Strategies for bleeding control during complete laparoscopic complicated splenectomy

Authors: Guo Yongqiang, Liang Ruopeng, He Yun, Chen Renyin, Zhang Yufeng

Source: Chinese Journal of Hepatobiliary Surgery, 2023, 29(9)

Summary

objective

To explore strategies for bleeding control during complete laparoscopic complicated splenectomy.

method

outcome

All 11 patients in this group successfully completed laparoscopic complicated splenectomy. The operation time of 11 patients was (242.8±43.6) min, the intraoperative blood loss range was 50~1 480 ml, the median was 180 ml, the postoperative exhaust time was (3.9±0.8) d, the time of abdominal drainage tube removal was (6.4±0.8) d, and the postoperative hospital stay was (13.1±3.9) d. Eleven patients had no complications such as bleeding, pancreatic fistula, gastric fistula, colon injury, and infection after surgery, and 1 case of splenic vein thrombosis, 2 cases of mild pancreatitis, and 4 cases of moderate ascites occurred.

conclusion

The prevention strategies of preferential splenic artery blockade and free bleeding of the perisplenic and splenic pedicle can effectively control and prevent intraoperative bleeding, which is one of the important guarantees for the success of complete laparoscopic complex splenectomy.

Complex spleen refers to the giant spleen, a spleen with extensive fibrous and/or vascular adhesions around the spleen, a spleen with perisplenitis, and a spleen with partial hematologic disorders [1,2,3]. Macrospleen is a severe splenomegaly type in which the lower edge of the spleen exceeds the umbilical or midline of the abdomen, the length of the spleen is ≥20 cm long, or the mass of the spleen is ≥ 1000 g [4]. Due to its particularity, clinical surgical resection of complicated spleen is risky and difficult, and complete laparoscopic complex splenectomy is rarely reported. This study analyzed the data of 11 patients with complete laparoscopic complex splenectomy performed by the First Affiliated Hospital of Zhengzhou University from May 2016 to October 2021, and is reported as follows.

Information and methodology

1. Clinical data:

The data of 11 patients who underwent complete laparoscopic complex splenectomy from May 2016 to October 2021 in the First Affiliated Hospital of Zhengzhou University were retrospectively analyzed, including 3 males and 8 females, aged (43.5±16.3) years. All 11 patients were clearly diagnosed with complicated spleen before surgery. The causes of complicated splenectomy in 11 patients: 8 cases of portal hypertension in liver cirrhosis and 3 cases of blood disease spleen. Among the 8 patients with portal hypertension, 7 cases had severe splenomegaly, 1 case had moderate splenomegaly (with history of splenic intervention), 1 case had Child-Pugh grade A and 7 patients had grade B for liver function. All patients were preoperatively gastroscopy, 3 patients had esophageal varices, and 5 patients had mild and moderate esophageal varices, and none of them underwent pericardia vascular dissection. Preoperative color Doppler ultrasound and CT diagnosed severe spleen enlargement in 7 cases (Fig. 1), and moderate enlargement with splenic artery embolization intervention in 1 case. There were 5 cases of hepatitis B viral cirrhosis in 11 patients, 1 case of hepatitis C viral cirrhosis and 2 cases of cryptogenic cirrhosis. Preoperative blood count: red blood cells (2.8±0.4) ×1012/L, white blood cells (2.9±0.4) ×109/L, platelet count (47.8±16.0) ×109/L. Among the 11 patients, 3 patients had severe splenomegaly with blood diseases, all of which were hemolytic anemia, 2 cases were complicated by gallstones, and preoperative color Doppler ultrasound and CT all diagnosed severe spleen enlargement.

