Pediatric Laparoscopic Splenectomy for Splenomegaly due to Hereditary Spherocytosis

CHAPTER 1

Hi, my name is Bryanna Emr. I'm a pediatric surgeon here at Penn State Health University. Today we're gonna be doing a laparoscopic splenectomy for a young gentleman who presented with hereditary spherocytosis, as well as splenomegaly and worsening hemolysis with pain and fatigue. The key steps for a laparoscopic splenectomy include gaining safe access to the abdomen, appropriate positioning, and then mobilizing the spleen. We start with mobilizing the splenocolic ligament, which is the splenic flexure along the inferior pole of the spleen. And then we take down the short gastric vessels with the LigaSure or another energy device in order to achieve good hemostasis. And then we focus our attention on the splenic vein and the splenic artery. Each of those structures is dissected individually. The splenic artery is divided and taken first, followed by the splenic vein. And then after this we have to turn our attention to the rest of the splenic attachments to the diaphragm, the kidney, and then the pancreas tail is the final step. And then we place it in a large Endo Catch bag and remove it in pieces through the umbilical incision. I have done these robotically on older and larger patients. That's definitely an option. The negative there is that they're bigger incisions than the laparoscopic incisions. And if you don't have the right amount of space on the patient's abdomen, you cannot fit the robotic trocars easily.

CHAPTER 2

It's not terrible. Didn't look bad. No. Sometimes the spleen crosses midline. It goes all the way down to the pelvis. But what's nice is in his case, it's not that big. So we'll have some more room for laparoscopy. All right, here's your suction. Make sure I don't lose this guy. Can we go to 15 medium flow on the insulation? Last time I did the short scope and it was a little bit tricky to get way up to the diaphragm. All right, we'll take some local please. Yeah, 15 medium flow. Okay. All right, injecting marking. And we'll take two Adsons and a knife. All right, needle is down. And I'll take a mosquito. We have a 12-port to start, a fifteen's here. Okay, let's do that. Starting. Incision. So we're gonna get access through the umbilicus. It's a safe place to start. And eventually we're gonna need to extend this incision, so that we can take out the spleen. We'll kind of take it out in pieces, so we don't have to make a huge incision for him. But the bag to fit the spleen is a 15 bag, so we have to put in a big enough port. So I go right through the base of the umbilicus. Almost all patients have a little bit of a natural defect here in the fascia, and it's an easy access point. Let's go down and up a little bit. We'll need it anyways for the end of the case, so... actually, let me see the Bovie mosquito one more time. All that Marcaine, making it kind of juicy. There we go. Okay. All right, that feels better. Different count of 15. All right, so I'll just tuck that guy in there, take a little look. Can we have gas on? Yeah, gas on please. We'll take the room lights down, you can leave the spots on. All right, so we are in the abdomen. So now we just gotta figure out where we're gonna put our ports. So this is the spleen. It's got a good covering of omentum over that. Nothing abnormal but just a big spleen. This is a little bit of air under the omentum. We'll just take a little look around. Maybe a pinpoint inguinal hernia down there, nothing too exciting. Bladder's nicely decompressed. This other side looks normal. And we have him bumped, so it's hard to see everything over there anyways. You have an OG tube in? Yes. Decompressing? Okay, there's a colon. All right, so where do we wanna put our ports? What do you think? Probably subxiphoid. I'm wondering if we wanna be, maybe a smidge down here, 'cause we have to think about what our working ports are gonna be. So here probably this is gonna be our working ports. And then you're gonna be helping me retract through here, or do we put in like another more lateral one for retraction and then we work through here? Because what we wanna be able to do is elevate the spleen. So that's one option is to put it in here. Right here. Yeah. And then you can get an arm to come and lift spleen up and away that way. And then we wanna be able to work comfortably, probably through here. We can cheat a little bit this way. Yeah, something like that. All right. Let's clean our camera. And then the other thing we can do is a rectus sheath block also before we start. So let's do that. Okay, so we're gonna find the rectus sheath. Can you fill that up to 10? We have a total of 30. So we're gonna use quarter percent Marcaine plain and we're gonna inject just above the posterior rectus sheath on both sides and that'll do a nice job of taking care of the pain in the center portion of his abdomen. Usually the umbilical site is the most painful for them because we have to extend it. So I just carefully go in with my needle aspirate and then inject just above the posterior rectus sheath like that and it should fill softly. And let's put in eight on this side. We'll take another full syringe. You can do your side. Yeah, somewhere there. Just fill it up to eight for me. Yeah. You can see his pericardium up there through the diaphragm. See that? And then we can put some five incisions in and start mobilizing. That looks good. You can also do this with ultrasound guidance, but it's fairly accurate with laparoscopic guidance as well. You just wanna be in that posterior rectus space. That's where the pain nerves are all running. Needle. All right. We'll take some more local. Yeah, we know we'll need this one. We're gonna need it, right? Let's do that one. See which way the spleen goes. Local. To the left or to the right? I think I'm gonna be slightly to the left, 'cause I don't wanna bump into this falciform every time. Needle down. Knife. I think I'll go up and down since we're kind of midline here. Back up a little bit. There we go. Okay, let me see a bullet. Thanks. Let's just take a quick peek at what side we think is gonna need more retraction. So here's spleen. We'll just peel this omentum off, a little bit of inflammation there. That part doesn't wanna come down nicely, we'll take that with a LigaSure. Yeah, I think we're gonna have to elevate the spleen more than anything. The thing about pediatric patients is they don't have as much abdominal space to put your ports, so a lot of times you have to make a decision based on their anatomy, not just what the textbook says. So you have to make space, especially when they're in the infant range. Five port. Yep. Good. And then see how that does for reflection. I think that's gonna help. Can we have some reverse Trendelenburg? Yeah, that'll be really nice, 'cause then we can peel everything outta the way. We're gonna have to take that omentum down with the LigaSure. And we put a bump under his left side before we prepped and draped as well. So he already has a little bit of left side up, but if we need some more, we can always airplane the table. All right, so let's put in another port, 'cause I need two hands and you need two hands. You always wanna try to triangulate as much as you can, so the camera's between your two working hands, it's more easier to see what you're doing. All right, we got this nice camera warmer now. Let's try that, that's good. Now do you wanna try to stand on that side or this side, Marc? See what's more comfortable for your shoulders. All right, so what's our first step? How do we start taking out this spleen? First step here is gonna be taking this omentum down. Yeah. Here, I'm just gonna, think go this way. So this is just a little omentum. We can take that down with our LigaSure bipolar device just so it doesn't cause bleeding later. We don't want it to just shear off. There it is. Okay, and I think these little attachments will go later, but let's just take anything that the omentum is gonna get hung up on. There we go. Okay. So now where do we go first? I would do the splenocolic.

