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Table 1. Potential Indications for Laparoscopic Gastric Resection — Table 1 Potential Indications for Laparoscopic Gastric Resection

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tric resection, which is slowly assuming greater impor- tance in the management of patients with benign and malignant diseases of the stomach. Dr. Poulin discusses issues relevant to laparoscopic splenectomy, including technical tips and the potential applications of hand-as- sisted surgery.

1 Port position for Pancreatic and Gastric Cancer staging (10 mm subumbilical blunt camera port, 10 mm port in the right upper quadrant placed laterally). This port is utilized for liver retraction and for insertion of the laparoscopic ultrasound. Additional, 5 mm ports are placed in the left upper quadrant midclavicular line and in the right upper quadrant as demon- strated.

2 Port placement for staging Hepatic malignancy. Metastatic colorectal disease to the liver is the commonest indication for laparoscopic staging of liver tumors in the United States. As these patients in general have had prior open surgery a right subcostal cut down is the preferred means of access to the peritoneal cavity. Additional ports are inserted along the line of incision as shown.

3 (A) Peritoneal metastases (blue arrow). Biopsy of suspi- cious peritoneal lesion (blue arrow). (B) Note also ascitic fluid present at hepatic flexure (red arrow).

4 (A) Examination of the left lateral hepatic sector (segments 2 and 3). (B) Examination of inferior aspect of the right hepatic lobe. GB = gallbladder, HDL = hepatoduodenal ligament, TC = Transverse colon. A metastastic lesion can be seen lateral to the hepatoduodenal ligament. 10-mm port. In general, we prefer to use the lateral port in the right upper quadrant. This allows for excellent exam- ination of the liver (Fig 8), hepatoduodenal ligament (Figs 9 and 10), stomach and pancreas. To examine the stomach, 500 mL of warmed saline is inserted into the stomach. The resultant distention facilitates examination of the anterior and posterior walls. The liver is examined sequentially with particular attention paid to the areas not seen on the standard laparoscopic examination. Suspi- cious lesions can be biopsied either by fine needle aspira- tion (FNA) or with a percutaneously inserted Tru-cut needle. Duplex scanning is useful to enable identification of vessels particularly in the hepato-duodenal ligament and around the pancreas (Fig 10). The relationship of the primary tumor to the surrounding vessels can be deter- mined.

1 Treatment algorithm of esophageal achalasia before and after the introduction of minimally invasive surgery.

3 Placement of the trocars. Five trocars are used for the operation. Trocar #1 is placed in the midline, 14 cm caudad to the xiphoid process. It is used for the 30° scope. Trocar # 2 is placed in the left mid clavicular line at the same level with the camera. It is used for inserting a Babcock clamp and instru- ments to divide the short gastric vessels. Trocar # 3 is placed in the right mid clavicular line at the same level as the previous 2 trocars. It is used for the insertion of a retractor to lift the left lateral segment of the liver and expose the gastroesophageal junction. Trocars # 4 and #5 are placed under the right and left costal margins, respectively, so that their axes form an angle of about 120°. These ports are used for the dissecting and suturing instruments. The electrocautery used to perform the myotomy is inserted through trocar #5.

2 Positioning of the patient on the operating room table. After induction of general anesthesia with a single lumen endo- tracheal tube, the patient is positioned supine on the operating table over a beanbag, which is securely fixed to the table. The lower part of the beanbag is used to create a saddle under the patient’s perineum to avoid sliding during the operation when a steep reverse Trendelenburg position is used. The legs are ex- tended on stirrups, with the knees flexed only 20° or 30°. Compression stockings are routinely used. An orogastric tube and a urinary catheter are inserted before the operation and are usually removed at the end of the procedure. The surgeon stands in between the patient’s legs, while the assistants stand on the right and left side of the table.

