BASIC INFORMATION

Date & Time: 2026-04-12 16:47:40 (Indian Standard Time)

Lecture Handout Prepared from the Teaching Session by: Dr. R. K. Mishra

SUMMARY

This lecture provides a comprehensive overview of the principles and techniques of laparoscopic splenectomy for postgraduate surgeons and gynecologists. The session covers essential splenic anatomy, including the five key ligaments: pancreato-splenic, gastro-splenic, phrenico-splenic, splenocolic, and phrenicocolic. Indications such as idiopathic thrombocytopenic purpura and contraindications like massive splenomegaly and portal hypertension are detailed. The standard patient positioning is a semi-lateral decubitus position. Port placement strategy is critical, with the primary camera port placed 5-10 cm superior to the umbilicus in the mid-clavicular line to avoid intestinal obstruction of the view. The lecture outlines two primary surgical approaches: the more common inferior pole approach and the French lateral mobilization approach. The inferior pole approach involves sequential division of the splenocolic ligament, short gastric vessels, and finally, hilar structures, with a focus on ligating the splenic artery before the vein. The lateral approach involves mobilizing the spleen laterally and flipping it medially before addressing the hilum. The use of various energy devices (Harmonic Scalpel, Ligasure, Tripolar), vascular staplers (Endo-GIA), and hemostatic agents (FloSeal) is discussed. Techniques for specimen retrieval using an endo bag and manual morcellation to prevent splenosis are explained. The lecture also touches upon the possibility of partial splenectomy, anesthetic considerations, and the management of potential complications like bleeding and pancreatic injury.

KEY KNOWLEDGE POINTS

• Anatomy: Understanding the five main splenic ligaments is crucial for systematic dissection.

• Patient and Port Position: Semi-lateral patient position and supra-umbilical port placement are standard to optimize access and visualization of the splenic hilum.

• Surgical Approaches: The two main techniques are the inferior pole-first approach and the lateral mobilization approach.

• Hilar Dissection: The splenic artery must be ligated before the splenic vein to allow the spleen to decompress, reducing its size and minimizing blood loss upon removal.

• Instrumentation: A variety of instruments, including energy devices, vascular staplers, and hemostatic agents, can be employed depending on the clinical scenario and surgeon preference.

• Specimen Retrieval: Use of a commercially available endo bag and careful morcellation are mandatory to prevent the complication of splenosis.

• Complications: Key risks include intraoperative bleeding, injury to the tail of the pancreas, and postoperative sepsis.

INTRODUCTION

Laparoscopic splenectomy has become the standard of care for the surgical management of various hematological disorders affecting a normal or moderately enlarged spleen. Compared to the traditional open approach, the minimally invasive technique offers significant patient benefits, including reduced postoperative pain, shorter hospital stays, improved cosmesis, and faster recovery. However, the procedure demands a thorough understanding of splenic anatomy, meticulous surgical technique, and familiarity with advanced laparoscopic instrumentation to manage the highly vascular nature of the spleen and its surrounding structures safely. This lecture provides a structured guide to the indications, techniques, and potential pitfalls of laparoscopic splenectomy.

LEARNING OBJECTIVES

• To identify the indications and contraindications for laparoscopic splenectomy.

• To describe the standard patient positioning and optimal port placement for the procedure.

• To understand the step-by-step methodology of the two primary surgical approaches: the inferior pole-first approach and the lateral mobilization approach.

• To recognize the principles of hilar dissection, including the sequence of vessel ligation and the use of vascular staplers.

• To outline the procedure for safe specimen retrieval and list common complications and their prevention.

CORE CONTENT

1. Anatomy and Preoperative Considerations

1.1. Ligamentous Anatomy

The spleen is anchored by five primary ligaments, the division of which is the basis of the surgical procedure:

• Pancreato-splenic ligament (containing the splenic vessels and tail of the pancreas)

• Gastro-splenic ligament (containing the short gastric vessels)

• Phrenico-splenic ligament (superior attachment to the diaphragm)

• Splenocolic ligament (inferior attachment to the splenic flexure of the colon)

• Phrenicocolic ligament (supports the inferior pole of the spleen)

1.2. Indications

• Idiopathic Thrombocytopenic Purpura (ITP)

• Autoimmune Hemolytic Anemia

• Microspherocytosis

• Benign tumors and cysts

• HIV-related thrombocytopenia

1.3. Contraindications

• Relative Contraindications:

  • Hematological malignancies

  • Moderate splenomegaly

• Absolute Contraindications:

  • Massive splenomegaly (where there is no room for instrument manipulation)

  • Portal hypertension (due to high risk of bleeding from engorged vessels)

2. Surgical Setup and Port Placement

2.1. Patient and Team Positioning

• Patient Position: Semi-lateral decubitus position, with the left side elevated. A cushion is placed under the patient to elevate the costal margin, widening the subcostal space.