CHAPTER 3

Agree. So you elevate. So the first attachments I like to take down is the splenic flexure. Here, let me switch with you here. There we go. And that way the colon is out of the way and we don't have to worry about injuring it. Yeah, if you could show me this and if you wanna switch sides, just lemme know, 'cause I don't want your left shoulder to hate you. So this is the colon splenic flexure right here. And this is an avascular plane. And this just gives us a safe margin for mobilizing and not having to worry about causing any injury to the colon. And you can see how high it goes, it really is a true structure. There's some colon attachments here and I'm just gonna hug the spleen, if I have a choice because that's coming out. There we go, there's the plane. So my left hand is kind of pulling down on the fatty tissue around the colon, creating tension. It makes my right hand look good. So I can sneak up in here, elevate away from danger. And that should really give us plenty of mobility. Yep. Perfect. Follow me over here. And you don't wanna get into the mesentery of the colon over here. So you just wanna be aware that in kids everything is a lot thinner and it's easier to get into the mesentery. All right, let's see what is left over here. That's starting to peel. We will be able to see much better when we're working in the hilum, this is just tough on the camera. All right, I think we need to take some of this stuff here. Oh yeah, that's the layer. Do you want me to move my retraction? No. And this is probably a friendly organ down here that we're gonna leave behind. Any idea what that is? Kidney. Kidney. Yes. The kidney lives back here. I'm gonna leave the kidney alone, at least for today. All right, let's see what we have left. Yep, you come back under there. Let's see how our colon is doing. That's looks good. Looks good. That looks like it's mobilized.

CHAPTER 4

All right, so now we're gonna head for the short gastrics and see if we can continue in the plane of the lesser sac. And we wanna be aware of any hilar vessels that might be sneaking up on us. So the short gastrics live between the greater curvature of the fundus of the stomach and the spleen. There it is. See that window? So now we're in the lesser sac. So we just keep following this plane. And I think there is an important, there's a vessel down here that we're gonna wanna get rid of, something that's feeding the lower pole right here. So the stomach for reference is right here. So, let's see if we can stay in this plane. There we go. And the short gastrics might not sound very intimidating, but they bleed a lot. And sometimes these planes are fused and not as nicely developed as we'd like. This little spot wants to cause trouble. And if you get lost, you can always go back to the stomach. All right, can we have some more left side up please? Let's see if that helps our... Switch sides, maybe? Yes, let's do that. That's good, let's try that. All right, make some room, Marc's gonna come over here, so his shoulder doesn't fall off. There we go. And we'll just, there we go. So colon is here. Stomach and some more omentum. Let's see. Let's find a better place to start. I'm not loving that plane right now. This might be a little more friendly. So stomach is gonna come my way. Spleen's gonna go your way. Let's try here for now. So then we can get into the lesser sac right here. All right, that looks a little more promising for now. We'll make that plane connect. I like to burn these twice, it makes me feel better. And as we get higher, the stomach usually becomes much more intimately connected to the spleen. Yep, so feel free to take your time, readjust the camera so we can see where we are. There we go. There we go. So this patient has hereditary spherocytosis. He's been struggling with a lot of hemolysis, pain, fatigue. He's had elevations of his bilirubin, and so he was referred to me by the hematologist for a splenectomy to try to help him with his hemolysis. The trade off is when you don't have a spleen, then you struggle with your ability to fight off certain infections. Do you know what those are, Kayla? Sadly no. Or like encapsulated bacteria? Yeah, anything with the encapsulated bacteria. So what do we do before we take out the spleen? Vaccinate them. Yeah. Good. So they get those pre-op vaccines and that really helps us protect them, so they don't get splenic infections and sepsis. All right, this little last part is the most frustrating it seems. So we try to save their spleens as long as we can, 'cause the younger they are, the more at risk they are for that overwhelming post-splenectomy infection. And then a lot of them will be on postoperative prophylaxis as well with penicillin. There's a nice big vessel right there. So we're almost up to the diaphragm, which is a good landmark for when we know we're done mobilizing the stomach. Let's burn this vessel. And then there's gonna be a nice retroperitoneal organ that we'll have to deal with next, so we can find the hilum and the splenic artery and vein, which I think I'm seeing it. All right, so let's make sure we're nicely mobilized, we can do some more of that later. There's still some stomach attachments here. Yep, there's some little vessels right here that will need to go. There we go. And whenever you're reflecting and grabbing these organs, it's good to take generous quote unquote bites of the tissue. You don't wanna take these little tiny bites, so that you don't cause serosal injuries and tears. All right, come up in here, zoom in. What are these attachments here? Do we need them? I think it'll help to take them out of the way. This right here. I have it all behind me. Beautiful. Yeah, there we go. That helped us send that guy. We'll take him before he decides to bleed more, little bit down here. So it really helps to fully release the stomach for exposure. Okay, and then this is the left crus of the diaphragm, right? So that's another good landmark. Okay, so now let's adjust our camera, 'cause we wanna begin looking back toward the floor.

