RU2831985C1 - Method for organ-preserving spleen resection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery. Branches of the splenic artery and splenic vein supplying the segment of the spleen, where the growth is located, are separated without opening the omental bursa with preserving all short gastric vessels under the control of laparoscopic intraoperative ultrasonic examination. Segmental artery and vein are clamped with laparoscopic vascular clamps. A laparoscopic Doppler ultrasound is used to assess the absence of blood flow in the segmental artery and vein in the distal direction from the previously applied clamp, as well as spleen hypoperfusion in the removed segment of the spleen. A segment of the spleen with the growth is resected along the demarcation line with electrosurgical instruments. Haemostasis is performed by bipolar coagulation.

EFFECT: method allows performing organ-preserving intervention, reducing number of postoperative complications, improving long-term results of treatment in patients who require surgical intervention on spleen.

1 cl, 3 dwg, 1 tbl, 2 ex

Description

The invention relates to medicine and surgery. The method allows improving immediate and remote treatment indicators for patients with various spleen diseases requiring surgical interventions.

Improved equipment of clinics, as well as the quality of patient examination, an increase in the frequency of detection of benign diseases of the spleen (non-parasitic and parasitic cysts, lymphangiomas) have led to an increase in surgical activity in these nosologies [1]. The development of surgical technologies, the active use of laparoscopic and robotic interventions have expanded the possibilities of using these treatment options in abdominal surgery [2]. As a rule, when benign formations of the spleen are detected, either insufficient (cyst fenestration) or excessively radical interventions (splenectomy) are performed [3]. This leads to both an increased risk of repeated surgical interventions and severe hematological and oncological diseases in the long term [4, 5].

Taking into account modern trends in surgery: minimal invasiveness and organ preservation, the basis for preventing the development of the above complications can be the use of partial resections of the spleen. To date, a number of methods have been described in the literature that allow performing these interventions, but surgeons do not have a unified approach to the tactics and scope of such interventions.

There are a number of analogues to the proposed invention in the available literature, however, in our opinion, they are not without drawbacks.

A technique for spleen resection is known, published by S.V. Berelavichus et al. in the article “Robot-assisted and laparoscopic resections of the spleen”, however, the authors performed resection, albeit partial, interventions, and did not use intraoperative ultrasound examination, which did not allow for a full determination of the resection boundaries, the effectiveness of vascular isolation and the adequacy of the blood supply to the remaining remnant of the spleen [6].

A method of organ-preserving operations for spleen injuries is known, proposed by A.N. Alimov (RU2237442C1), however, this option is not performed during planned surgical treatment, but is aimed at preserving the organ in case of spleen injury, while the technique of implementation is significantly different [7]. There is an experimental method of hemostatic suture during spleen resection in the experiment, proposed by E.P. Kuzmina (RU 2145194), however, given the experimental nature of the work, as well as the "open" technique of implementation, this option cannot be a direct analogue [8]. The method of spleen resection developed by K.A. Apartsin (RU 2113177) and the method of gas-jet resection of the spleen, published by V.L. Despite their focus on organ preservation, semi-ectoplasmic resections (RU 2386405) cannot be considered sufficiently minimally invasive, while the precision of these methods is also significantly inferior to the proposed method [9, 10].

"Method of polar wedge resection of the spleen" RU 2802674 (Pikin I.Yu. et al.) suggests performing an organ-preserving intervention in the volume of resection and suturing of the parenchymatous organ without the use of coagulation in patients with spleen injuries [11]. In practice, performing this intervention is usually complicated by the fact that the patient's condition with abdominal trauma with bleeding does not always allow such a volume of surgery to be performed, and the use of microsurgical techniques in routine practice is difficult to implement. It should also be noted that this version of the operation is performed in a cavity, which cannot be considered a minimally invasive procedure.

The method of “bloodless resection of the spleen” proposed by Ionkin D.A. et al. (RU 2675355) does not seem to be sufficiently minimally invasive and safe, since the intervention is performed through a cavity, the splenic vessels are ligated rather than preserved, and coagulation of the parenchyma is performed using radiofrequency ablation, which is also not precise due to significant thermal damage to tissues along the resection line [12].