Strategies for bleeding control during complete laparoscopic complicated splenectomy

2. Surgical methods and bleeding control strategies:

After successful anesthesia, adjust the patient to the supine leg position, raise the left costal area by 30°, and tilt the operating table 30° to the left. After disinfecting the cloth, 10 mm was cut under the umbilicus, a pneumoperitoneum needle was inserted through puncture, CO2 pneumoperitoneum was established, and the pressure was set at 15 mmHg (1 mmHg=0.133 kPa). Pull out the pneumoperitoneum needle, insert a 10 mm Trocar, and insert a laparoscopic lens. Under direct vision, 3 cm below the xiphoid process, 3 cm below the costal margin of the left midclavicle, 3 cm below the costal margin of the left anterior axilla, and 3 cm below the costal margin of the right midline clavicle, 5 mm, 5 mm, and 5 mm Trocar were placed, respectively. The subxiphoid puncture hole and the left clavicle midline subcostal margin puncture hole are the main operating holes. The surgeon is located between the patient's legs, the glass-holding hand is located on the right side of the patient, and the first and second assistants are located on the left and right sides of the patient. The surgeries are all done by the same group of doctors. Laparoscopic exploration showed that there were 10 cases of severe enlargement of the spleen, and 1 patient had moderate enlargement of the spleen, atrophy of the spleen after intervention, severe adhesion with the diaphragm, and collateral circulation between the spleen and diaphragm was clustered. Four patients had few to moderate ascites. After exploring the abdominal cavity for the presence of a paraspleen, the omentum is opened from the middle of the large curvature of the stomach by ultrasound, and the free left blood vessel of the gastric omentum and the short blood vessel of the stomach are dissected upward, and the spleen-o-lok clamp is clamped and severed, and the spleen and stomach ligaments are cut off to the superior pole of the spleen.

Intraoperative bleeding control strategies:

Splenic artery priority occlusion strategy: push the stomach to the right and back, pull the omentum forward and down, fully expose the splenic hilus, find the splenic artery (Figure 2A), free space, double ligation with a 10-gauge silk thread (Figure 2B).

Prevention strategies for bleeding in the free process around the spleen: turn the operating table 30° to make the patient into a right recumbent position, and tilt the spleen to the right front with the help of gravity to facilitate the exposure of the back of the spleen. Gradually break the spleen-colon ligament, spleen-kidney ligaments, lift the inferior pole of the spleen, gradually separate the spleen-diaphragmatic ligament upward, and converge with the free area of the superior splenoid pole. After splenic artery embolization, the spleen with dense splenic diaphragmatic adhesions and rich collateral circulation will not be treated temporarily, and after the posterior splenic tunnel is established and the splenic pedicle is severed, the splenic capsule resection at the splenic diaphragmatic adhesion is performed.

Prevention strategies for bleeding during the treatment of the spleen: raise the inferior pole of the spleen and free the spleen-pancreatic space from the back of the spleen, and the free range does not affect the application of the laparoscopic cutting closure. Use the esophageal belt from the back of the spleen to bypass the upper and lower poles of the spleen, lift the splenic pedicle, and gradually separate the splenic pedicle from the splenic hilar with a laparoscopic incision closure to complete splenectomy (Figures 2C, Fig. 2D).

The removed spleen is removed in a specimen bag. Rinse the abdominal cavity and place one abdominal drainage tube in the spleen fossa and one abdominal drainage tube in the back of the stomach through the puncture hole in the left abdominal wall. Close the pneumoperitoneum, withdraw the laparoscopic instruments, suture the wound, and end the operation.

3. Observation indicators:

Surgery time, intraoperative blood loss, postoperative exhaust time, postoperative removal of abdominal drainage tube, postoperative complications (bleeding, pancreatic fistula, gastric fistula, colon injury, hepatic encephalopathy, subphrenic effusion, infection, etc.).