• Surgeon Position: Stands anterior to the patient.

• Assistant Position: Stands posterior to the patient.

• Scrub Nurse Position: Stands on the surgeon's right side.

• Monitor Position: Placed across from the surgeon, often behind the patient. A dual-monitor setup can be beneficial.

2.2. Port Placement Strategy

The "baseball diamond" concept is used, with the splenic hilum as the target.

• Camera Port (10 mm): Placed 5-10 cm superior to the umbilicus, typically on the mid-clavicular line. This high entry point prevents the small bowel from obscuring the view of the upper abdomen. Pneumoperitoneum is established using a Veress needle at this site prior to trocar insertion.

• Working Ports (5/12 mm): Two additional ports are placed to form a triangulation with the camera port and the hilum. Their precise location varies with spleen size but are commonly in the mid-axillary and posterior-axillary lines.

• Accessory Port (5 mm): An optional epigastric port may be placed for a liver retractor if needed. A 12 mm port is required if a vascular stapler is planned.

3. Surgical Technique: Inferior Pole Approach

This is the most common approach. The dissection proceeds in a systematic, inferior-to-superior fashion.

3.1. Division of Inferior Ligaments

The procedure begins by mobilizing the inferior pole of the spleen. The splenocolic and phrenicocolic ligaments are identified and divided. This can be accomplished with a hook electrode, harmonic scalpel, or Ligasure. Freeing the inferior pole allows the spleen to be lifted superiorly, improving exposure of the short gastric vessels and the hilum.

3.2. Division of Short Gastric Vessels

The surgeon then addresses the short gastric vessels located within the gastro-splenic ligament. These can be secured using bipolar energy, Ligasure, Harmonic scalpel, clips, or an endovascular stapler.

3.3. Hilar Dissection and Ligation

This is the most critical step.

• Exposure: The peritoneum over the hilum is opened, and the perihilar fat is dissected to clearly identify the splenic artery and vein. The tail of the pancreas must be identified and preserved.

• Artery Ligation (Artery First): The splenic artery, located posterior to the vein, must be ligated first. This allows the spleen to exsanguinate, reducing its size and minimizing blood loss. A window is created between the artery and vein.

• Ligation Methods:

  • Vascular Stapler (Endo-GIA): This is the safest method, especially for beginners. A white (vascular) cartridge is used. The stapler applies three rows of staples on either side of the cut line.

  • Energy Devices: Advanced energy devices like Ligasure or Harmonic may be used, but this requires significant expertise. Sealing should be done at multiple points without traction.

  • Clips/Sutures: Titanium clips or suture ligation can also be used but require complete skeletonization of the vessels.

• Vein Ligation: After waiting a few minutes for the spleen to decompress, the splenic vein is divided using similar methods.

3.4. Final Attachments and Specimen Removal

The remaining phrenico-splenic ligament is divided, freeing the spleen completely. The specimen is then placed into a large, commercially available endo bag to prevent cell spillage and splenosis. The bag's opening is brought out through the 12 mm port site (which may need to be enlarged), and the spleen is manually morcellated within the bag using ring forceps before being removed in pieces.

4. Surgical Technique: Lateral Mobilization Approach

This technique, favored by some European surgeons, mimics the open surgical approach.

• Lateral Mobilization: The procedure begins by incising the lateral peritoneal attachments of the spleen (phrenico-splenic ligament).

• Medial Flip: The spleen is bluntly and sharply dissected from its retroperitoneal bed and completely flipped medially, often coming to rest against the stomach or liver.

• Hilar Ligation: With the spleen mobilized and flipped, the posterior aspect of the hilum is directly accessible for dissection and vessel ligation, similar to the inferior approach.

• Advantage: This approach may offer better protection for the tail of the pancreas and provides excellent hilar exposure once the mobilization is complete.

5. Partial Splenectomy

With advancements in stapling technology, partial splenectomy is now feasible for focal lesions like abscesses or in some trauma cases.

