**8.2.1 Installation**

214 Updated Topics in Minimally Invasive Abdominal Surgery

Surgery is the only option to guarantee the viability of the spleen; however it should not trigger any secondary ischemia. Its objective will be to restore the spleen in its anatomical position as close to normal as possible to avoid the dangling effect of the spleen at the end of

Surgery is the appropriate therapeutic choice, but many different approaches are available:

In the literature, we found that in 49% of the cases the diagnosis was made during surgery (Brown et al, 2003). In this context, laparoscopic surgery is the procedure of choice. It allows for an etiological diagnosis, a good evaluation of the surgical situation while offering several therapeutic possibilities: splenectomy (Carmona et al, 2010), splenopexy (Hirose et al, 1998; Kleiner et al, 2006), gastropexy (François-Fiquet et al, 2009; Fiquet-François et al, 2010) or even a combination of several techniques such as gastropexy and splenopexy (Okazaki et al,

The choice for classic open surgery or laparoscopic surgery varies according to the different surgical teams. When there is no history of abdominal surgery, laparoscopic procedure

The risk of gastric perforation is an argument for laparotomy as the procedure of choice in case of gastric volvulus, but it does not seem to be a limiting factor for an experienced laparoscopic technician. (Mayo et al, 2001) The surgical treatment should only take place after medical treatment has been administered. The gastric suction avoids the risk of

Nowadays, it is commonly accepted to try and preserve the spleen, when viable, during the

It is necessary to be aware of this rare clinical pathology in order to avoid delaying surgical

Nevertheless, splenic ischemia after torsion is quite common and the rate varies from 43% to

Splenectomy will be the gold standard for major splenic ischemia, when there is splenic

Faced with a viable or almost viable spleen, the surgery should aim for splenic conservation.



laparoscopic surgery, laparotomy, splenopexy, gastropexy, and splenectomy.

**8. Surgery** 

its pedicle.

2010)

**8.1 States of art** 

**8.1.1 Surgical approaches** 

seems to be the procedure of choice.

**8.1.2 Surgical procedures** 

Soleimani et al, 2007)

ischemia. (Fiquet-François et al, 2010)

spontaneous or laparoscopy-induced gastric perforation.

procedure, to avoid post-splenectomy infectious complications.

necrosis after torsion repair and the spleen is no longer viable.

The surgery should focus on a fixation technique that will:

care, which could lead to splenic ischemia or even gastric ischemia.

65% of cases according to the series (Fiquet-François 2010; Romero et al, 2003).

After gastric tube decompression (in case of gastric volvulus), the patient is positioned supine on the surgical table.

A general anesthetic technique completed by bilateral Transversus Abdominis Plane Block (TAPB) to allow for eviction curare substances.

Tracheal tube and positive pressure ventilation with O2-air (0.5,0.5) was used. The nitrous oxide is formally cons indicated. (intestinal dilatation)

In children, the surgeon and assistant are at the right of the child. The laparoscopy column is placed at the level of the patient's left shoulder. (Fig 11) In adults, the French lover position allows for the surgeon's assistant to be perfectly positioned for this procedure.

Fig. 11. Diagram presenting the positions of: the patient, trocar entry sites, surgeon, surgeon's assistant and laparoscopic column.

Laparoscopic Gastropexy

for the Treatment of Wandering Spleen With or Without Gastric Volvulus 217

We created an extra peritoneal pocket. We performed a parietal peritoneal posterolateral

(a) (b)

Fig. 15. Gastropexy by suturing the peritoneal wall to the greater curvature of the stomach We proceeded to the gastropexy. (Fig 18) We fixed the anterior stomach lining with sutures (Mersuture® 3/0; Johnson and Johnson, Somerville, NJ) on the free anterior peritoneum (Fig

No drain was inserted. The nasogastric tube was removed at the end of the procedure. Carbon dioxide gas was expelled, trocars removed, and incisions were are closed.

It is essential in case of splenectomy to ensure vaccination (pneumococcal, meningococcal, and haemophilus) and prescribe the usual antibiotic course post-splenectomy. In case of conservative splenic management, in spite of some signs of splenic suffering, it can be useful

This suture can be done in separate stitches sutures or by two surgeons.

incision, opposite the large gastric curve, up to the diaphragm (7 cm). (Fig 14)

Fig. 14. a - b Parietal peritoneal posterolateral incision

15), in two planes. (Fig 16-17-18)