CHAPTER 5

And now we can try to find our splenic vessels. Can we open the stapler? So we did not finish this connection, that's the other thing that will help us. Nothing in there. I think the vessels. Colon is down here. I think the vessels are further up here. In there, see that? That's the hilum. There's definitely something here. But I need to take this bridge, so that we can see. Let's take this bridge of omentum. You can see the spleen doesn't look super healthy, it's very engorged with blood. This is in comparison, a nice healthy looking liver that he has over here. So there's two ways, you can either go for the main splenic artery and take it before it starts branching into the splenic hilum. Or you can take all the little branches if it's confusing as to where things are going. I like to usually go for the splenic artery, not where it takes off from the celiac, of course, but before it starts branching into the hilum if I can. So this is a branch over here that we saw and we could take it separately if it turns out to be helpful, or we can try to come just proximal to it. And I'm gonna take it with a stapler. How about a 30 vascular? It doesn't have a little thing. I know it doesn't have the little foot on it. Come on in. Some little attachments here. And I think it's right under me. See that? And it's a very tortuous vessel. So we'll take the artery first and then we'll take the splenic vein afterwards. Do you know why we take the artery first, Kayla? It's mostly, so if we take the vein first, then this vein still has blood flow in and then it becomes even bigger as we're looking at it, it gets engorged. Yep. So you want it to try to empty the spleen. You don't want it to be under pressure and tension because it's filling with blood, but the blood has nowhere to go. So the pancreas is gonna live right here. That's a little bit of pancreas looking at us. And that organ, the tail of it can be very frustrating, it can really be involved in the hilum very closely. And so you have to be aware of where your pancreas is, 'cause you don't wanna cause a pancreas injury and then have a leak post-op that can be hard for them to deal with. And depending on how much mesenteric fatty tissue they have, it can be very obvious where the artery is, or it takes more work. But we're coming to it. I think the vein might be just below us there. We'll find out for sure, but this is pulsatile. Yeah, there you are. I'm always more cautious with the vein than the artery, I mean I'm cautious with both of them, but the artery has some actual strength to the wall, it doesn't really tear so easily. The vein is more like tissue paper and so if you put a little hole in it, the hole usually just keeps tearing and that's harder to deal with. The good thing is, it's a low flow system, so if you hold pressure and weight, it'll probably clot off. There's see all these little capillaries here. So we need to make a safe window. Confirm our anatomy. Oh, that might be vein over there. And then we'll take them individually. Let's get rid of some of this stuff in the forefront. Huh? You can do this with a Maryland, I'm doing it with a LigaSure, 'cause I keep finding little capillaries and attachments that I'd like to be able to divide. Getting there. Yeah, I think the vein is just under us. Let's take some of these little attachments here. There we go. All right, that's probably the vein. Let's see. It's got some lymph nodes, and I found a little lymph node that probably got mad. Do you have that small Tegaderm? I mean Ray-Tec. I think it's gonna have to go through the 15-port, Marc. We're putting a Ray-Tec in the belly. Actually, will the bigger one fit? Let's try that. Give it a shot. Yeah. Let me try in the middle since we've got a big port, we can fit a bigger sponge. There we go. This can be handy just to have inside to hold pressure and dab things up. It's probably a lymph node or something that decided to be annoying. Just use this to kind of tuck things away too. All right, where were we working? Yeah, I see the pulsations. Get this guy out of the way. Nope, we're just gonna have to fight each other for a second here. Okay, I'm trying to use this to tuck the stomach away a little bit too. There it is. That's the artery, and there's the vein. So something to always be cautious of is, you don't see the other side of what you're dissecting a lot of times. And there can be a branch that you don't know about, that's just out of view. So again, never get yourself in a hole where you can't see what you're doing. So if you need to get better exposure, rotate the patient, readjust your retraction. But that's a nice view of the splenic artery. Have you done any pancreas- or spleen-preserving distal pancreatectomies? Yeah. Those are always tough. You really have to stay on the vessels the whole time and take down every single little branch. So you can see how closely involved the artery is with the pancreas, they really run together, 'cause pancreas tissue is right here. All right, so the question is this just a branch of it or... It should be more proximal... Yeah, I think we gotta get proximal of this lymphatic tissue here. Use it as a handle. Yeah, right in here was where we were, right? Yeah. I think we just need to be able to see it just a little bit better. Let's just take our time, get some of this extra tissue off, so we can really see what we're doing. There we go. I'm gonna see if I can grab just a wee bit of this tissue here. You always wanna be gentle with pancreas. We don't want it to leak. All right, let's see if we can see the other side of this. That's a nice view, okay. So let's get this side developed. All right, can I see a Maryland maybe? That'll help. I think I have it up here. I think when I had it back here, that was the best view. There we go. It's okay to have a little adventitia on it still. I just wanna have a clear window for the stapler. And all these little capillaries are angry and there's all these little branches that go to the pancreas and all right, are we good with our positioning and everything? Okay, we just gotta make our window. It is just slightly thicker than we'd like. And there's just like some little branch over there that I can't see right now. It'll get better once we staple it off. Find ourselves again. We're not really gonna be triangulated, but maybe just a slightly different view is what we need. There we go. It's just this tissue on the other side is what's giving us trouble. Yeah, that's the tissue that is getting in our way. That looks good. That looks clearer than before, right? There's just not a lot to grab onto. There we go. Yeah, that's always helpful, right? There's... Lemme see. I might just have to grab the artery itself. I can be in the middle with the suction with