A group of authors led by K.V. Puskov (“Method of laparoscopic resection of the spleen”, RU 2768591) proposed a method that is closest to the proposed method, however, to perform this technique, the authors open the omental bursa, which increases the risk of injury to short gastric vessels, the splenic artery is isolated by the main trunk, which leads to the development of ischemia in the non-removed part of the spleen, complete vascular isolation with compression of the branches of the splenic vein is not performed, which also significantly increases the risk of intraoperative blood loss [13].

Thus, there is no data on the optimal minimally invasive organ-preserving option for intervention on the spleen, which necessitates the search for new options for such operations that allow for a standardized approach and a reduction in postoperative risks.

The task, which the claimed invention is aimed at solving, is to expand the arsenal of surgical methods for treating patients with various formations of the spleen, by performing an operation with a minimum number of perioperative risks.

The proposed method is implemented as follows. To improve the treatment results for patients with various spleen formations, the following surgical intervention option was developed and implemented in the surgical clinic of the Botkin Hospital.

Surgical intervention in the volume of minimally invasive resection of the spleen is performed under combined general anesthesia in the operating room. The patient is placed in a position on the right side at an angle of about 30 degrees. Trocars are installed, a laparoscope and surgical instruments are inserted. Then the operation is performed according to the following scheme:

- under the control of laparoscopic intraoperative ultrasound examination, without opening the omental bursa while preserving all short gastric vessels, the branches of the splenic artery and splenic vein that supply blood to the segment of the spleen where the formation is located are isolated,

- the segmental artery and vein are compressed with laparoscopic vascular clamps to obtain a demarcation zone, while the presence of a reduction in blood flow in the removed segment of the spleen is assessed using laparoscopic ultrasound examination,

- perform resection of the spleen using electrosurgical instruments, and perform hemostasis using bipolar coagulation.

The essence of the proposed method is explained using graphic materials:

Fig. 1 – Cystic tumor of the spleen.

Fig. 2 – Laparoscopic vascular clamp on the segmental branch of the splenic artery.

Fig. 3 – Resection of the spleen. Final view of the operation.

The essence of the proposed method of treatment is explained by the results of its application and examples that do not limit the scope of legal protection.

Since 2021, patients with various spleen diseases, when surgical treatment was indicated and organ-preserving surgery could be performed, have undergone minimally invasive spleen resections using the developed method.

In order to substantiate the efficiency of the proposed method of treatment, we conducted a comparative study that assessed the results of splenectomy and organ-preserving surgery. Two groups of patients were formed. The retrospective group (Group I) included 30 patients who underwent laparoscopic splenectomy for benign neoplasms of the spleen, the prospective group (Group II) included 21 patients who underwent surgery using the organ-preserving technique described above. Group I included 19 (63.3%) women and 11 (36.7%) men. In the second group, 13 patients (61.9%) were women and 8 (38.1%) were men. The average age of patients in the first group was 32.4±13.2 years, in the second - 29.3±11.4 years. The body mass index (BMI) was calculated. The average BMI value in the retrospective group for women was 28.2±3.3, in the second group - 26.1±2.9.

The following parameters were assessed: duration of surgery, volume of blood loss, postoperative complications according to Clavien-Dindo, postoperative complications according to ISGPS, postoperative hospital stay (Table 1).

Table 1

Comparative analysis of treatment of patients in retrospective and prospective groups

Parameters Retrospective group (n=30) Prospective group (n=21) Duration of the operation 97.5±25.7 min 104.3±21.7 min Blood loss 314±25 ml 150.8±54 ml Clavien Dindo
I
II
III
IV
V
Total 4 (13.3%)
4 (13.3%)
6 (20%)
3 (15%)
1 (3.33%)
18 (60%) 1 (4.8%)
1 (4.8%)
1 (4.8%)
0 (0%)
0 (0%)
3 (14.3%) ISGPS Pancreatic fistula
A(BL)
B
C 17 (56.6%)
2 (6.66%)
1 (3.33%) 0 (0%)
0 (0%)
0 (0%) Postoperative hospital stay 11±1.3 4±0.8

Thus, the proposed method allows for safe organ-preserving intervention, reducing the overall number of postoperative complications (from 60% to 14.3%) and significantly improving long-term treatment results in patients who require intervention on the spleen.