5 The Dor fundoplication is an an- terior 180° fundoplication. It is con- structed by using two rows of sutures. The first row of sutures is on the left, and comprises three stitches. The up- permost stitch is triangular, and in- corporates the gastric fundus, the left side of the esophageal wall (avoiding the anterior vagus nerve) and the left pillar of the crus.

vantage of keeping the edges of the myotomy separated and avoiding recurrent dysphagia, an anterior fundopli- cation avoids the posterior dissection, it covers the ex- posed esophageal mucosa, and it has been shown to be an effective antireflux operation. A posterior 220° fundoplication can be used instead of a Dor fundoplication to prevent gastroesophageal reflux.’ While a posterior fundoplication has the theoretical ad-

4 After placement of the laparo- scopic ports, the peritoneal cavity and liver surfaces should be in- spected for associated pathology. Any suspicious lesions should be bi- opsied and analyzed by frozen sec- tioning. A retractor is inserted via the right subcostal port to elevate the left lateral segment of the liver. The greater curvature is elevated with a Babcock grasper and counter- traction is placed on the omentum. The initial step in the dissection is to divide the gastrocolic omentum to mobilize the greater curvature of the stomach and gain access to the lesser sac. Division of the gastrocolic omentum is facilitated by the use of the ultrasonic shears, although some surgeons prefer to use electrocau- tery in conjunction with endoscopic clips for larger vessels. The dissec- tion is carried just proximal to the planned site of division of the stom- ach.

6 The gastrohepatic omentum is divided in the avascular plane be- tween the liver and the lesser curva- ture vessels and the nerves of Later- jet. The dissection is carried down to the pylorus and the right gastric ar- tery is divided, usually with clips. The vessels along the lesser curva- ture can be divided laparoscopically at this point or this can be done once the stomach is exteriorized if a laparo- scopic-assisted technique is planned.

12 The technique for laparoscopic gastric wedge resection of benign gastric lesions varies depending on the size of the lesion and its location. Lesions in the fundus of the stomach are ideally suited for wedge resection as shown above. The greater curvature of the stomach has been completely mobilized by dividing the gastrosplenic ligament and short gastric vessels. The lesion is elevated with a Babcock grasper by grasping adjacent normal stomach. If the lesion is difficult to grasp or elevate, sutures may be placed in the gastric wall adjacent to it. These sutures can then be used for traction to facilitate placement of the stapler. An endoscopic linear cutting stapler is then placed below the lesion to obtain a margin of normal tissue of 1 cm or greater. More than one stapler application may be necessary. The gastric staple line may need to be inverted with interrupted or running absorbable suture if there is bleeding from it. For lesions in the antrum or those near the gastroesophageal junction, intraoperative gastroscopy may be important to visualize application of the stapler so that the gastric or gastroesophageal lumen is not compromised. Gastroscopy may also be used intraoperatively to localize smaller lesions. Once the specimen is free, it is placed in an entrapment bag and removed at the conclusion of the procedure. It should be examined by the pathologist to ensure negative gross resection margins. An alternative technique for posteriorly located lesions, especially those that protrude into the gastric lumen, is excision via an anterior gastrotomy. Although not shown here, the anterior stomach is opened over the lesion with the ultrasonic shears. The lesion is identified, elevated and excised with a linear cutting stapler using the same techniques and principles as described above.

Table 2. Series of Laparoscopic Resection of Gastric Stromal Tumors TSome patients in series had other gastric tumors, including polyps, lipomas, lymphoma, and other lesions *Includes one patient converted to a laparoscopic-assisted resection *R esumption of diet and length of stay varied by type of procedure-wedge versus intragastric resection.

Table 3. Major Series of Laparoscopic Gastrectomy for Gastric Cancer *Includes 15 patients who had gastric lesions other than adenocarcinoma tThere were 9 of 12 patients alive at 18 months follow-up.