my right hand. I don't know. It's not like a huge amount of blood. It's just annoying for visualization. Just make sure I'm not coming through the vein on the other side. That looks pretty clear. Okay, there we go. That's all we needed. All right, so we wanna get good control of the vessel. Confirm that this is truly going to the hilum, it's going into spleen, not anything else. All right, let's take our stapler with the 30 gold. This is the vascular load. Let's turn this, so the skinny side's on the bottom. Same angle that I was doing the dissection from. And then we wanna make sure that we're all the way across with staples and that we're gonna cut at the right spot and nothing else is sitting in our grasper. Yes. Agree? Agree. Okay, good. All right, so then we'll just fire this stapler. So it fires six rows of staples and cuts between. And then you wanna be very steady with your hand. You don't wanna just tear the tissue. So we wanna come back slowly. And I always like to staple off of tension. I don't like the stapler to be pulling up on anything. That way the vessel doesn't run away from us. All right, good. So that's a splenic artery. Let's clean up a little bit here, and then we'll look for our vein. All right, so you can see our staples here. All right, so now we have to find our vein, which I think is right in here, but we gotta prove it to ourselves. Is this all stomach? Yeah, that's all stomach. I just gotta clean that off and then we'll use another, let's do another 30 gold vascular. Lemme see if I can maybe just tuck this up here. It's like helpful but then it sometimes gets in the way. Okay, so see that nice vein? We're gonna start to dissect that one out now. And then we should have completely devascularized the whole spleen after taking, 'cause we took our short gastrics already. We took our splenic artery, so this is the last main structure. And then we just have to take down all of the attachments that are surrounding the spleen, which are many. And again, the pancreas is right here. So I'm trying to be aware of that, that's this organ in front. And then I'm trying to be gentle with the vein as much as I can, 'cause I just don't want it to tear, that's harder to deal with. Bail out, you can always open if you can't see because of a bleeding or anything like that. And you can also do a little blunt dissection. All right, let's try to find a friendly spot. What's friendly? Like someone dominant, red blood cell that makes the red blood cells less flexible to going through, usually elevated T billy. And then decreased levels of haptoglobin. Increased level of LDH. The red blood cells aren't quite that flat disc shape that they usually are. They're more like spheres. And there's this spherocytosis component, like you said, it's more so that they get stuck when they get filtered out. That's how you get the hemolysis of these red blood cells. Yeah, so this will let him keep more of his red blood cells around, 'cause the spleen will not be there to sequester them and hemolyze them. So hopefully that helps with his fatigue, and anemia, and overall wellbeing. Come on in. And the vein is just sticking. Let's see if I can lift up on this staple line, maybe that'll help me for a second. It's large, as you can see. It's actually bigger than the artery in most cases. And it's much thinner wall like we talked about. And there can be like lots of little branches that cause bleeding. You just take your time, safely develop that plane. I might have you switch the camera back in a second, 'cause I'm not loving this angle with my LigaSure. Yep, yep. LigaSure. That's right. It's just I can't quite make this move as well as I would like. Yeah, let's try to switch. Put the camera through the belly button and then I'll come around this way. So where were we working? Somewhere in here. There we go. It's coming, it's coming. This is a better angle. I'm gonna have to staple from the other angle, but that's okay. You just wanna make sure you're not dissecting into the wall and causing a posterior hole, that would kind of be hard to find. And a good bail out here is if you do get into bleeding is stop and hold pressure, come back after it's thrombosed, clotted off. And if you can't see, then you open. That's all vein, but we're getting there, we're almost around it. And then I think if we do some... Yeah, maybe a Maryland, I can switch hands. We can see how that looks. So this is a right angle. Try and see if this helps us get around our vessel. I can't quite see it from this side, but maybe I can at least do some dissection on that side. I think it's pretty free. Yeah. It's moving in between that posterior wall. Yeah. I just can't see all the way. That might be it. Yeah, there it is. There it is. See if you can lean a little bit more up here. I like having this gauze in here, but occasionally it's getting in my way. And then this other end of the artery. Yeah. There we go. There we go. Just find that spot. It almost looks like vein wall, but it's not. Just try to find the same spot. There we go. Now you could put another 12 port in if you wanted to, if you needed it for better angling for stapling, we can make it through this umbilical port, so that saves him another big incision. Bigger incision, it's not really that big, but, all right. So this is basically the vein. Slightly different plane from this angle, but we can get there. Where was that spot? Here? No. I'm a little more away from the spleen. That's the vein. If we need to make another one, that's okay. I just don't love how much stretch I'm putting on this vein, but there we go. I'm just gonna be gentle. Gentle, gentle. You could put a vessel loop around it. I don't think we need to. There it is. Just make sure it's big enough for the stapler. Okay. Yeah, we'll see. All right, so we have the vascular load and I think I'm gonna want a little bit of articulation toward my left. Yeah, let's try that. All right, so we gotta get in the same window and the stapler is so big, but we are gonna take our time, get in the window. There we go. Okay, good. So that's vein, we don't have anything else in there. And again, I don't wanna take this on tension, so I'm just gently laying my hand down. There's the other side of the artery there. There's our artery there. Good, so now we're just gonna, I'm gonna stabilize my hand, so I'm not accidentally jerking or putting undue tension on the vessel. Fire the staples, it might ooze a little bit just because kids have such thinner structures and the staples don't close as tightly as they do on adults with extra tissue. But that looks good. Good. All right, so let's regroup here. Everyone gets to breathe a sigh of relief. You heard that? Yeah. I'll give this back to you. I'll give this Maryland back to you. Okay.

