Pal Kamalesh
Department of Surgery, King Fahad Hospital of the University, College of Medicine, University of Dammam, Al Khobar, Kingdom of Saudi Arabia.
J Indian Assoc Pediatr Surg. 2010 Jul;15(3):93-5. doi: 10.4103/0971-9261.71750.
Laparoscopy is becoming the preferred modality for concomitant cholecystectomy and splenectomy (CAS). Usually, six to seven ports are employed for CAS, and spleen is removed by classical lateral approach or anterior approach. We report here our modified five-port and pedicle first approach for CAS in children to minimize the intraoperative bleeding and maximize the access.
Twenty-one children underwent laparoscopic CAS with this new approach and their data were recorded prospectively. Following cholecystectomy (with ports 1-4), left side was elevated by 30°. The spleen was lifted by a grasper/fan retractor through port no. 5. The pedicle was dissected and splenic vessels were divided by ligasure (vessels < 8 mm), and for bulkier pedicle, vascular endo-GIA stapler was used. Short gastric and gastrosplenic ligament, lower pole and phrenico-colic attachments and upper pole attachments were dissected by ligasure in that sequence. Spleen was placed in endosac and delivered by digital fracture technique. Occasionally, lower transverse incision was made to deliver a massive spleen.
There were 12 males and 9 females with an average age of 8 years. Fourteen had sickle cell disease (SCD) and 7 had SCD and beta thalassemia. All CAS were completed successfully without any complication. Total duration was 160 minutes. Cholecystectomy took an average of 35 minutes. Average blood loss was 140 ml. The mean splenic weight was 900 g and mean length was 20 cm. Duration of hospitalization was 3-4 days.
CAS can be successfully performed by five ports. The pedicle first approach is extremely helpful in moderate to massive spleens as it reduces splenic size, vascularity and bleeding from capsular adhesions or inadvertant lacerations.
腹腔镜检查正成为同期行胆囊切除术和脾切除术（CAS）的首选方式。通常，CAS需使用6至7个端口，脾脏通过经典的外侧入路或前入路切除。我们在此报告我们改良的五端口及先处理脾蒂入路用于儿童CAS，以尽量减少术中出血并最大化手术视野。
21例儿童采用这种新方法接受了腹腔镜CAS，并前瞻性记录了他们的数据。胆囊切除术后（使用端口1-4），将左侧抬高30°。通过第5号端口用抓钳/扇形牵开器提起脾脏。解剖脾蒂，用结扎器（血管直径<8mm）切断脾血管，对于较粗大的脾蒂，使用血管腔内切割吻合器。按此顺序用结扎器解剖胃短血管和胃脾韧带、脾下极与膈结肠韧带附着处以及脾上极附着处。将脾脏放入内囊，通过手指骨折技术取出。偶尔，做下腹部横切口以取出巨大脾脏。
男性12例，女性9例，平均年龄8岁。14例患有镰状细胞病（SCD），7例患有SCD和β地中海贫血。所有CAS均成功完成，无任何并发症。总时长为160分钟。胆囊切除术平均用时35分钟。平均失血量为140ml。脾脏平均重量为900g，平均长度为20cm。住院时长为3-4天。
五端口可成功完成CAS。先处理脾蒂入路对中度至巨大脾脏极为有用，因为它可减小脾脏大小、减少血管供应以及减少因包膜粘连或意外撕裂导致的出血。