Whereas most anatomy texts imply that the splenic artery is constant in its course and branches, the classic essay of Michels demonstrates the fact that each spleen has its own peculiar pattern of terminal artery branches. The splenic branches exhibit so many variations in num- ber, length, size, and origin that no two spleens have the same anatomy. Michels divides splenic artery topography into two types: distributed and bundled (magistral). He reports that the distributed type is found in 70% of dis- From the Center for Minimally Invasive Surgery, St. Michael’s Hospital, Uni- versity of Toronto, Toronto, Canada.

3 General scheme of splenic artery branches. * = present in only 20% of cases. The splenic artery in the hilum can include up to seve branches at various division levels and in various anatomic arrangements; they are the superior terminal artery, the inferior terminz artery, the medial terminal artery, the superior polar artery, the inferior polar artery, the left gastroepiploic artery, and the short gastri arteries. Veins usually lie behind arteries except at the ultimate division level, where they may be anterior or posterior. According t Lipshutz, 72% of spleens have three terminal branches (superior polar, superior and inferior terminal) and 28% have two, the othe remaining branches being collaterals. When the superior terminal is excessively large, the inferior terminal is rudimentary, and mor blood supply often comes from the left gastroepiploic and polar vessels. Up to six short gastric arteries may arise from the fundus of th stomach, but usually only those (1-3) opening into the superior polar artery of the spleen need to be ligated during laparoscopi splenectomy.'?-!° (“The anatomical basis for laparoscopic splenectomy”—Reprinted from: Can J Surg 36:484-488, 1993, by permissio: of the publisher. © 1993 Canadian Medical Association.)

4 Suspensory ligaments of the spleen. Duplications of the peritoneum form the many suspensory ligaments of the spleen. On the medial side, posteriorly, the lienorenal ligament contains that tail of the pancreas and the splenic vessels. Anteriorly, the gastro- splenic ligament contains the short gastric and the gastroepiploic arteries. The remaining ligaments are usually avascular except in patients with portal hypertension or myeloid metaplasia. The longest is the phrenocolic ligament, which courses laterally from the diaphragm to the splenic flexure of the colon; its top end is called the phrenosplenic ligament. The attachment of the lower pole on the internal side is called the splenocolic ligament. Between the phrenocolic and the splenocolic ligaments, a horizontal shelf of areolar tissue is formed on which rests the inferior pole of the spleen. It is often modeled into a sac that opens cranially called the sustentaculum lienis, acting as a brassiere to the lower pole of the spleen.'? (“The anatomical basis for laparoscopic splenectomy”— Reprinted from: Can J Surg 36:484-488, 1993, by permission of the publisher. © 1993 Canadian Medical Association.)

> Port placement anterior approach. Position of the operating team and the trocars: (S) surgeon, (A) assistant, (1) 5-mm trocar, (2) 12-mm trocar, (3) 10 or 12 mm trocar. For the anterior approach, a 12-mm trocar is introduced through an umbilical incision using an open approach under direct vision. A 10-mm laparoscope (0-degree or 30-degree) is connected to a video system and three or four 5 and 12-mm trocars are placed in a half-circle away from the left wpper quadrant. Placement of trocars is essentially dictated by body habitus and the size of the spleen. Careful selection of all trocar sites is made to optimize work angles. As needed, the 12-mm ports are used to allow introduction of clip appliers, staplers, or the laparoscope from a variety of angles. The anterior approach is probably better suited to a situation where concomitant surgery is needed, such as cholecystectomy. Moreover, dealing with a very large spleen is probably safer with an anterior approach and HALS techniques or possibly prior splenic artery embolization.