Example 1. Clinical example

Patient D., 58 years old, was admitted for elective surgery for a splenic cyst. Under combined endotracheal anesthesia, a trocar was inserted above the umbilicus. A laparoscope was inserted. In the abdominal cavity, the parietal and visceral peritoneum is smooth and shiny. The liver, stomach, small and large intestines are without visible pathology. In the spleen, along the anterior edge in the middle third of the spleen, a large cyst measuring 55x50x45 mm is determined (Fig. 1).

Additionally, 12-mm and 5-mm trocars were installed. Intraoperative ultrasound was performed, and the splenic vessels were visualized. Using the LigaSure device, the artery and vein to the middle third of the spleen were isolated. Bulldog clamps were applied to the vessels (Fig. 2). Using laparoscopic ultrasound examination with the GE Logic 7 device (General Electric, USA) in Doppler mode, the absence of blood flow in the segmental artery and vein distal to the previously applied clamp, as well as hypoperfusion of the spleen in the cyst area were determined.

Minimally invasive laparoscopic spleen resection was performed using bipolar coagulation and Ligasure (Fig. 3). Clamps were removed from the splenic vessels. Hemostasis. A hemostatic sponge was placed in the bed of the resected cyst. The specimen was removed through a 12-mm trocar. Layer-by-layer wound suturing. Iodine. Cosmetic suture. Intraoperative blood loss 50 ml.

In the postoperative period, the drainage was removed on the 2nd day. The patient was discharged on the 4th day of the postoperative period without complications.

Example 2. Clinical case

Patient Zh., 37 years old, was admitted on a planned basis for an echinococcal cyst of the lower pole of the spleen measuring 53x71x75 mm. The patient was discussed at a council: a decision was made to perform organ-sparing resection of the spleen. Under combined endotracheal anesthesia, a 12-mm trocar was inserted in the right upper point of Calca, carboxyperitoneum was formed up to 14 mm Hg. There is no effusion in the abdominal cavity. The parietal and visceral peritoneum are smooth, shiny. Trocars were inserted in the epigastric and mesogastric regions on the left (one 5-mm, one 12-mm). The stomach, small intestine, and large intestine are without pathological changes. There is an adhesive process subdiaphragmatically on the left. Adhesiolysis was performed, the spleen was visualized. Using intraoperative ultrasound navigation with a laparoscopic sensor, an echinococcal cyst of the lower pole of the spleen was identified, vascular clamps were applied to the segmental branches of the splenic artery and veins in order to reduce splenic blood flow. In the Doppler mode, a reduction in blood flow in the spleen section in the cyst area was determined. The resection zone was outlined along the demarcation line. The spleen was mobilized using the LigaSure device. Resection of the lower pole of the spleen with a parasitic cyst was performed in the bipolar coagulation mode. Dry. A hemostatic sponge was installed at the edge of the splenic resection. A silicone drain was installed through a counter-opening in the left mesogastric region at the edge of the lacrimal resection. Sutures were placed on the surgical wounds. Aseptic dressings. Intraoperative blood loss was 100 ml. The postoperative period was uneventful. The drainage from the abdominal cavity was removed on the 2nd day. The patient was discharged from the hospital on the 3rd day.

Thus, the method we proposed has proven its effectiveness. The proposed technique allows for safe organ-preserving intervention, reducing the overall number of postoperative complications and improving long-term treatment results in patients who require intervention on the spleen.

Claims (1)

A method of organ-preserving resection of the spleen, characterized by the fact that under the control of laparoscopic intraoperative ultrasound examination, without opening the omental bursa with preservation of all short gastric vessels, the branches of the splenic artery and splenic vein are isolated, supplying blood to the segment of the spleen where the formation is located, the segmental artery and vein are clamped with laparoscopic vascular clamps, the absence of blood flow in the segmental artery and vein distal to the previously applied clamp is assessed using laparoscopic ultrasound examination in Doppler mode, as well as hypoperfusion of the spleen in the segment of the spleen being removed, the segment of the spleen with the formation is resected along the demarcation line with electrosurgical instruments, and hemostasis is performed using bipolar coagulation.