Laparoscopic splenectomy

Traumatic splenectomy was first performed by military surgeons, and splenectomy for non-traumatic diseases was initiated by Quittenbaum (1926). After 1970, splenectomy was widely carried out worldwide. There are four reasons for the increase of spleen surgery frequency: 1 routine splenectomy in gastric cancer surgery has been widely recognized and popularized; 2 selective proximal vagotomy and Nissen fundoplication and other adjacent spleen areas Surgery, resulting in increased iatrogenic spleen injury; 3 serious car accidents increased year by year; 4 spleen surgery indications have expanded trends, such as the development of transplant surgery, and the use of staged laparotomy for the treatment of Hodgkin's disease involves the spleen . With the deep understanding of the importance of the spleen in the body's immunology, the spleen surgery technique has been improved. Despite this, splenectomy is still the preferred procedure for some patients, and proper preoperative preparation and selection of the best surgical time can help reduce the incidence of complications after splenectomy. In the past 10 years, with the continuous development of endoscopic surgical techniques, laparoscopic splenectomy has been successfully applied. Due to its advantages of micro-trauma, less pain, quick recovery and short hospital stay, it is developing rapidly. Now laparoscopic spleen resection can be applied to most diseases requiring surgical removal of the spleen, including blood diseases and spleen. Benign and malignant tumors, spleen cysts, free spleen and AIDS splenectomy. At the same time, laparoscopic splenectomy can be combined with other operations, such as laparoscopic spleen and gallbladder combined resection or gynecological attachment combined surgery. At present, the application in pediatric surgery is gradually increasing, and the advantages of laparoscopic surgery are more obvious. Treating diseases: swimming spleen and spleen cyst Indication 1. Idiopathic or HIV-related thrombocytopenic purpura. 2. Hematological hemolytic anemia. 3. Spleen cysts. 4. Travel away from the spleen. 5. Traumatic spleen rupture blood pressure is stable or stable after treatment. 6. Spleen tumors. 7. Lymphoma, leukemia. 8. Additional surgery for laparoscopic portal hypertension. Contraindications 1. The upper abdomen is severely attached. 2. Spleen length > 30cm spleen. Preoperative preparation 1. Device preparation: 1 set of laparoscopic main machine, 1 30° laparoscope, 1 ultrasonic blade with curved separator head, 4 corresponding puncture bushings, 1 five-jaw pull hook, separation pliers, grasping pliers and application One clipper, one suction device, and a snare and side-to-side stapler. 2. In other chronic cases, liver function should be improved before surgery to correct bleeding tendency and anemia. 3. Preoperative antibiotics should be applied 1 to 2 days before surgery, and those with low immune function should be advanced to 1 to 2 weeks before surgery. Surgical procedure 1. Puncture hole position and function The observation hole was located 1 cm to the left of the umbilicus, and a laparoscope was placed at 30°. The main operation hole is located under the left anterior line and the left clavicle midline rib, and is inserted into a separation forceps or an ultrasonic scalpel to be responsible for the main surgical operation. The auxiliary operation hole is located on the left side of the xiphoid process, and the five-jaw pull hook is inserted to expose the surgical field. 2. Establish a pneumoperitoneum insertion surgical instrument After the abdominal puncture, CO2 gas was injected to establish the pneumoperitoneum, and 10 puncture points were respectively placed into a 10 mm puncture cannula, and the corresponding surgical instruments were inserted. 3. Separation of spleen ligament The spleen and stomach ligament was separated from the middle and upper part of the large curved side of the stomach with an ultrasonic scalpel to reveal the spleen. The splenic artery was isolated at the near spleen gate, and the silk was ligated. At this time, the spleen was shrunk, and the possibility of major bleeding due to the capsule was reduced. The spleen lower spleen, the posterior peritoneum and the spleen upper pole were separated along the spleen of 4. Treatment of spleen vascular The main vessel of the spleen pedicle is clipped and cut off by a blood vessel automatic stapler. It can also be cut after the middle and large titanium clips are clamped. In order to avoid the automatic stapling or titanium clamps over the thick tissue and the blood vessels slip off, the adipose tissue outside the spleen should be separated as much as possible before clamping. With the improvement of laparoscopic techniques, the spleen pedicle can be ligated or sewed, and the operation method is no different from laparotomy. 5. Spleen removal After cutting off the spleen pedicle, the left upper abdomen puncture hole is expanded into 18~20cm, and the hole is built into the plastic recycling bag. Both sides of the bag mouth are grasped by the pliers under the xiphoid process and the front line of the iliac crest, and then the tongs are clamped. Put the spleen in the bag. The bag mouth was pulled out of the abdominal wall, and the spleen was crushed with an oval pliers and then removed. If the spleen is huge, it is recommended to take a small incision in the left lower abdomen to remove the spleen. 6. Looking for the spleen After the end of the spleen operation, the surgical field was reviewed to observe the presence or absence of active bleeding and surrounding organ damage, and actively search for the presence or absence of the spleen. 