Single Incision Laparoscopic Splenectomy With Double Port

Abstract

In response to the increasing interest in minimally invasive surgery by both patients and surgeons, most abdominal surgery today is carried out laparoscopically. Laparoscopic splenectomy has become a gold standard in the treatment of spleen disorders related to hematologic diseases. Increasing laparoscopic surgery experience and improved new vessel sealing equipment have led to a decreasing number of ports in laparoscopic surgery and to operations from 1 incision. We carried out single-incision double-port laparoscopic splenectomy in a patient with immune thrombocytopenic purpura using only 2 trocars with a simple manipulation. Our review of the related literature revealed no earlier description of a single-incision double-port laparoscopic splenectomy. We therefore present herein this earlier unreported technique.

Full text

Single Incision Laparoscopic Splenectomy With Double Port
Celalettin Vatansev, MD and Ilhan Ece, Jr, MD
Abstract: In response to the increasing interest in minimally invasive
surgery by both patients and surgeons, most abdominal surgery
today is carried out laparoscopically. Laparoscopic splenectomy has
become a gold standard in the treatment of spleen disorders related
to hematologic diseases. Increasing laparoscopic surgery experience
and improved new vessel sealing equipment have led to a decreasing
number of ports in laparoscopic surgery and to operations from 1
incision. We carried out single-incision double-port laparoscopic
splenectomy in a patient with immune thrombocytopenic purpura
using only 2 trocars with a simple manipulation. Our review of the
related literature revealed no earlier description of a single-incision
double-port laparoscopic splenectomy. We therefore present herein
this earlier unreported technique.
Key Words: single incision, double port, laparoscopy, splenectomy,
vessel sealing system
(Surg Laparosc Endosc Percutan Tech 2009;19:e225–e227)
Laparoscopic splenectomy (LS), first used in 1992, has
gained in popularity for use in hematologic diseases with
splenectomy indication. It has emerged as the gold standard
of treatment owing to its effectiveness, reliability, and low
complication rate and hospital stay.
1
Surgical field compli-
cations and pulmonary complications have decreased greatly
with LS. The more educated public desires fewer scars after
surgery, which has led to an increase in the type and num-
ber of single-incision laparoscopic surgeries in the hands of
experienced surgeons.
In this study, we examined the available literature and
determined that with sufficient surgical experience and the
appropriate equipment, LS, the gold standard treatment in
benign hematologic diseases, can be carried out safely with
a single incision using only 2 trocars.
MATERIALS AND METHODS
LS was planned in a 33-year-old female patient who
had been followed with medical treatment in the Hematol-
ogy Department for 1 year owing to immune thrombocy-
topenic purpura. Platelets were increased to 70,000/mm
3
with steroid treatment.
The patient was immunized against pneumococcal
infections (Pneumo 23, Sanofi-Pasteur) 2 weeks before the
operation, and 1g cefazolin sodium was administered intra-
venously as preoperative prophylaxis. In the radiologic
examination, the long axis of the spleen was determined as
12 cm; no accessory spleen was identified on the computer-
ized tomography
Surgical Technique
The patient was placed in a semilateral position on the
right side with her left arm fixed over the head. The surgeon
and the assistant stood on the right side of the patient with
the monitor placed on the patient’s opposite side.
After intratracheal anesthesia and application of naso-
gastric decompression, the umbilicus, pulled out using a
towel clamp, was incised 25 mm in inverted U shape and the
first 10-mm trocar was inserted. The abdominal cavity was
insufflated with 12 mm Hg pressure, and the patient was
adjusted into the reverse trendelenburg position. The
second 10-mm trocar was inserted from the same incision
through a different facial defect to minimize CO
2
leakage
(Fig. 1). According to the patient’s position, the abdominal
tissues and spleen were monitored with a 30-degree
standard scope from the lower trocar.
Zero number fine needle prolene suture material was
inserted percutaneously from the ninth intercostal aperture to
the abdomen. Starting from the head of the spleen toward the
tail with continuing suture 3 times and exiting from the 11th
intercostal aperture, thus tractioning the spleen (Figs. 2, 3).
Continuous suturing technique that we have developed was
to minimize the laceration risk of spleen.
The reliability has been proven in some series,
2–4
the
10-mm vessel sealer (LigaSure Atlas 10-mm Laparoscopic
Sealer/Divider/USA) equipment has been used for hilar
dissection. Splenocolic and gastrosplenic combinations and
ligaments have been sealed and incised with the vessel sealer.
Using this vessel sealing equipment, hilar dissection
was carried out and hilar vessels were sealed and incised.
With incision of the splenophrenic ligament, the splenect-
omy was completed (Fig. 4). A 10 20 cm endobag was
inserted into the abdominal cavity from the trocar.
The sutures holding the spleen were cut and collected
into the bag. The spleen removed with trocar was broken
FIGURE 1. Trocar placements.Copyright r2009 by Lippincott Williams & Wilkins
Received for publication May 25, 2009; accepted September 25, 2009.
From the Department of General Surgery, Selcuk University Meram
Medical School, Turkey.
Reprints: Celalettin Vatansev, MD, Department of General Surgery,
Selcuk University Meram Medical School, Turkey (e-mail: cvatan-
sev@hotmail.com).
TECHNICAL REPORT
Surg Laparosc Endosc Percutan Tech Volume 19, Number 6, December 2009 www.surgical-laparoscopy.com |e225