Results

All 11 patients in this group successfully completed laparoscopic complicated splenectomy, and 2 patients with gallstones underwent laparoscopic cholecystectomy at the same time. The operation time of 11 patients was (242.8±43.6) min, the intraoperative blood loss ranged from 50~1 480 ml, and the median was 180 ml. Eleven patients had significantly improved platelets 1, 2, 5 days after surgery and before discharge, and red blood cells, white blood cells and hemoglobin improved significantly. Eleven patients had postoperative exhaust time (3.9±0.8) d, abdominal drainage removal time (6.4±0.8) d, and postoperative hospital stay (13.1±3.9) d. Eleven patients had no complications such as bleeding, pancreatic fistula, gastric fistula, colon injury, hepatic encephalopathy, subphrenic effusion, and infection after surgery, and 1 case of splenic vein thrombosis, 2 cases of mild pancreatitis, and 4 cases of moderate ascites. Patients with splenic vein thrombosis are given active anticoagulation therapy, and anticoagulation therapy is continued outside the hospital for 1 month, and the thrombus disappears after review. Two patients with pancreatitis were cured after fasting, somatostatin and parenteral nutrition. In 4 patients with moderate ascites, the ascites gradually regressed after hepatoprotective, diuretic, plasma supplementation, or albumin. There were 11 patients in this group, followed up for 1 year, and 10 patients had no abnormalities. In one patient with pancreatitis after surgery, CT was reviewed 3 months after surgery, indicating pancreatic tail pseudocyst (about 5 cm), and observation and treatment were ordered, and 1 year after surgery, re-examination CT showed that pancreatic tail pseudocyst was reduced (about 3 cm), and continued observation was ordered.

Discussion

The technical difficulties of complex splenectomy lie in free total spleen, control intraoperative bleeding, and avoidance of iatrogenic damage to perisplenous tissues and organs [5]. However, complex splenectomy under complete laparoscopy still has problems such as large spleen, narrow abdominal space, and insufficient space for laparoscopic operation [6]. Complex splenectomy has adhesions between the spleen and surrounding tissues, poor mobility, poor surgical field exposure, laparoscopic lack of hand touch, increased difficulty of freeing, and predisposing to perisplen tissue and organ damage [7]. Patients with portal hypertension with cirrhosis have abundant collateral circulation in the spleen supply, heavy vascular adhesions, tortuous and thickened splenic vessels, coagulation dysfunction, and difficulty in managing intraoperative bleeding laparoscopic [8]. In this study, a total of 11 patients underwent complete laparoscopic complex splenectomy, and all of them were successful. Strategies for bleeding control during complete laparoscopic complex splenectomy are reviewed:

First, adhere to the principle of priority blockade of the splenic artery. Priority ligation to block the splenic artery can reduce spleen congestion, gradually shrink and soften, increase the surgical operation space, and facilitate surgical operation. The priority blockade of the splenic artery can also fully return the retained blood of the spleen, play the role of autologous blood transfusion, and reduce the ineffective blood loss of patients [9,10]. Priority blocking of the splenic artery can control the blood supply to the spleen, reduce the risk of difficult to control bleeding during surgery, and grasp the initiative of intraoperative bleeding control. It is recommended that before freeing the spleen, if there are no special circumstances, the work of ligating the splenic artery should be given priority. During the operation, the peritoneum can be incised at the most obvious place where the splenic artery pulsation is most obvious in the upper caudal caudal of the pancreas, explore the splenic artery and free the space, take care not to damage the splenic vein and the vascular branch between the splenic artery and the pancreas, and double ligation with a 10-gauge silk thread. If there is an adhesion between the splenic artery and the splenic vein space, it is necessary to carefully identify and protect the splenic vein to avoid tearing the splenic vein when the splenic artery is free [11,12], and a 2-0 injury-free needle can be used to close the splenic artery and the venous space to suture the splenic artery. After ligation of the splenic artery, the collateral circulation of the spleen can be assessed by observing the color change of the spleen. Of course, in some special cases, such as abnormal splenoid development, the position of the splenic artery is deep, short, not easy to explore, ligation, or the pancreatic tail, splenic hilar area inflammation and adhesion are heavier, can not separate the spleen artery, or the spleen is too large, the spleen is not fully exposed, priority ligation of the spleen artery is difficult, it is necessary to analyze the specific problem and choose the appropriate spleen incision program. Do not blindly pursue priority ligation of the splenic artery, resulting in uncontrollable bleeding during surgery.