CHAPTER 6

And now what kind of attachments do we know about? We found the splenocolic and the splenogastric, a little bit of the splenorenal. And then primarily the splenophrenic Yeah, all that stuff up there. And we can kind of do a lot of this by... Yeah. We just gotta be careful. We're gonna have to be careful of pancreas sneaking up on us in here. We're gonna have to take that down. Yeah, let's take your time. We'll see what works and what doesn't and then I'll give some of this to you as well. This looks fairly easy over here. And then this is some of the hilum, let's get some of this out of the way, 'cause this is definitely pancreas. It can be hard to tell over here what's pancreas and what's not. Some of this might be pancreas. Oh, good. I found something. That's probably one of those little vessels that I didn't take individually, so now they're back bleeding. We just wanted to demonstrate that for you. I think this is part of it. Yeah, there you go. I just stay there. The other thing about laparoscopy is it makes everything look like there's more blood than there is. So it just zooms everything in, makes it look more impressive. The question is, I just don't know where his pancreas ends yet, so we need to define the tail of his pancreas. So let's see if we can tuck this here for a second. There we go. Let's see. So our hilum that we took is nicely here. Whatever is bleeding is kind of in this mess. There's a vessel right there that I think is what is causing some trouble. How do you think our camera is? Do you think we need to, I think it's this structure that I'm holding. So see if you can clean, dab a little bit and then pull this fatty tissue back, yeah. That's spleen behind me. Do we have that clip applier? We don't have it, but we had it. 5 millimeter? All right. Yeah, I was just trying to see if I can clip it off and then it'll stop bugging us. We got a staple in there or something? Because that's... That's the vessel. That's the main vessel there. So we definitely took it there. So do we just need to get it in here? There's a vessel here. And then, all right, let's see the clip applier. Let's see, I think there's something in here. I am just making it madder. I can also clip it from this side. This clip applier looks kind of small. Whatever it is, it's only partially... This clip didn't work. All right, lemme give that back to you. There's part of the clip there. All right, it's part of the Ray-Tec now. I'll come on and get it out later. See we can maybe come way up here. Okay, let's do that. Can you grab that, Fred? All right, let's come in here. Let's find ourselves again. We can also roll it towards us. That's another option. Let's see if we can get anything in the forefront here safely. Just make sure there's no other vessels hiding in here. There's a lot of lymph nodes. There we go. This is a lot of lymph nodes right here, see that tissue? I just need to separate that. Yep. Yeah, I think that's what's killing us. And then I can do this and then we can safely get this stuff out of the way. Zoom on in if you can. Yeah, there you go. There we go. That's the window. Okay. Make sure we're off the vessels, yes, we are. So always be suspicious of another. Sorry, let's clean the camera. Have another splenic vessel hiding in that perihilar tissue. Okay, good. So looks promising. Is there anything else that we can safely see from this side? That's an attachment, maybe not, a little something here. Diaphragm is right up there. Okay, come on back. Let's see if we can rotate the spleen towards the middle. Shove this thing here. There we go. All right, posterior. This is actually a really nice view. Good job, Marc. So diaphragm's up here. This is some retroperitoneum here. And these are all attachments that need to go that have no vascular structures in them. Just some little flim flams, capillaries, I guess, I should say. Not flim flams. That's right. All right, so that's coming down nicely. Here Marc, don't let me steal all the fun. I'll hold this camera if you do those two hands. This orientation make sense, Kayla? Yes. It's a unique view. The kidney is below us, this is some Gerota's. Sometimes you see adrenal. And the spleen. When it's this large is really at risk for the capsule tearing. So you have to be careful with how you're elevating it and everything. You don't wanna use the point of your instrument. It just gets a little messy in here, if you rupture the spleen, it's not like we're gonna lose any significant blood, but it will be hard to see. And here you just wanna be conscious of the diaphragm. You don't wanna cause a diaphragm injury. We didn't take these attachments in the beginning because then the spleen wouldn't have anything suspending it in the left upper quadrant and it would be kind of falling onto our field when we were trying to find the hilum. So you really wanna, I like to leave these to the end. There, spread there. Yep. Just thin that out. Good. I would just try to divide that. If you wanna switch hands, you can come at it from another angle. See how we got the whole spleen, not quite the whole spleen, but a lot of the spleen up in the air. Looks like there's some more easy stuff in the front we can take. Is that fatty tissue easy for you to get? Or is that just me? That would be slightly further away, yeah. Yeah, right in there. Good. See if I can look around that corner at all. Maybe come, I think you're doing good. Yeah. Come around that fatty tissue if you can. I'm not sure... I see what you mean. Yeah, it's close. Just be gentle to the spleen. Yeah, that's nice. Just don't dig into spleen. Try to release this little bit here. And then we'll see if there's anything else that's a little bit easier on this side. All right, good. Let's give that one a rest for a second. All right, let's see. Get some of that. And if you need to switch hands again, you can. Yeah. All right, let's stay on the spleen. And Kayla, if you see the ports jiggling around, you can just stabilize them as their instrument changes are happening. Nice. Can we go to high flow? Yes, exactly. Yep. Good, good, good. It's a workout holding the spleen up. Good. Yeah, so you can almost see through it, it's happening. There you go. There's our splenic artery from the other side. So that key move, how you're grabbing the tissue and then lifting up and away before dividing it is safety. So the upper pole is good. So, let me do a little work if that's okay. Yeah. Down where you are. Yeah, I'm gonna give you this camera. Get the camera here. Thank you. And let me see what I can see. Thank you. I think from the back we had a little bit of a view here that I wanted to work on. And then let's get our bearings again. All right, so this is all, this is the last little bit here, huh? So the question is what do we need and what can we take? There's not like a very nice plane. And I just know that those two vessels that are gonna cause us trouble again, but that's okay, 'cause we know that it's all just back bleeding at this point. I always like to be