down in the bag using tissue forceps (Figs. 5, 6). During the
45-minute operation, no bleeding or organ injury occurred.
Preoperative hemoglobin value was determined as 10 g/dL
and platelets as 70,000/mm
3
; these values at the postope-
rative second hour were hemoglobin: 9.8 g/dL and platelets
150,000/mm
3
.
The patient’s nasogastric catheter was removed after 8
hours, food was started at the 12th hour and the patient
was discharged at the 36th hour.
DISCUSSION
In patients with splenectomy indication related to
hematologic disease, a small incision is more reliable when
compared with open surgical method because of the
painless and fast recovery, rapid improvement in respira-
tory functions and fewer early and late complications.
5–7
It is certain that there is a clear decrease in post-
operative surgical field infections and pain with the contri-
bution of single-incision LS to minimally invasive surgery
by decreasing the port number.
8,9
It is an economically
beneficial operation because the equipment requirements
are limited to a 30-degree standard telescope, vessel sealing
equipment, and endobag. It can thus be carried out at every
medical center with the requisite experience.
The umbilical access we used is a well-known and
standardized site for access to the abdominal cavity for
laparoscopy. It presents no new risks, and facilitates an
operating view comparable to that in standard LS.
To enhance the cosmetic results, we developed a
particular umbilical technique whereby the umbilicus is
completely extroflexed and the skin incision is made in
inverted U shape extending for about 2 to 3 cm. When the
fascia is exposed, it is possible to enter the abdominal cavity
with various devices or by using an ‘‘open’’ technique. At
the end of the procedure, a careful reconstruction of the
umbilicus allows it to be replaced in its original position,
thus achieving a completely invisible scar. The 2 subcuta-
neous sutures used leave no scar in the abdominal wall, and
thus we can truthfully claim a ‘‘minimally visible scar’’
procedure. The use of an extralong scope or a scope with a
cable connection on the posterior rather than the lateral
aspect permits full rotation of the 30-degree optic device
without interference from the operative instruments. Never-
theless, an understanding between the operating surgeon
and the camera assistant is essential because each move-
ment of one can interfere with the other.
The advancement in vessel sealing has enabled vessel
dissection clips and incision in laparoscopic surgery to be
carried out at the same time, thereby shortening the opera-
tion time.
10
We have been using vessel sealing equipment in open
and laparoscopic surgery and laparoscopic solid organ
surgery in our clinic for 3 years. In this case, with the obtuse
end of the 10-mm vessel sealing equipment, the spleen hilus
was incised securely, when needed, the spleen was tractioned,
and the hilar splenic vessels smaller than 7 mm were sealed.
One of the most important manipulations in this case
is the manner in which we sutured continually from the
anterior side of the spleen including the parenchyma to
traction the spleen. The spleen was suspended on the
abdominal wall and hilus elements were easily dissected
FIGURE 4. Hilar dissection with vessel sealing system.
FIGURE 5. Removal of spleen with endobag.
FIGURE 2. Traction of spleen with propylene suture.
FIGURE 3. Ports and traction sutures.
Vatansev and ece Surg Laparosc Endosc Percutan Tech Volume 19, Number 6, December 2009
e226 |www.surgical-laparoscopy.com r2009 Lippincott Williams & Wilkins

with upper traction. Whereas the lower pole of the spleen
was dissected, the end of the continual suture exiting the
spleen was tractioned to incise the splenocolic ligament and
to seal the hilar elements close to the lower pole. For
the elements in the upper pole, the starting end was
tractioned to stabilize the spleen and splenectomy was
completed.
Furthermore, in this approach, 1 trocar required for at
least 1 element was cancelled. Another difficult and time-
consuming procedure is the collection of the spleen in the
endobag. The fact that the spleen is suspended and fixed on
the abdominal wall by suturing makes it easier to collect the
spleen into the endobag, and this is an important advantage
of the technique.
In conclusion, we believe that LS can be carried out safely
and effectively with our improved traction-suture method,
single-incision double-port standard, and laparoscopic tools.
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FIGURE 6. The fragmented spleen.
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