Second, the prevention of bleeding in the free process of the perisplenism: mechanical ligation should be used for the treatment of the collateral circulation around the spleen, and subcapsular resection of the splenic without space adhesions can be adopted [13]. Most complex spleens have inexperienced failure of laparoscopic surgery due to cirrhosis of the liver, portal hypertension, large spleen volume, poor coagulation function, abundant peripheral collateral circulation and tortuous dilation of blood vessels, thin and brittle vascular walls, high pressure in the lumen, and uncontrollable bleeding during the free process [14]. For collateral circulatory vessels, clipping with Hem-o-lok is disconnected. Clamping and disconnecting collateral circulating vessels should be carried out within the scope of Hem-o-lok clamps, in the state of no traction on the blood vessels, and should not be torn, separated and treated together [15]. The tortuous collateral circulation veins have a thin wall and poor traction tolerance, and once the blood vessel is torn or ruptured and bleeding, the broken end of the blood vessel retracts into the tissue, and hemostasis is extremely difficult. For perisplen adhesions, an appropriate free regimen should be selected according to the situation. If the local adhesion around the spleen is dense, combined with calcification, no gap, if the range is small, the splenic capsular resection can be taken directly, and the bleeding of the splenic wound can be treated with gauze compression or electrocoagulant rod burning; If the extent is large, after the rest of the perisplen is completely free, a retrosplenic tunnel is established, the splenic pedicle is severed, and then the subcapsular splenic resection at the adhesion site is performed. Bleeding at the residual splenic capsule, because there are many abundant collateral vessels at the adhesions, it is recommended to suture to stop bleeding, and it is not recommended to simply compress hemostasis or electrocoagulation to stop bleeding. In this group, there was one case after splenic vascular intervention, the spleen body and diaphragm were widely adhered and collateral circulation vascular adhesions, due to the large range, the direct subcapsular resection of the splenic during the free process had more bleeding, then the free was stopped, gauze tamponade was pressed to stop the bleeding, and the splenic pedicle was resected by retro-splenic pedicle tunneling, and then forcibly resected the splenic capsule at the adhesion site, electrocoagulation hemostasis and suture hemostasis combined to treat the residual splenic capsular bleeding point of the diaphragm, resection of the spleen, and more bleeding during the operation.

Third, the prevention of bleeding during the treatment of the spleen: the secondary splenic pedicle dissection method is recommended for the dissection of the splenic pedicle [16], and the laparoscopic dissection closure is recommended. The difficulty of surgery in patients with macrospleen is how to control bleeding, especially the management of the spleen pedicle [17]. When the spleen is completely free, an esophageal band can be bypassed the spleen, lift the splenic pedicle, open the anterior splenic serous membrane in front of the splenic pedicle to carefully identify the secondary splenic pedicle vascular space. The white nail compartment of the closure is cut laparoscopically along the blood vessels of the secondary splenic pedicle, referring to the vascular space, and the splenic pedicle is dissected in stages. Because the splenic portal blood vessel wall is thin, tortuous, dilated, and there is a risk of vascular rupture and bleeding during the free process, it is recommended to use a laparoscopic cutting closure for the resection of the splenic pedicle, and it is not recommended to free the secondary blood vessels of the splenic pedicle one by one, and use Hem-o-lok clamp to block and disconnect. A white nail compartment is recommended for laparoscopic cutting closure nail compartments for better hemostasis. When dissociating, it is necessary to clamp the blood vessel completely, disconnect it in the intervascular area of the secondary splenic pedicile, and dissect it in stages under normal tension, and should not be disconnected by cluster dissection to save the nail compartment of the laparoscopic cutting closure. The bleeding point at the broken end of the splenic pedicle should be stained with vascular sutures to stop bleeding, and it should not be solved simply by electrocoagulation to stop bleeding or compress hemostasis.

In conclusion, effective control of intraoperative bleeding is an important guarantee for the success of laparoscopic complex splenectomy. Priority blockade of the splenic artery and prevention of free bleeding in the perisplen and pedicle are important components of strategies to control intraoperative bleeding.

bibliography

[1]

YANG Lianyue,LIU Zhen. Advances in surgical treatment of portal hypertension and upper gastrointestinal bleeding[J]. Journal of Clinical Surgery, 2007, 15(3):162-163. DOI: 10.3969/j.issn.1005-6483.2007.03.010.

[2]

LeiteLA, Pimenta FilhoAA, Ferreira RdeC, et al. Splenectomy improves hemostatic and liver functions in hepatosplenic schistosomiasis mansoni[J]. PLoS One, 2015, 10(8)：e0135370. DOI: 10.1371/journal.pone.0135370.

