how to perform a splenopancreatectomy with removal of pancreatic cancer while keeping sufficient safety margins. Augmented reality is used in order to clearly identify the position of the anatomical landmarks: the splenic vein and artery, as well as the exact position of the tumor so that a sufficient resection margin can be identified.

We report the case of a 39-year-old woman who underwent morphological examination (CT-scan and MRI) for poorly systematized abdominal pain, which demonstrated the presence of a unilocular macrocystic lesion at the tail of the pancreas. The diagnosis established reported a mucinous cystadenoma, and a robotic distal spleen-preserving pancreatectomy was decided upon.
The dissection is initiated at the inferior border of the pancreas. Dissection has been performed at the level of the splenic hilum with freeing of the pancreatic tail. The splenic branches of the splenic vein are identified at the posterior aspect of the pancreas. These branches are freed progressively. As a result, the distal part of the pancreas is freed from the splenic hilum, and dissection will be performed from left to right. This dissection was decided upon as the lesion is located very distally. The splenic vein and the splenic artery are freed at the level of the hilum. Dissection is continued progressively to the right.
Dissection of the cyst in relation to the splenic vein is uneasy as there are several inflammatory adhesions. Dissection is then performed at the isthmic part of the pancreas. The splenic artery is dissected at the superior border of the pancreas. Dissection is then carried out at the posterior aspect of the pancreas. Considering the presence of adhesions, the operative strategy is changed. It is decided to perform a distal pancreatectomy with preservation of the spleen without vessels preservation. However, the splenic vessels are divided. Consequently, the splenic artery is ligated by a clip and divided. The distal part of the splenic artery is also ligated. Proximally, the splenic vein is dissected and divided. The distal part has also been clipped.
The distal division of arterial and venous vessels is performed. The pancreas was divided at the level of its body. The specimen is placed into a bag and extracted by means of a small Pfannenstiel incision. At the end of the procedure, the spleen appears to be well-vascularized by short vessels. The CT-scan performed on postoperative day 5 demonstrates that the spleen is well-vascularized and rules out the presence of any collection in the place left by pancreatectomy. The postoperative outcome is uneventful. There is no pancreatic fistula. The patient is discharged on postoperative day 7. Pathological findings confirm the presence of a mucinous cystadenoma without any malignancy.

This video demonstrates a three-trocar laparoscopic splenectomy performed for atypical idiopathic thrombocytopenic purpura in a 33-year-old patient. An anterior approach, as in this case, is a very interesting one as the spleen does not need to be manipulated in this patient.