safe. Better safe than sorry. Just assume it's pancreas until proven otherwise. If we wanna leave a drain or something. All right, let's come back. Yeah, that's good. All right, so this is the only bit left. This part of the spleen is all free. Yeah, that all looks free. Okay, good. And then this is where... I think that's the... I think this is pancreas, but is this pancreas? I don't think it's pancreas. This is definitely pancreas. That's pancreas. Maybe a little, a little bit higher. Just go down that line. Just down that line. Just I think we have to be, yeah, in here. Yes. The thing about pancreatic tissue is it bleeds a lot. The pancreas is very vascular. And the fact that going through this fat, is not really, even when you burn it, it likes to bleed. I think it's bleeding. And you we're pretty much right on the spleen because you can see the capsule right on this right there. And it's where our clips are. This is fat. The clips are now kind of annoying. If you take it right here, I think you have like a straight shot. Can you look around there because I think there's clearly some vessels here. Okay, and leave the rest. Yeah. Let's see how it looks. Got it. Maybe, let's see here. Let's just clean things up a smidge. So this is where it's really still stuck, but we can make a plane there. All right. Where did we, we were working from here. We're working right along spleen here, so somewhere right in this window is where we need to connect, right? Something like so, see if you can come around that way, yeah. Because this is where it's still tethered, right? I could fire another staple load back here, but where would we fire it? 'Cause there's clearly a vessel in here. Maybe, this is pancreas down below me. So can I just make a window in this stuff and come through it? Okay. Careful. And is there a little window between these two spots? Right, that's what we need. Without taking that vessel. Hey, I just wanted a second set of eyes on pancreas. So back up a little bit. So we are almost done. Yeah. We took the vessels up there. Okay. And then this pancreas tail is just really stuck. Stuck. So it's hard to tell if this is just fat or if this is pancreas, like down here, this is pancreas. Yes. I would agree there. That's fat. This is more fatty tissue. And this is our last little bit, but we're just getting into like vessels again when we try to come around it. So I'm just trying to find a safe spot to take it get without getting into pancreas. Back up a little bit, Marc. Yeah. 'Cause this, I think, is pancreas still here? Hard to tell. Got a little Gauze in there? Do you have gauze in there? Yeah. I love it. Little Ray-Tec in there. Oh, you are my hero. Yeah. Oh, Bryanna. Lemme switch hands again. But this is like our last attachment. Everything else is free. Yeah. And we had to clip a couple things, 'cause they were oozy over here. But it's all right. I think what you have in your hand is fat. Okay. There. I think I would take that, 'cause I think that's under the, I think that vessel you could probably separate off. Like separate here. Yep. It's always good to have a second set of eyes. It's just, we're really so close to... Because is that really a vessel or is that just the spleen? Do you see? I guess that is a vessel that's just coming up there. I see, yeah. This is definitely vessel. Yeah, I agree. So I would just take that vessel a little further up. Like over here? No, to the left. Right there. Because where I stapled it... I see what you're doing. Is right here. I think... It's just a big old vein. Yeah. It's a big vein that is like fused with spleen over here. I think you can get around it. This is a plane right here. But can we leave it? Yeah. And that's the other option is try to match those two lines up. Yeah. Because I think we're close. You gotta check that out a little bit more Bryanna. Yeah. But do you think this is pancreas? Yeah. Here, can I show you... This looks like pancreas. Yep. This is potentially pancreas. Right, and look at how fused it is. So I would go there. That's why. Careful in there, Marc. Come out. If you can come there. Yeah, yeah, yeah. Let me switch with you again. Let's clean this port. I'll stay here for moral support. I mean, even if we get into it, it's already been controlled, but, back, find ourselves again. So here's where it's stuck. Come on in if you can. Yeah, this whole thing is vein, right? Yeah. That's all vein. So you just gotta, yeah, that's the spot there. Man, this pancreas tail. Because I could just side bite it like that. There you go. Let's see what happens. Sorry. Awkward angles. Okay, just a wee bit more. That's the view right there. Wee bit more. I'd say hit it. It's like there's a... It's like there's a God after all. It's amazing. Nice. Okay. Big picture for a second. Yeah. There you go. Good. All right, so I think we're off of that vein. So you're on the vein right now. There we go. Oh, that vein. Suction. It really is huge. I was just telling Marc, we could take the tail and just staple across it. Could just staple. I'm not sure if you staple down there like is there a plane to staple right across? Because this is... I think you're just getting into splenic capsule there. That's like bleeding. Yeah. There's just a smidgy left here. Yeah, because can you lift? Like can you get under, I mean, are you freed up down there? Yeah, we should be freed up all the way here. Will this lift up Marc. I just want to kind of see how much of the... I can flip it. Well, we can, we're gonna have to go back, 'cause I can't see the vessels from that side, but there's... There's a little splenic, or that's the vein or something? That's the vein. Yeah. This is the other side though. Okay. There you go. So see that? Yeah. So you got. That's all free. So there's just this little blip. There's a fair amount of parenchyma there, whatever that is. Whether it's fatty or actual pancreas. I can't imagine that's actual pancreas, like... But you can come right there with your liggy, you know? Yep, yep, yep. I see what you're saying. All right, let's view. Watch that suction. Like look at how close it is to this vein right here. There's no free lunch. I think that is pancreas though. Yeah. Could be. Like look at the tissue. We'll see. It looks like pancreas. You gonna leave a drain? That's, probably. That's some raw surface of pancreas, I think. But I think you're in the right plane. And that's nice. That should be the last of it. That's nice. Yeah, we should be... Should I let it go? Yeah, let it go, so... You kind of... Would you leave a drain? What do you think? If I was concerned I came across pancreas, I would leave a drain. Yeah. All right. Let's get a 10 Blake in here. 10 Blake. - [Bryanna] We'll use that. I mean, I will tell you, I'm not convinced you came across pancreas, but if you... Were pretty darn close. Were concerned about it, the answer is leave a drive. Yeah, pretty darn close to pancreas, if not across it. That's nice, Bryanna. Nice dissection. Great job. Thanks for stopping in. Yeah, my pleasure.