[3]

NomuraY, KageM, OgataT, et al. Influence of splenectomy in patients with liver cirrhosis and hypersplenism[J]. Hepatol Res, 2014, 44(10)：E100-109. DOI: 10.1111/hepr.12234.

[4]

SmithL, LunaG, MergAR, et al. Laparoscopic splenectomy for treatment of splenomegaly[J]. Am J Surg, 2004, 187(5)：618-620. DOI: 10.1016/j.amjsurg.2004.01.016.

[5]

GUAN Jiao, ZHOU Zunqiang, TONG Danian, et al. Clinical efficacy of complicated splenectomy in 235 cases[J]. Chinese Journal of Digestive Surgery, 2016, 15(7):680-683. DOI: 10.3760/cma.j.issn.1673-9752.2016.07.008.

[6]

ZHOU Guangwen. Complex splenectomy: 126 cases[J]. Chinese Journal of General Surgery, 2013, 28(8):590-592. DOI: 10.3760/cma.j.issn.1007-631X.2013.08.008.

[7]

KaradagCA, ErginelB, KuzdanO, et al. Impact of spleen size on outcomes in laparoscopic splenectomy in children[J]. Gastroenterol Res Pract, 2015, 2015：603915. DOI: 10.1155/2015/603915.

[8]

HongD, ChengJ, WangZ, et al. Comparison of two laparoscopic splenectomy plus pericardial devascularization techniques for management of portal hypertension and hypersplenism[J]. Surg Endosc, 2015, 29(12)：3819-3826. DOI: 10.1007/s00464-015-4147-4.

[9]

LI Youwei,HE Ping. Application of splenic artery preferential occlusion technique in laparoscopic splenectomy[J]. Minimally Invasive Medicine, 2017, 12(4):501-503. DOI: 10.11864/j.issn.1673.2017.04.16.

[10]

WU Haifu, SHENG Weizhong, LIU Fenglin, et al. Experience of 67 cases of laparoscopic splenectomy[J]. Chinese Journal of Practical Surgery, 2010, 30(7):584-586.

[11]

ZhangY, WenTF, YanLN, et al. Preoperative predictors of portal vein thrombosis after splenectomy with periesophagogastric devascularization[J]. World J Gastroenterol, 2012, 18(15)：1834-1839. DOI: 10.3748/wjg.v18.i15.1834.

[12]

HorowitzJ, SmithJL, WeberTK, et al. Postoperative complications after splenectomy for hematologic malignancies[J]. Ann Surg, 1996, 223(3)：290-296. DOI: 10.1097/00000658-199603000-00010.

[13]

JIANG Hongchi,LU Chaoyang,SUN Bei. How to safely perform macrosplenectomy[J]. Chinese Journal of Hepatobiliary Surgery, 2006, 12(9):586-588. DOI: 10.3760/cma.j.issn.1007-8118.2006.09.008.

[14]

ZHOU Jinhang, WU Liming, WANG Jianghua, et al. Analysis of factors related to complications after laparoscopic splenectomy in patients with portal hypertension with cirrhosis[J]. Journal of Clinical Hepatobiliary Diseases, 2015, 31(11):1870-1873. DOI: 10.3969/j.issn.1001-5256.2015.11.024.

[15]

AkahoshiT, UeharaH, TomikawaM, et al. Comparison of open, laparoscopic, and hand-assisted laparoscopic devascularization of the upper stomach and splenectomy for treatment of esophageal and gastric varices: a single-center experience[J]. Asian J Endosc Surg, 2014, 7(2)：138-144. DOI: 10.1111/ases.12096.

[16]

ZHOU Jinxue, ZHAN Xiangyu, LI Qingjun, et al. Application of secondary splenoid pedicle dissection in laparoscopic splenectomy[J]. Chinese Journal of General Surgery, 2017, 32(2):119-121. DOI: 10.3760/cma.j.issn.1007-631X.2017.02.008.

[17]

WuZ, ZhouJ, PankajP, et al. Comparative treatment and literature review for laparoscopic splenectomy alone versus preoperative splenic artery embolization splenectomy[J]. Surg Endosc, 2012, 26(10)：2758-2766. DOI: 10.1007/s00464-012-2270-z.