The lateral approach to laparoscopic splenectomy was first described for laparoscopic adrenalectomy and has become the approach of choice for most patients (Table 2: Figs 6 and 7).”

are used to hold the two rigid edges of the bag and effect partial closure. One should note that it is difficult to insert the spleen into the plastic bag before unfolding and open- ing the bag completely. Bagging the resected spleen re- quires patience and imagination and at first can be a frustrating experience (Fig 12). The 10-mm jaw forceps holding the edges of the lower end of the bag inside the abdomen is pushed through one of the mid anterior trocar sites, and the tip of the bag is grasped and brought out of the wound. Gentle traction on the bag from the outside brings the spleen close to the peritoneal surface of the extracting incision. It is important during this maneuver to pull out only the ridged edges of the plastic bag while keeping a finger inside; otherwise it is easy for the spleen to flip out of the bag, and the maneuver has to be repeated again. The use of sterilized home freezer bags is the most cost-effective means of bagging and extracting the spleen. The thick freezer bags should not be confused with other

10 Approaching the hilum from the front. Peeking in the splenic tent in front of the splenic hilum allows the surgeon to survey for a number of technical options. First, a tortuous main splenic artery may be observed above the tail of the pancreas and distal to the pancreatic magna artery. It can be clipped early and control most of the arterial splenic supply, except for the collateral vessels (short gastric vessels and branches of the gastroepiploic artery to the lower pole). Second, the short gastric vessels may be found to be easily accessible and taken early, thus exposing the superior pole. Third, the branching pattern at the hilum (two, three, or more branches) can be assessed. For example, a bundled blood supply with two main branches can allow safe creation of a window above the tail of the pancreas allowing stapling of the entire arterial and venous blood supply with a single stapler application.

Approaching the hilum from the back. To approach the hilum from the back, the phrenocolic ligament is first incised towar¢ the diaphragm. A 2-cm wide portion of the ligament is left attached to the spleen, making a long structure from which the spleet can be manipulated with graspers. With the camera in the lower or posterior trocar site, the tail of the pancreas is then dissectec from the structures of the hilum in the areolar avascular tissue of the retroperitoneum. It is important to locate the tail of th pancreas and dissect it away from its position close to the splenic hilum to avoid injury during control of the vessels. If a distributec type of anatomy is present with its wide hilum, the splenic branches will necessitate dissection and clipping. The bundled type lend itself more to a single use of the linear stapler as long as the tail of the pancreas is identified and dissected away when required. Whe this is possible, a window is created above the hilar pedicle in the lienorenal ligament so that all structures can be included withit the markings of the linear stapler under direct vision. The viewing angles provided by moving the camera into the various trocar make this maneuver much easier in the lateral position than in the anterior approach. The dissection is continued with individua dissection and clipping of short gastric vessels. Occasionally, these vessels can also be taken en masse with the linear stapler. Suture are rarely necessary during laparoscopic splenectomy and have been used only occasionally to control a short gastric vessel too shor to be clipped safely. This portion of the operation is performed while the spleen hangs by the upper portion of the phrenocoli ligament. The experienced surgeon also learns to move the spleen back and forth so that it can be observed both from an anterio and posterior perspective. The surgeon will then decide whether vessels are more easily approached from the back or the front fo dissection and ligation.

12 Securing and extracting the spleen. Spleens removed through the anterior or lateral approach are extracted after finger fragmentation in a plastic bag from the umbilical or subcostal trocar site. It is rarely necessary to enlarge this incision to more than 2 or 3 cm. A small subcostal incision has been used as the extraction site during laparoscopic splenectomy through the anterior approach to deal better with diaphragmatic adhesions. When the lateral approach is used, extraction is more easily performed through one of the ports situated anteriorly. This extraction site also requires little or no enlargement. On occasion, for a spleen longer than 20 cm, a 7.5 to 10 cm Pfannenstiel incision is used, and the forearm is introduced into the abdomen to deliver the spleen in the pelvis for extraction in large fragments under direct vision. The surgeon can also use this incision to hand-review the hilum videoscopically to ensure that all vascular structures have been properly identified and controlled. The abdomen is copiously irrigated before closure. Special mention should be made of laparoscopic splenectomy for malignant disease. In cases where lymphoma or Hodgkin’s disease is suspected, preoperative splenic artery embolization or finger fragmentation ina plastic bag is not used for fear of making the histological diagnosis difficult to obtain. Extraction of intact spleens through a small left subcostal or median incision has also been described when it is required to preserve tissue architecture. The various techniques of fragmentation and extraction of splenic tissue during laparoscopic splenectomy should be discussed and agreed on with the pathologist to ensure that proper pathological diagnoses are not compromised by necrotic tissue in the case of preoperative splenic artery embolization or altered tissue architecture through finger fragmentation, especially if the diagnosis of malignancy is suspected but not proven. The choice of the appropriate extraction technique is, therefore, largely dependent on the type of splenic pathology and the size of the spleen.