• The procedure involves using a vascular stapler, often reinforced with a buttressing material like a Gore-Tex sleeve (now commonly integrated as Tri-Staple technology), to divide the splenic parenchyma.

• Topical hemostatic agents, such as FloSeal, are valuable for controlling bleeding from the cut surface.

SURGICAL PEARLS

• Always ligate the splenic artery before the vein to decompress the spleen and facilitate its removal.

• When using a Maryland dissector to retract the spleen, keep the convex surface towards the splenic capsule to avoid inadvertent puncture and bleeding.

• When introducing a vascular stapler, gently spread the perihilar tissue rather than bunching it to ensure the jaws close properly without encompassing too much tissue.

• Use a commercially manufactured endo bag for specimen retrieval. Do not use gloves or other makeshift bags, as the risk of rupture and subsequent splenosis is high.

• Always search for and remove accessory spleens, as leaving one behind can lead to the recurrence of the underlying hematologic disorder.

COMPLICATIONS AND THEIR MANAGEMENT

• Intraoperative:

  • Bleeding: The most common and serious complication. Can occur from the splenic capsule, short gastric vessels, or major hilar vessels. Management includes pressure, clipping, energy application, or conversion to open surgery if uncontrollable.

  • Pancreatic Injury: Injury to the tail of the pancreas can occur during hilar dissection. Meticulous dissection close to the spleen minimizes this risk. If an injury occurs, a drain should be placed.

• Early Postoperative:

  • Hemorrhage: May result from a slipped ligature or failed staple line. Requires re-exploration.

  • Pancreatitis/Pancreatic Fistula: Can result from thermal injury or direct trauma to the tail of the pancreas.

• Late Postoperative:

  • Overwhelming Post-Splenectomy Infection (OPSI): A life-threatening sepsis. Patients must receive appropriate preoperative vaccinations and lifelong antibiotic prophylaxis education.

  • Splenosis: Implantation of splenic fragments in the peritoneal cavity, which can occur if the spleen is ruptured during removal. This can cause pain or mimic malignancy and may lead to disease recurrence.

  • Port-site Hernia: A general risk of laparoscopic surgery.

MEDICOLEGAL AND PATIENT SELECTION CONSIDERATIONS

• Informed Consent: Must include the risks of bleeding, conversion to open surgery, pancreatic injury, and overwhelming post-splenectomy infection (OPSI).

• Vaccinations: Patients must be vaccinated against encapsulated organisms (e.g., Streptococcus pneumoniae, Haemophilus influenzae type b, Neisseria meningitidis) at least two weeks before elective surgery.

• Contraindications: Absolute contraindications like massive splenomegaly and portal hypertension must be strictly respected to avoid catastrophic bleeding. The surgeon's judgment regarding spleen size and technical feasibility is paramount.

• Accessory Spleens: Failure to identify and remove an accessory spleen may be considered a deviation from the standard of care, as it can lead to treatment failure.

SUMMARY AND TAKE-HOME MESSAGES

• Laparoscopic splenectomy is a safe and effective procedure for normal-to-moderately enlarged spleens when performed by a skilled surgeon.

• A systematic approach, beginning with inferior pole mobilization and prioritizing ligation of the splenic artery before the vein, is the most common and reproducible technique.

• The use of vascular staplers for hilar control is recommended for safety and efficiency, especially in the early phase of a surgeon's experience.

• Strict adherence to the principles of specimen containment in an endo bag is mandatory to prevent the long-term complication of splenosis.

MULTIPLE CHOICE QUESTIONS (MCQs)

1. Which of the following is considered an absolute contraindication for laparoscopic splenectomy?

   a) Idiopathic thrombocytopenic purpura

   b) Massive splenomegaly

   c) Benign splenic cyst

   d) Microspherocytosis

2. What is the recommended initial step in the most common surgical approach for laparoscopic splenectomy?

   a) Ligation of the splenic artery

   b) Division of the short gastric vessels

   c) Mobilization of the lateral aspect of the spleen

   d) Division of the splenocolic ligament

3. During hilar dissection, which vessel should be ligated first and why?

   a) Splenic vein, to prevent air embolism.

   b) Splenic artery, to allow the spleen to decompress.

   c) Splenic vein, to reduce blood loss.

   d) Splenic artery, as it is more superficial.

4. What is the primary reason for placing the camera port 5-10 cm superior to the umbilicus?

   a) To be closer to the spleen.

   b) To avoid the falciform ligament.

   c) To prevent the small bowel from obstructing the view of the hilum.

   d) To improve the ergonomics for the surgeon.