CHAPTER 7

All right, then the fun part. Good. All right. So here's our pancreas tail. Our vessels are somewhere there. Staple line, see that in the foreground right there. There's our hilar vessels. Now the fun part, try to get it in the bag. Okay, let's get that camera somewhere else. And then let's get the Ray-Tec outta here, 'cause it's gonna get in the way. All right. Yeah, there we go. Corner of it. Oh, that didn't work. It could also just put it in the bag, but... All right, where's another spot? Let's try here. That should be our only Ray-Tec here. Okay. Ray-Tec's out. All right, less is more here. All right, now where am I? There I am, all right. So this is a size 15 bag. It's much stronger than the 11, or 12, or 10 bags, 'cause we're gonna really be using it and taking the spleen out in pieces. So we really want something that's strong and not gonna tear easily. And trying to wrangle the spleen in the bag is a bit of a challenge. Do I have some omentum there? No. That's the part we cut. That's the part we cut off. Yep. Okay. So scoop, scoop, scoop, scoop. Look under, so I'm not grabbing some other organs with me. No, doesn't look like it. Okay, good, I'll keep heading north. I have had to use two bags before, but I don't think we're gonna need two bags. All right, is that? That's the top, I think. Get it in the bag. And then Carrie, we're gonna need suction and a bucket and those ring forceps. And everyone has eye protection on. All right, let me try to slowly close it. That might be what we need to do. It's just a capsular tear in the spleen, 'cause I can pull this a good bit toward me. It's almost there. It wants to, I don't think so, it's pretty darn mobile. There we go. Aha. Okay. Good. All right, let us level the bed and then let's start getting this spleen out. This part is always a bit messy, big Yankauer would be good. All right. So the spleen's in the bag. All right, can you actually put him left side down a little bit? That'll kind of even his belly. Is his arm okay? Okay. No more left side down, is that good? We'll use, we might need that port again, but here's your bag. Woo. Make sure we're in the middle. Do you have a little phrenic or something? Yep. Good. Forceps in here. Let's get a little bit more fascia up here. Let's make sure we're in the middle. Good. All right, we got a bucket. Got like two blue towels or something. Gotta kind of get some of this bag up to start, but there's so much spleen in still. There we go. All right. I'll take Kelly. All right, let's get some ring forceps. This part gets a little bit messy and just don't go through the bag, okay? That's the only rule. It usually starts out slow and then it gets much faster as you take out pieces at a time. Yeah, just a little extra layer. Thank you. I'll take a pair too. Thank you. We'll clean everything up once we're done. Do you have that blue towel? Let's put it under him, here. There we go. You can just twist around a little bit, but sometimes we're on the bag and so you just have to... I think we'll leave a drain. We'll put some Tisseel in the pancreas bed. Can we get 2-0 PDS for closing? Is there a UR? Probably not. And then we'll do 5-0 Monocryl and 5-0 plain gut. Or fast, whatever you have. Fast is fine. Good. All right, slowly but surely. We got a lot more spleen to go. Nice. That's probably some of the vessels. There we go. Good. The pathologist loved this. This is not for the faint of heart. This part, huh? Also, if you faint, it's not a bad job, okay? I know the pathologist won't believe me. Ooh, that was a good one. Trying to break it up too. Otherwise we'd be making a big open cut and that would be kind of sad. We did all that nice work laparoscopically. Can you let the family know everything's going great? Suction won't puncture it, don't worry, it's more likely that these will tear it. Getting there. Okay. Can you flush out the sucker Carrie? We're getting there, that's what I keep saying. Obviously if this was for cancer, we wouldn't be morcellating the spleen. We would take it out intact. There we go. Well, we're getting there. Still a good bit in there, but we're getting there. No, not yet. Keep pushing. Nice. Nice. There she is, excellent. One spleen.

CHAPTER 8

Okay, let's clean up a little bit. Change our gloves and then we'll make sure everything's still dry inside. One spleen. Probably gonna have to put fascia stitches in. It's gonna leak a ton. Yes. Hey Aaron, can you take these so I can see better? Thank you. No problem. Safety goggles off now. Yes. Let's see. You can try it if you want to, I guess. All right, gas on please. Camera on. Let's see if we have a seal at all. Right. High flow or you wanna? Okay. You have that Q-tip thing? Yep. Probably. Do you have a clamp for this suction? Here we go. All right, room lights down. And I'll take a bullet. Can we have reverse T-burg again? All right, so the colon found its way back up here. Get this light out of the way for my glare. All right, so come on up here. Good, there we go, that's the plane and some omentum. And then these are, I think these are hilar vessels right here. That's where our staple lines are. Those look very nice. So just make sure everything's hemostatic. Check this stomach over here. Is spleen for permanent? Yeah. I can pass it off? Yeah. Just wanna make sure there's no gastric, short gastrics that try to cause trouble. Nope. All right, so here's the left crus of the diaphragm right here. Here's the back wall of the stomach. This is the splenic bed. Here's the vessels. And then here's pancreas here. I'm just gonna do a little irrigating here. Irrigate, irrigate, irrigate. Just clean it out. Here's kidney. All right, do you have that Tisseel? That all looks okay. So this is all thawed and ready to go? Yeah. All right. So this is a Tisseel, it's a little hemostatic agent. I'll put some here and some on pancreas here. You have to kind of spray it fast, 'cause it sets up really quick. Put that around any raw surfaces. There we go. Good. All right, now we just need to put our drain in. Maybe the one in between will be easier. I don't want him to have to lay on top of it, you know? Okay. And then do you have a drain stitch? Yes. Can you put a clamp on the end of this drain? All right, let me grab it. Where's our black dot? Do we need to trim it at all? Maybe let's trim it a little bit, like right here. Back up your camera a little bit. Great. All right, good. So we'll put that somewhere up in this left upper quadrant, right? We don't need to put it directly on top of the pancreas. Trying to make the camera go where I want it to, but it doesn't want to. All right, maybe it back a smidge. Yeah. See if I can tuck it along this lateral wall. That'll be nice. I like that, what do you think? Just in case there's a little bit of a leak from the pancreatic tail, I think I'd pull it back a little bit. There's a lot of drain in here. There you go. Good. All right, why don't you suture that in. Push it in a little bit more and we'll put some omentum up there. Good. I think this 15-port really came in handy. Yeah, it was nice. Not having to struggle with the skin incision. You wanna pull that other port out, Kayla? You can reach under his arms. You that port right there? You can pull that right out. Yeah, it takes a little bit of force. No bleeding, no bleeding. Good. Okay, lights on, gas off, then we just need to close. Did you pinch that off? No, you're good. Okay.

