Upper GI

Splenectomy (Laparoscopic)

OPERATION: Laparoscopic Splenectomy
ANAESTHETIC: General anaesthesia
PRE-OPERATIVE VACCINATIONS: Pneumococcal, Haemophilus influenzae type b, and meningococcal vaccines administered minimum 2 weeks pre-operatively.
POSITION: Right lateral decubitus, left side up at 60° angle, reverse Trendelenburg. Beanbag support. Left arm positioned as for left lateral thoracotomy. Orogastric tube inserted.

INDICATION:
[Idiopathic thrombocytopenic purpura (ITP) / haematological malignancy / haemolytic anaemia / symptomatic splenomegaly / trauma / incidental]. [Platelet and blood products available. Haematology review completed for ITP.]

PROCEDURE:
WHO Checklist performed. Abdomen prepared and draped.

PORT PLACEMENT:
Veress needle insufflation. Initial 12 mm port placed in the left upper quadrant approximately five finger-breadths below the costal margin — laparoscope introduced. Four to five 12 mm ports placed in a triangulated configuration: one each side of the umbilical port for surgeon's right and left hands; one laterally under the left costal margin for the assistant; optional sub-xiphoid port for irrigation/suction. Abdominal cavity explored — accessory spleens noted and excised [if present].

DIVISION OF SHORT GASTRIC VESSELS AND LESSER SAC ENTRY:
Short gastric vessels divided with energy device (harmonic shears) along the greater curvature, close to the spleen rather than to the stomach. Division carried superiorly then inferiorly until the tail of the pancreas was fully exposed. Additional clips applied to larger vessels as required.

INFERIOR POLE DISSECTION:
Spleen retracted superiorly and laterally. Splenocolic ligament divided with energy device. Inferior pole vessels dissected, controlled with clips or endo-GIA vascular stapler, and divided. Inferior pole of spleen fully mobilised.

HILAR VESSEL DIVISION:
Surgeon and assistant applied opposing retraction — inferior pole superolateral by assistant, tail of pancreas pushed inferiorly by surgeon. Hilum exposed. Proximity of pancreatic tail to splenic hilum identified and respected. Splenic artery and vein divided at the hilum: [single firing of 30 mm endolinear vascular stapler / artery and vein individually clipped and divided separately due to distributed vascular anatomy]. Haemostasis of hilar staple line confirmed.

PHRENIC ATTACHMENTS:
Phrenosplenic and remaining diaphragmatic attachments divided with energy device. Spleen fully mobilised.

SPECIMEN RETRIEVAL:
Endoscopic retrieval bag introduced. Spleen manoeuvred into bag using hilar and fatty attachments as handle. Bag closed securely. Umbilical port removed, fascia extended minimally. Spleen morcellated within bag between fingers and anterior abdominal wall and fragments extracted. No fragments dropped into abdomen.

Final inspection of splenic bed — haemostasis confirmed. [Drain placed if pancreatic tail injury suspected]. Ports removed. Fascia of 10/12 mm ports closed. Skin subcuticular suture.

FINDINGS:
[Spleen size]. [ITP / haematological condition]. Splenic vascular pattern: [magistral / distributed]. Pancreatic tail proximity: [in contact / within 1 cm — carefully dissected]. [Accessory spleen(s) identified and excised]. Haemostasis satisfactory.

SPECIMEN: Spleen (morcellated) and any accessory spleens to histopathology.
EBL: [Volume] ml. COMPLICATIONS: None.

POST-OPERATIVE INSTRUCTIONS:
Lifelong prophylactic antibiotics (penicillin V or equivalent). Patient education re: asplenic state and infection risk. Haematology follow-up. Booster vaccinations as per protocol. Thromboprophylaxis — monitor platelet count if ITP.