5. Which ligament contains the short gastric vessels?

   a) Phrenico-splenic ligament

   b) Gastro-splenic ligament

   c) Splenocolic ligament

   d) Pancreato-splenic ligament

6. The "baseball diamond" concept in port placement refers to the triangulation between:

   a) The surgeon, assistant, and monitor.

   b) The camera port, two working ports, and the target tissue.

   c) The spleen, stomach, and colon.

   d) The umbilicus, xiphoid, and anterior superior iliac spine.

7. What is the primary purpose of using a commercially available endo bag for specimen retrieval?

   a) To make morcellation easier.

   b) To prevent port-site hernias.

   c) To prevent splenosis.

   d) To measure the size of the spleen.

8. Which structure is most at risk of injury during dissection of the splenic hilum?

   a) The left kidney

   b) The tail of the pancreas

   c) The left adrenal gland

   d) The duodenum

9. What color cartridge is typically used for an endovascular stapler (e.g., Endo-GIA) on the splenic vessels?

   a) Blue

   b) Green

   c) White

   d) Black

10. The lateral mobilization or "French" approach involves which initial major step?

    a) Dividing the short gastric vessels.

    b) Securing the splenic hilum.

    c) Mobilizing the spleen from its lateral attachments and flipping it medially.

    d) Dividing the splenocolic ligament.

11. What is splenosis?

    a) A bacterial infection of the spleen.

    b) The auto-transplantation of splenic tissue fragments in the peritoneum.

    c) Congenital absence of the spleen.

    d) A malignant tumor of the spleen.

12. FloSeal is a hemostatic agent primarily composed of:

    a) Oxidized cellulose and fibrin.

    b) Cyanoacrylate glue.

    c) Gelatin granules and human thrombin.

    d) Polysaccharide spheres.

13. When retracting the spleen with a Maryland dissector, which orientation is recommended to prevent injury?

    a) Tip pointing towards the spleen.

    b) Jaws open to grasp the capsule.

    c) Convexity of the curve facing the spleen.

    d) Concavity of the curve facing the spleen.

14. What is a key advantage of the lateral mobilization approach?

    a) It is faster than the inferior pole approach.

    b) It provides direct posterior access to the hilum after mobilization.

    c) It avoids the need for a vascular stapler.

    d) It reduces bleeding from short gastric vessels.

15. The Ligasure device seals vessels up to what diameter, according to the lecture?

    a) 3 mm

    b) 5 mm

    c) 7 mm

    d) 10 mm

16. Which of the following is NOT one of the five primary ligaments of the spleen mentioned in the lecture?

    a) Gastro-splenic ligament

    b) Phrenico-splenic ligament

    c) Falciform ligament

    d) Splenocolic ligament

17. What is the recommended patient position for laparoscopic splenectomy?

    a) Supine

    b) Prone

    c) Lithotomy

    d) Semi-lateral decubitus

18. Failure to remove an accessory spleen can lead to:

    a) Overwhelming post-splenectomy infection.

    b) Pancreatic fistula.

    c) Recurrence of the underlying hematological disease.

    d) Portal vein thrombosis.

19. In the context of the Endo-GIA stapler, what does a green indicator signify after clamping the tissue?

    a) The cartridge is empty.

    b) The tissue is too thick for the staple height.

    c) The tissue thickness is appropriate for the selected cartridge.

    d) The battery is low.

20. A "Tripolar" instrument is described as being:

    a) A combination of monopolar, bipolar, and ultrasonic energy.

    b) A three-pronged grasper.

    c) A bipolar device with an integrated cutting blade.

    d) An instrument that requires three separate electrical poles.

Answer Key: 1-b, 2-d, 3-b, 4-c, 5-b, 6-b, 7-c, 8-b, 9-c, 10-c, 11-b, 12-c, 13-c, 14-b, 15-c, 16-c, 17-d, 18-c, 19-c, 20-c.

MOTIVATIONAL MESSAGE FROM DR. R. K. MISHRA

The sharpest scalpel in your armamentarium is a mind honed by relentless study and disciplined practice. Each case is a new text, each complication a stern teacher. Read, reflect, and respect the anatomy, for in that discipline lies the safety of your patient and the mastery of your craft.

I wish you all continued success and clarity in your surgical journey. Keep learning, and keep excelling.