CHAPTER 9

And then, yeah. Thank you. You wanna feel his aorta? If you put your finger in the belly toward the spine, there's, it feels elastic and it's pulsatile. It's about this big around. Feel that? Yeah. All right. Sponge. It's just good to know how close it is to your fascia when you're getting into the belly. All right, let's grab fascia here. Can I have the phrenic or something? So now we wanna close them up and we extended our fascia incision on the umbilicus. Grab the edges of that and do a running PDS. And just make sure we don't have anything extra in there. Okay, good. So you just wanna be able to see the fascia, see the inside. Thank you. So you're not grabbing any bowel or omentum when you're taking your stitches. Come a little bit more this way. Okay. And then do we have more local? Did we use it all? We'll use it in a little bit. All right, you can come up with that Kocher, I think so I can really get this knot down. Do you have a second one of these 0 PDSs? It's thick stuff. Let's see. I'll take a rat tooth. All right, so here's the edge of the fascia here and then you can come out with your retractor. Yeah, there we go. Switch sides. Good. I am gonna take it in two. So we will admit him, keep him on telly overnight. He can have PRN morphine, Tylenol, ibuprofen. Keep him on fluids. Let's give him clears tonight and then regular diet tomorrow. Okay. What else? I don't think we really need labs unless there's any concern. Oh, I see. Yeah, we can do the amylase thing. Post-op day one, and then three, I guess. Just to go from the bottom? Yeah, let's go from the bottom. Can you hold that for a second? Hold this for a second. Okay, let go for a second. Lemme just make sure. There's some surgeons who will leave an NG tube overnight for concerns of bleeding from the short gastrics if the stomach gets too distended. Yep. Sorry. Yep, grab it. Curve and then I'll come outta your way. Good. Yep. Yep. Okay, at least one more. Maybe just one more. Yeah, lemme relax a little bit. There you go. Good. That'll be nice. All right, let's just take a feel for safety. Okay, I'm gonna cut these needles off. Good. And then I'll take the rest of the local and he'll take a Monocryl. Just one second. We got all of our Ray-Tecs, good. It's normal for this to have like serosanguinous drainage. You just don't want it to look like brown murky stuff. Thank you. So I'll just inject this belly button a little bit more. I always talk to the family about the pancreas chance of leaving a drain if we're worried. So it's not a surprise. And an Adson. So again, I just like to re approximate the skin with a plain gut or a fast gut suture here, as opposed to trying to bury some subcuticular sutures that they're never gonna see. On the knot, yeah, it's a tear. This umbilical incision is typically the most painful, 'cause of the fascia underneath. The skin itself is not, a huge incision, you can see how it kind of, all buries down, you don't see much on the outside. Yep, you can leave like a one-millimeter or two-millimeter tail. And then we'll use Dermabond and a drain sponge. Dermabond. Dermabond, and like a two by two teggy for the drain. I will take that needle back. So Aaron, we did laparoscopic splenectomy, placement of drain, one spleen, no complications, clean. Oh, he needs to go on penicillin postoperatively for prophylaxis. You can cut please. One more. Needle on the pink. Thank you. I think our ports actually worked out really well. We weren't fighting each other. No, no. And we had good exposure, 'cause you can really go much higher if it's a normal-sized spleen too. But given how big the spleen is, I don't like to start my ports that close. Good, and then we'll do a drain two by two thingy. We'll do one on top and one on bottom like so like so. Like so. Yep, Tegaderm. Okay, thank you.

CHAPTER 10

The operation went well. We were able to safely remove the spleen from our patient's abdomen. We were able to do it with laparoscopic, smaller incisions. There was a little bit of difficulty initially getting around the splenic artery and vein due to the pancreas and some branches that were involved there, but ended up dividing just fine. The pancreas tail, I would say was the most difficult portion of that procedure. I was thankful to have a partner next door who came in and it's always good to have a second set of eyes in some of these cases. And the pancreas tail was able to be safely mobilized off of the spleen and the hilum with some difficulty. But due to that, we did leave a drain behind, which will hopefully come out in a couple days in the hospital. Pediatric surgery is a very specific field. There's a lot of unique things that go into it, and that's why it's a subspecialty with extra training after general surgery. There's differences in the patient's anatomy, how they respond to surgery, how they respond to anesthesia. The tissue quality is very different. It can be extremely fragile in the youngest patients that we take care of. And then just the amount of space that you have to do laparoscopic or even open surgery is completely different in a pediatric patient. So we have to be creative with our laparoscopic port placements. We can't put them as far apart as we would like to sometimes. And you have to just get creative with your instrument sizes, and the amount of blood that they can tolerate losing is very different than the amount of blood that an adult patient can tolerate losing as well. But in general, they heal very, very quickly. They're typically very healthy patients and recover from surgery much faster than adults do.