Equipment

A standard laparoscopic tray is used for a laparoscopic splenectomy, including laparoscopic scissors and atraumatic graspers.

Telescopes, including a 30° or 45° 5- or 10-mm laparoscope, are used, depending on the surgeon’s preference and need for visualization.

Three or four trocars are usually needed; one trocar should be a 12-mm port that can be used for laparoscopic stapler introduction and specimen removal.

Electrosurgical devices such as an electrothermal bipolar sealing device (Ligasure; Covidien, Mansfield, MA) or ultrasonic coagulation shears (Harmonic; Ethicon Endo-Surgery, Cincinnati, OH) can be used to assist with splenic mobilization and dissection.

Typically, the splenic hilar vasculature is divided by using an endoscopic stapling device with a vascular load; however, reports have described the safety and efficacy of the electrothermal bipolar sealing device.^{[17, 18, 19, 20]}

An impervious retrieval bag is needed for morcellation and removal of the specimen. Usually, sacs made from ripcord nylon are used because materials such as polyurethane are vulnerable to perforation.

Special items such as a suction/irrigator and fan or snake retractors for elevation of the spleen are sometimes needed; however, this is left to the discretion of the surgeon.

Ring forceps are useful for morcellating the spleen in the retrieval sac.

Anesthesia

General anesthesia is required for laparoscopic splenectomy. Adjuncts for pain management are left to the discretion of the surgeon and anesthesiologist.

Positioning

There are two major approaches to laparoscopic splenectomy: lateral and anterior.

Lateral approach

For the lateral or semilateral approach, the patient is positioned in the right lateral decubitus position at an angle of approximately 45-90° (see the images below).

Laparoscopic splenectomy. Patient positioning for lateral approach with port placement.

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Laparoscopic splenectomy. Patient positioning for lateral approach.

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Positioning and stabilization of the patient are facilitated by the use of a beanbag mattress, though various rolls and pads may be used. The patient is positioned with the umbilicus at or near the break in the table. This allows more distance between the lower ribs and iliac crest when the table is flexed and the bolster/kidney rest is elevated. All pressure points must be adequately padded. The surgeon and camera operator stand on the patient's right side, with the video monitors above and lateral to the patient’s left shoulder (see the image below).

Laparoscopic splenectomy. Port placement for lateral approach.

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Anterior approach

For the less frequently used anterior approach, the patient is placed supine in the modified lithotomy position; this allows the surgeon to operate while standing between the patient’s legs or on the right side of the patient.

Technique

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Media Gallery

Laparoscopic splenectomy. Division of splenocolic ligament with clear visualization of pancreas.
Laparoscopic splenectomy. Division of lateral attachments to spleen.
Laparoscopic splenectomy. Continued mobilization and takedown of lateral attachments of spleen.
Laparoscopic splenectomy. Medial dissection of spleen.
Laparoscopic splenectomy. Division of short gastric vessels.
Laparoscopic splenectomy. Division of short gastric vessels with use of endoscopic stapling device.
Laparoscopic splenectomy. Ligation of splenic hilum.
Laparoscopic splenectomy. Placement of spleen in retrievable sac.
Laparoscopic splenectomy. Patient positioning for lateral approach with port placement.
Laparoscopic splenectomy. Patient positioning for lateral approach.
Laparoscopic splenectomy. Port placement for lateral approach.
Laparoscopic splenectomy. Port positioning.
Laparoscopic splenectomy. Port positioning for normal-sized spleen.
Laparoscopic splenectomy. Accessory spleen found in splenocolic ligament.
Laparoscopic splenectomy. Ligation of splenic hilum with endoscopic stapler.
Laparoscopic splenectomy. Ligation of splenic hilum with endoscopic stapler. Blunt retractor is used to elevate spleen.
Laparoscopic splenectomy. Ligation of splenic hilum with endoscopic stapler.
Laparoscopic splenectomy. Blunt grasper used to mimic proposed staple line for transection of hilum.
Laparoscopic splenectomy. Placing spleen in retrievable sac.
Laparoscopic splenectomy. Pulling spleen up to 12-mm trocar site to allow morcellation and removal.
Laparoscopic splenectomy. Patient positioning and port/hand placement for hand-assisted technique.
Laparoscopic splenectomy. Technique of hand-assisted technique.
Laparoscopic splenectomy. Port and hand placement for hand-assisted approach for enlarged spleen.
Hand-assisted laparoscopic splenectomy. Enlarged spleen may be removed in total from hand-assist incision.

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Author

William W Hope, MD Assistant Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Director of Surgical Education, Department of Surgery, New Hanover Regional Medical Center/South East Area Health Education Center

William W Hope, MD is a member of the following medical societies: American College of Surgeons, North Carolina Medical Society, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cr bard, WL Gore, Intuitive Surgical<br/>Received research grant from: CR bard, WL Gore, Intuitive surgical, Allergan, Medtronic<br/>Received income in an amount equal to or greater than $250 from: CR Bard, WL Gore, Intuitive surgical, Medtronic, Allergan<br/>Received grant/research funds from CR Bard, WL Gore, Intuitive, Medtronic, and Allergan for consulting.

Coauthor(s)

Damon E Sheneman, DO Trauma Director, Valley Hospital, Spokane Valley, WA

Damon E Sheneman, DO is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Kent W Kercher, MD, FACS Clinical Associate Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Chief of Minimal Access Surgery, Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center

Kent W Kercher, MD, FACS is a member of the following medical societies: American Association of Endocrine Surgeons, American College of Surgeons

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Ethicon Inc, Bard Inc<br/>Received honoraria from Ethicon Inc for speaking and teaching; Received honoraria from Davol Inc for speaking and teaching; Received honoraria from Cooper Surgical for speaking and teaching. for: Ethicon, Bard, Cooper Surgical.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Associate Professor, Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Yale University School of Medicine; Chair, Department of Surgery, Saint Francis Hospital, Trinity Health of New England Medical Group

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

The authors thank Cissy Swartz for her assistance with manuscript preparation and editing.