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Jessica McQuerry University of Kentucky College of Medicine M1.

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Presentation on theme: "Jessica McQuerry University of Kentucky College of Medicine M1."— Presentation transcript:

1 Jessica McQuerry University of Kentucky College of Medicine M1

2  Female in early 20’s presents with abdominal discomfort and feelings of early satiety  On physical exam, a palpable mass is found in the left upper abdominal quadrant

3 A CT scan was performed and showed a splenic cyst

4  Uncommon  Incidence of 0.07% in general population  Majority of cases are due to parasitic infection with Echinococcus granulosus resulting in hydatid disease  Non-parasitic cysts account for < 1/3 of all splenic cyst cases  Pseudo cyst (75%)  True cyst (25%)

5  Surgical cystectomy or splenectomy  Depends on the size of the splenic cyst  Depends on the position of the cyst in relation to the splenic hilum

6  Indications:  Idiopathic thrombocytopenic purpura (ITP)  Autoimmune hemolytic anemia  Microspherocytosis  Benign tumors and cysts  AIDS-related thrombocytopenia  Relative contraindications:  Hematological malignancies  Moderate splenomegaly  Absolute contraindications:  Massive splenomegaly  Portal hypertension

7  Right lateral decubitis, flexed at waist  A cushion is placed under the lumbar fossa to open up the operating field and facilitate trocar placement

8 The surgeon faces the patient, the assistant is behind the patient. They each have their own video screen. The camera person stands next to the assistant.

9  Optical trocar, 10mm  Anterior axillary line below the left costal margin  Operating trocar, 5mm  Mid-axillary line below left costal margin  Operating trocar, 5mm  Mid-clavicular line, a few cm below the left costal margin  Retractor or operating trocar, 8-12mm  Mid-scapular line below the 12 th rib

10  30 ⁰ scope  Atraumatic graspers  Ultrasonic dissectors  Linear Stapler  L-hook Electrocautary tool  Flexible retractor  Suction-irrigation device  Specimen retrieval bag  Spleen scoop

11  Exploration  Check for mobility of the spleen and location of possible adhesions. 00:00- 6:40  Exposure  Dissection of the splenophrenic ligament with the harmonic scalpel. 6:40- 8:43 & 18:30- 23:20

12  Dissection of the splenocolic ligament. 9:14- 13:53  Check for and remove any attachments to the abdominal wall. 13:53- 15:42

13  Exposure and transection of the tissue and vessels in the gastrosplenic ligament. 23:20- 28:30  An L hook cautery is used to dissect some of the retroperitoneal attachments. 28:30- 31:32

14  Drainage of Cyst  Locate and drain the splenic cyst 32:40- 42:20

15  Dissection of the splenorenal ligament. 42:20- 46:27  Careful dissection of the splenic hilum. 46:27- 56:45  Identify and staple the splenic artery. 56:45- 1:02:03  Identify and staple the splenic vein. 1:02:03- 1:02:50 Splenic Artery

16  Detachment  Fully detach the spleen by removing any remaining attachments. 1:02:50- 0:40 (2)  Extraction  A bag is introduced in the retraction trocar. 3:30 (2)

17  Insert the spleen in the bag and close. 3:30- 19:20 (2)  Pull the tip of the bag up through the retraction trocar. 31:20 (2)  The bag is cut away from the rim.  The spleen is morcellized with spleen scoops and removed.

18  Closure  Check for tissue damage and accessory spleens 00:00- 5:31 (3)

19  Liquid diet- the night of or the morning after surgery  Regular diet and discharge from the hospital by the second postoperative day  Within two weeks, patients are usually able to return to work  Steroid dosages can be tapered rapidly and then discontinued

20  Intraoperative complications:  Uncontrollable bleeding  Injury to regional organs during dissection  More common with larger spleens  Postoperative complications:  Minor wound infections  Postoperative ileus  Infection  ITP:  Recurrent or persistent decrease in the number of blood platelets  Chronic ITP

21  Curative in about percent of patients  Improves another percent  Fails to help 5-10 percent

22  Primary benefit of laparoscopic is several small incisions instead of one large incision  Shorter hospital stay  Quicker recovery  Better cosmetic result  Laparoscopic procedure is a more demanding technique  Highly vascularized organ  Fragile parenchyma  Attached by several ligaments to other organs  Hematological disease often associated with a low platelet count

23  Targarona, EM. (2002, March). Laparoscopic splenectomy: anterior posterior approach. Retrieved from  The University of Texas Southwestern Medical Center at Dallas. (2010). Laparoscopic spleen surgery. Retrieved from les/89885.html les/89885.html  Adas, G, et al. (2009). Diagnostic problems with parasitic and non-parasitic splenic cysts. BMC Surgery, 9(9), Retrieved from 2482/9/9 doi: / http://www.biomedcentral.com/ /9/9  Kalinova K. (2005). Giant pseudocyst of the spleen: A case report and review of the literature. Journal of Indian Association of Pediatric Surgeons, 10(3), Retrieved from


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