l Computerized tomographic scan of a large, thick walled pancreatic pseudocyst within the lesser sac.

5 Following anterior wall gastrotomy, the pseudocyst is aspirated to further confirm its location. The surgeon may use either a spinal needle or a Veress needle percutaneously passed through the posterior wall of the stomach.

Z The first step in the laparoscopic management of pancre- atic pseudocysts is obtaining access to the peritoneal cavity and establishing pneumoperitoneum. We prefer to accomplish this using an open cut-down technique to place a blunt Hasson trocar at the umbilicus under direct vision. In patients who have undergone prior abdominal procedures and in whom we suspect dense adhesions in the midline, we use a blind Veress needle technique in the left upper quadrant to establish pneu- moperitoneum. We then place a 5 mm trocar followed by a 5 mm 30° laparoscope in either of these locations. We have found this to be a safe way to access the abdominal cavity in patients with significant midline adhesions.

5 The pseudocyst-gastrostomy is elongated. This can be accomplished with the use of a 60 mm endoscopic linear stapling device with 2.5 mm staples. For thicker walled pseudocysts 3.5 mm or larger staples must be used. The anastomosis must be closely examined for hemostasis. If any hemorrhage occurs, it should be controlled with interrupted figure of eight sutures. The surgeon must be prepared to complete the whole anastomosis by intracorporeal suturing if the psuedocyst is not suitable for stapling. Alternatively, the pseudocyst-gastrostomy may be created using an ultrasonic dissector, followed by marsupialization of the margin with a running nonabsorbable suture.

7 Roux-en-Y pseudocyst-jejunostomy is a technique that is useful for pseudocysts that are not intimately adherent to the posterior wall of the stomach. Port positioning in part will be determined by the position of the pseudocyst. Port positioning can be liberal, but likely can be accomplished using a 5 to 12 mm right upper quadrant epigastric trocar, a 5 to 12 mm left upper quadrant subcostal trocar, a5 mm left upper quadrant trocar just above the level of the umbilicus, and an umbilical camera port. The creation of a Roux limb of jejunum proceeds by using upward retraction on the transverse colon to identify the ligament of Treitz. This also exposes the pseudocyst through the transverse mesocolon. The jejunum is then followed downstream to a point that will reach the pseudocyst without undue tension. The small bowel is transected at this point with an endoscopic 2.5 mm linear stapler. One additional firing of an endoscopic 2.5 mm linear stapler is used to transect the mesentery of this segment of jejunum perpendicular to the long axis of the intestine to gain added mobility.

6 Once hemostasis is verified, the anterior wall of the stomach is closed. This can be accomplished with an endoscopic linear sta- pling device or continuous run- ning suture, depending on sur- geon preference.

8 After mesenteric diver- sion, the distal segment is fol- lowed downstream at least 40 cm, at which point a side-to- side jejunojejunostomy is performed using an endo- scopic 2.5 mm linear stapler.

Q The Roux limb of jeju- num that has been fashioned is delivered into the upper abdo- men. An ultrasonic dissector is used to create a pseudocysto- tomy through the transverse mesocolon and a jejunotomy. An endoscopic 2.5 mm linear stapler is then used to create a side-to-side pseudocyst-jeju- nostomy. The access pseudo- cystotomy-jejunotomy is then closed using running or inter- rupted suture.

Related topics:

Laparoscopic Surgery

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