7. After placing the drainage tube in the spleen socket, the gas is discharged, the puncture cannula is taken out, and the puncture hole is sutured complication Infection The incidence of immediate infection after surgery is 5% to 55%, including pneumonia, wound infection, underarm abscess, urinary tract infection and sepsis, and the mortality rate is 3% to 4%. The pathogens of sepsis and urinary tract infection are Escherichia coli, Staphylococcus aureus, Enterococcus, Klebsiella, Enterobacter, and Pseudomonas. Prophylactic application of broad-spectrum antibiotics before and after surgery can prevent the occurrence of various infections. Overwhelming postpleced infection (OPSI) has been recognized as a clinical syndrome, which can occur several weeks to several years after surgery, and is more common within 2 to 3 years after surgery. Its clinical features are occult morbidity, which may begin with mild flu-like symptoms, followed by high fever, headache, vomiting, nausea, confusion, and even coma, shock, and often can be killed within hours to ten hours. Often complicated by diffuse intravascular coagulation, bacteremia. Despite the timely use of large doses of antibiotics after the onset, the mortality rate is still high. The pathogenic bacteria in 50% of patients are pneumococci, others such as Haemophilus influenzae, meningococcus, Escherichia coli, and Streptococcus hemolyticus. According to the statistics of large-scale clinical data, the mortality rate of patients with sporadic diseases due to infectious diseases is much higher than that of normal people, especially children. On the other hand, this increased risk is also closely related to the type of disease. Such as globin-producing anemia, mononuclear phagocytic system diseases such as Hodgkin's disease, histiocytosis-X and other splenectomy, the highest risk of OPSI, due to trauma, primary thrombocytopenia Patients with splenectomy and hereditary spherocytosis have a low risk of developing splenectomy. In view of the above facts, in general, a full-spleen resection, especially in children under 4 to 5 years of age, should be cautious. Since half of OPSI's pathogens are pneumococcal, it can be prevented by penicillin (allergic to penicillin, erythromycin, etc.) or by inoculation of multivalent pneumococcal vaccine. It is mainly used for children, but the method of vaccination is not used under 2 years old. Once OPSI occurs, large doses of antibiotics should be actively applied to control infection, infusion, blood transfusion, anti-shock, and correction of water and electrolyte disorders. Spleen repair, suture, partial splenectomy and spleen transplantation to preserve the spleen is undoubtedly beneficial to maintain the immune function of the spleen, but the question is how much spleen tissue should be preserved, enough to prevent serious infectious diseases after splenectomy, so far clear. 2. Postoperative bleeding About 2% of splenectomy. Mostly because of the incomplete hemostasis, neglecting the small bleeding point or the ligature line falling off. It is rare to cause bleeding due to coagulopathy or damage to the tail of the pancreas leading to high fibrinolysis. If there is a sign of internal bleeding within 12 hours after surgery, surgical exploration should be performed immediately. 3. Thrombosis and embolism The incidence rate is 5% to 10%. It is caused by an increase in the number of platelets and an increase in blood viscosity after splenectomy. Most of the thrombus originates from the residual part of the splenic vein and can spread to the portal vein. If the upper mesenteric vein is blocked, it can cause adverse consequences. Portal vein thrombosis formation often presents clinical symptoms at the peak of platelet counts at the second week after surgery, which is characterized by dull upper abdominal pain, nausea, vomiting, bloody stools, elevated body temperature, increased white blood cell count, and accelerated erythrocyte sedimentation rate. But there are also people with no clinical symptoms. A B-ultrasound can confirm the diagnosis. If there is no contraindication, you can try fibrinolysis. After the acute phase of anticoagulation, fasting, infusion and antibiotic treatment, the portal vein can be recanalized. Heparin therapy can be used to prevent thrombosis after splenectomy. 4. Pancreatitis The incidence rate is about 2.5%. It is associated with injury to the pancreas during the free spleen bed during surgery. Ligation of the splenic artery at the proximal end of the pancreas is also one of the reasons for affecting the blood supply to the tail of the pancreas. Pancreatitis can be diagnosed if serum pancreatic amylase is elevated for more than 3 days with symptoms. Treated with somatostatin, has a good effect. 5. Gastrointestinal disorders Common gastrointestinal motility recovery after splenectomy is slow, and this shift to the left of the colon causes distortion of the small intestine and changes the kinetics of portal vein blood flow associated with temporary congestion of the small intestine. Spleen bed exudate and surgical trauma can also affect the functional recovery of the stomach and upper small intestine. If not treated in time, symptoms of paralytic ileus intestinal obstruction can occur rapidly. Therefore, it must be differentiated from mechanical intestinal obstruction and intestinal paralysis caused by metabolic reasons, so as to take effective treatment in time. Spleen fever After splenectomy, there is often unexplained fever, and the body temperature rises to 39 ° C, and lasts for several days, and will gradually decline without treatment. For patients with spleen fever, the abdominal infection should be excluded first, then indomethacin (indomethacin) 12.5 ~ 25mg, 3 times a day, can make the fever temporarily relieved. There are also those who advocate no need for treatment for their natural remission. 7. Other complications Unexplained leukocytosis can occur after splenectomy. The white blood cell count can be as high as 40×109/L, and can be reduced to the normal range with platelets without treatment. There are still excessive exertion of the application of the hook in the operation, compression of the pericardium, pericarditis, clinical manifestations of fever, heart rate acceleration and typical ECG changes. There are also reports of concurrent mechanical small bowel obstruction.