title: Single-incision laparoscopic splenectomy using the "tug-exposure technique" in adults: results of ten initial cases.
abstract: BACKGROUND
  The application of single-incision laparoscopic surgery (SILS) to splenectomy is still challenging with much room for technical improvement. The purpose of this study was to describe the tug-exposure technique, an innovative technique for performing safe single-incision laparoscopic splenectomy (SILS-Sp).
  
  
  METHODS
  We performed SILS-Sp in ten consecutive adult patients with a variety of pathology requiring total splenectomy. A SILS™ Port with three 5-mm trocars was placed in the umbilicus as a single-access site. A flexible 5-mm laparoscope and an articulating grasper were used in addition to standard laparoscopic equipment. A cloth tape was introduced intraperitoneally to encircle and tug the splenic hilum. Both ends of the tape were extracted through an extra needle hole in the skin. Pulling the tape in appropriate directions provided excellent exposure of the splenic hilum (the tug-exposure technique). Under sufficient tension and exposure by tugging the spleen, a linear stapler was introduced for stapling and dividing the splenic hilum and the splenic artery and vein. The spleen was extracted through the umbilical wound within a retrieval bag. The umbilical wound was closed with subcutaneous sutures.
  
  
  RESULTS
  The tug-exposure technique was successfully used in all patients and markedly improved the exposure of the splenic hilum during SILS-Sp. The median intraoperative blood loss was 15 (range 0-1,000) ml. Only one patient (10%) required conversion to open surgery. Median operative time was 230 (range, 150-378) min, the median extracted spleen weight was 260 (range, 100-580) g, and the median postoperative hospital stay was 7 (range, 4-9) days. All patients were discharged uneventfully. The umbilical incision was nearly invisible at the 1-month follow-up.
  
  
  CONCLUSIONS
  The tug-exposure technique is an innovative technique that enables easy and safe SILS splenectomy by experienced surgeons.
authors.affiliation: Department of Surgery, Jikei University School of Medicine, Tokyo, Japan. take-misawa@jikei.ac.jp
authors.forename: Takeyuki
authors.initials: T
authors.lastname: Misawa
authors.forename: Taro
authors.initials: T
authors.lastname: Sakamoto
authors.forename: Ryusuke
authors.initials: R
authors.lastname: Ito
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Shiba
authors.forename: Takeshi
authors.initials: T
authors.lastname: Gocho
authors.forename: Shigeki
authors.initials: S
authors.lastname: Wakiyama
authors.forename: Yuichi
authors.initials: Y
authors.lastname: Ishida
authors.forename: Katsuhiko
authors.initials: K
authors.lastname: Yanaga
mesh_terms: D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D013156:Splenectomy / Q000295:instrumentation / Q000379:methods*; D013528:Surgical Staplers; D013536:Suture Techniques; D013997:Time Factors; D016896:Treatment Outcome