title: Single-incision laparoscopic splenectomy for massive splenomegaly combining gastroesophageal devascularization using conventional instruments.
abstract: BACKGROUND
  Single-incision laparoscopic splenectomy has been reported and was proved to be feasible and safe. Yet reports on single-incision laparoscopic surgery (SILS) for massive splenomegaly is not seen, neither is SILS for gastroesophageal devascularization; another correlated procedure for patients complicated with bleeding esophageal varices. From February 2011 to March 2012, 6 male patients with a median age of 45.1 years (range, 25 to 65 y) who were diagnosed of liver cirrhosis, portal hypertension, splenomegaly, and hypersplenism underwent SILS by the same surgical team in our hospital. Of them, 4 patients who were indicated had combined gastroesophageal devascularization, except for 1 conversion to hand-assisted laparoscopic approach because of bleeding, the operations were performed uneventfully and the surgical outcomes were satisfactory. Preoperative diagnosis was hypersplenism secondary to liver cirrhosis, the surgical outcome was satisfactory. This video, Supplemental Digital Content 1 and 2, http://links.lww.com/SLE/A104 and http://links.lww.com/SLE/A105 illustrates the crucial steps regarding the SILS for massive splenomegaly combined with gastroesophageal devascularization. The preoperative diagnosis are, hepatitis B, the patient's liver function is Liver Child-Pugh grade A.
  
  
  METHODS
  The patient was placed in reverse Trendelenburg position, with the legs open. The surgeon was standing on the right side of the patient and an assistant standing in between the legs. One 20-mm incision was made under the umbilicus, a 10-mm Trocar (Johnson & Johnson Investment Co. Ltd., NJ) was introduced in the middle of the incision, and the abdominal cavity was explored with a 10-mm, 30-degree scope (Storz Co. Ltd., Germany). Then a 12-mm and a 5-mm trocar were introduced through the same incision, respectively, 45 degree to the 10-mm trocar at both sides to form a "∇" shape. The procedure started with the dissection of the splenocolic ligament at the lower pole of the spleen, followed by creating a window by dissecting the gastrocolic ligament. The secondary branches of splenic pedicle were dissected and divided. The dissection of splenogastric ligament was continued along the gastric greater curvature, and short gastric vessels were encountered and divided. The left gastric artery was clipped and secured, followed by gastroesophageal devascularization along the cardiac to the esophagus 5 cm away from the esophagocardia junction, with Ligasure device. The splenic artery was identified, clipped, and divided. The splenic vein was finally divided followed by intraoperative autologous blood transfusion technique by collecting the blood from the distal splenic vein. The spleen was removed from the umbilical incision in a sample bag after being sliced into pieces. A drainage was placed through the incision.
  
  
  RESULTS
  The operation was successful and the patient recovered well postoperatively: the operation time was 265 minutes, and the intraoperative blood loss was 300 mL. The postoperative course was uneventful and the patient was discharged 13 days later.
  
  
  CONCLUSIONS
  SILS combining gastroesophageal devascularization for massive splenomegaly is technically feasible in the hands of surgeons with experiences of laparoscopic splenectomy. Indeed, the relative large scale of operation field for laparoscopic splenectomy makes the conflicts of instruments less practically challenging; however, techniques and sequences of the laparoscopic procedures should be modified to facilitate it, given the unavoidable constriction of movements for each instrument.
authors.affiliation: *Department of General Surgery, the First Affiliated Hospital of Harbin Medical University †Department of General Surgery, the Fourth Hospital of Harbin Medical University, Nan Gang District, Harbin ‡Department of HPB Surgery and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, Xiacheng District, Hangzhou, China.
authors.forename: Jun
authors.initials: J
authors.lastname: Xu
authors.forename: Lei
authors.initials: L
authors.lastname: Zhao
authors.forename: Zhifei
authors.initials: Z
authors.lastname: Wang
authors.forename: Bo
authors.initials: B
authors.lastname: Zhai
authors.forename: Chunfu
authors.initials: C
authors.lastname: Liu
mesh_terms: D000328:Adult; D000368:Aged; D004932:Esophageal and Gastric Varices / Q000150:complications; D004947:Esophagus / Q000098:blood supply*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D013156:Splenectomy / Q000379:methods*; D013163:Splenomegaly / Q000150:complications / Q000601:surgery*; D013270:Stomach / Q000098:blood supply*