Chapter 1 of 4 · Case-Based Learning
Port placement
Case presentation and port placement
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The cyst was seen on an ultrasound performed for abdominal pain in a 14 year old girl.
A CT scan showed a giant cyst measuring more than 10 centimeters in greatest diameter in the upper pole of the spleen.
25 millimeter ports and 210 millimeter ports are placed, with the camera at the umbilicus, the superiormost epigastric port for retraction, and the mid epigastric and left lower quadrant ports for working instruments.
The use of 210 millimeter ports allows for a 10 millimeter energy device to be deployed parallel or perpendicular to the splenic axis as needed.
All 3 midline port incisions are oriented vertically so that they can be included in a midline incision if conversion is necessary.
The patient is positioned on a bean bag in a partial left lateral decubitus position, as is used for a laparoscopic splenectomy.
The dissection starts by dividing the adhesions between the cyst and the left lobe of the liver.
The short gastric vessels are divided in order to devascularize the superior pole of the spleen containing the cyst.
The cyst closely approaches the hilum, so a hilar branch vessel is also divided.
I prefer to use the 10 millimeter ligature device, as I find that it compresses the tissues more securely and is less likely to simply fracture the spleen.
Despite devascularization and despite using an energy device, a fair amount of bleeding should be expected during transaction.
A suction device should be used to evacuate the blood intermittently as the transaction progresses.
Once the transaction is complete, the posterolateral peritoneal attachments to the diaphragm and kidney are divided, resulting in complete detachment of the superior pole of the spleen containing the cyst.
The raw surface of the spleen is then cauterized using spray coagulation set at 30 to 40.
It is important to confirm complete hemostasis of the splenic surface.
A large sheet of surgicel is then brought into the abdomen and draped over the raw surface of the spleen.
An omental pedicle is also brought to the vicinity of the same surface.