Transumbilical Single-Port Splenectomy

Abstract

Laparoscopic approach is now considered the gold standard technique for the treatment for many hematologic diseases requiring splenectomy, both in case of a normal or enlarged spleen. During the last few years, new surgical approaches such as natural orifice transluminal endoscopic surgery and single-port laparoscopic surgery have been described. We describe details of the surgical technique for transumbilical single-port splenectomy. A 55-year-old man was referred to our department for spleen removal, a treatment of idiopathic thrombocytopenia and immune anemia. He had no previous significant medical history. Reusable single-port device and coaxial curved instruments were used to perform splenectomy, reproducing the same technique used in the standard laparoscopic approach. For single-port laparoscopic splenectomy, we use a reusable single-port access system (Endocone® Karl Storz GmbH & Co. KG) that was designed to enable instrument triangulation. The proximal conical section of the Endocone® is capped with a separate seal cap (bulkhead), which houses eight valved instrument seals: two along large midline (for instruments up to 15 mm in diameter) and six (three on either side) for instruments up to 5 mm in diameter. The patient is placed in right lateral decubitus as in standard laparoscopic splenectomy, and the surgeons second the camera assistant stand on the side of the bed. The pneumoperitoneum is established using a Veress needle inserted in the umbilicus; at this point, a 5-mm-longitudinal incision is performed right through the umbilical scar and a standard trocar inserted for exploration of the abdominal cavity to evaluate the local condition and contraindications to the single-port approach such as severe adhesions and abnormal anatomy. At this point, the umbilical scar is pulled out using toothed forceps, and the incision is enlarged for up to 3 cm longitudinally: this technique will later allow to hide the scar inside umbilicus itself. A size small surgical wound protector (Alexis O; Applied Medical Rancho Santa Margarita) is inserted through the incision to protect the abdominal wall as well as to improve the stability of the port system and facilitate its introduction. As in standard laparoscopic splenectomy, the procedure starts with division of the small vessels of the lower pole of the spleen by means of combination of bipolar electrocautery and harmonic scalpel (Ethicon Endosurgery). The procedure carries on with the isolation of the main splenic artery that can be then closed by endoscopic clips and divided; surgical stapler can also be used according to surgeon's preferences. Once the artery is divided, the main vein is dissected gently and then closed and divided with an endoscopic surgical stapler with a vascular cartridge (Ethicon Endosurgery). At this point, the short gastric vessels are divided using the harmonic scalpel, and finally the spleen is mobilized by division of the splenodiaphragmatic, splenogastric, and splenocolic ligaments. A large endobag is then introduced through the Endocone®, and the spleen retrieved inside it through the incision. The surgical filed is finally checked for hemostasis, and the incision is carefully closed with an interrupted reabsorbable suture. The operative time was 95 minutes, and there were no intra- or postoperative complications. The patient was discharged on postoperative day 2. No competing financial interests exist. Runtime of video: 6 mins 11 secs