Tricks of the Senior Surgeon

■ Detailed knowledge of splenic anatomy constitutes the single most important factor that will allow the surgeon to consider all the options available to save splenic parenchyma. There are two patterns of terminal artery branching: distributed and bundled or magistral (see STEP 1). Most specimens have two or three terminal branches (superior polar, superior and inferior terminal) determining lobes or segments. Relative avascular planes are identified between lobes and segments. The surgical unit of the spleen is based upon surgically accessible vessels at the hilum.

■ The keys to success with partial laparoscopic splenectomy are experience with advanced laparoscopy, case selection, ability to dissect branches of the splenic artery close to the hilum, and foremost the realization that leaving a 5-mm margin of devitalized spleen in situ greatly simplifies homeostasis.

■ Specially in the laparoscopic approach, improper use of the cautery can cause iatrogenic injury to the stomach, colon, and pancreas. Structures close to the lower pole in the gastrocolic ligament can be approached aggressively with the cautery, but blind fulguration of fat in the hilum can result in serious bleeding. The instrument should be activated only in proximity to the target organ to avoid arcing and spot necrosis, which may result in delayed perforation and sepsis.

■ The role of the assistants is also important in the prevention of complications. In the laparoscopic approach, all instruments, including those handled by assistants, should be moved only under direct vision. Retraction of the liver and stomach and elevation of the spleen require constant concentration to avoid lacerations with subsequent hemorrhage or perforation and jeopardizing the performance of partial splenectomy.

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