**4. Techniques**

The laparoscopic surgery is classically done via four ports (trocars) through the abdominal wall viz.12mm left umbilical trocar, 5mm trocar positioned 5cm distal to the xiphoid process and slightly to the right of the midline, a 12 mm trocar positioned below the left costal arch

Spleen Preserving Surgery and Related Laparoscopic Techniques 201

10mm diameter (disposable) probes are employed. It provides an optimum hemostasis. Argon beam coagulator uses a no-touch technique, and the stream of argon gas, as it conducts the electrical energy, simultaneously has a" blast" effect on the target tissues, momentarily blowing away blood, fluid, and debris for more efficient coagulation. The electrical generator is inexpensive but the electrode tips are relatively expensive, requiring frequent replacement. However, the efficacy of the argon beam coagulator, with its potential for a reduction of operating room time and its efficient achievement of (otherwise tedious)

The laparoscopic techniques have bought about essential changes in the surgery and have given a different vision and most importantly precision. The innovative robotic technologies at some centers are used in conjunction with laparoscopy. The use of robotic cameras have added the function of zoom in and zoom out and the 180 degree view have provided surgeons with the desired angle to see splenic pedicle and surrounding landmarks. Robotic cauteries, cameras can also be used with joysticks and voice activation so in delicate moments like achieving hemostasis during pedicle dissection, The surgeons just have to give a command to get the exact view thus saving time manpower and with ease. There are many centers using the davinci system to perform procedures asdelicate as splenectomies.

Not only the tools to obtain optimum results during the surgeries are evolving but also the laparoscopic surgery have also evolved. The minimal invasive is on a path of becoming even more minimal. The technique like SILS (single incision laparoscopic surgery) has bought revolution in the laparoscopic world. There are many literatures world wide showing the use of SILS for partial splenectomies. This technique in particular draws lot of attention owing to the fact that it's used through single trocar introduced through a small umbilical incision. From a single port three to four instruments as camera, scalpel, suction can be introduced and operated. The instruments have a multiple operating and viewing angles so the surgery doesn't need many ports. The tips of the instruments are available with multiple degree of rotation, which is the basic tenet of SILS. Partial splenectomies can be done with intricate surgical maneuvers made easy. The reduced operating room time and the nearly

Although, it will need more trial for this technique to be worldwide adopted.

invisible scar also improve the pain, hospital stay and post operative complications.

that minimal incision is enough to introduce the hand in the abdominal cavity.

During the laparoscopic surgeries there are many instances where accidents causes oozing of blood and a condition of momentary panic because of either the unsuccessful clamping of vessels or the spillage of resected spleen from the bag and also due to the deprived view of the surgical site. The new idea of HALS (hand assisted laparoscopic surgery) prevents momentary panic and also is an efficient and clever choice. In HALS there is a umbilical incision where lap pad is fixed through which gloved hands are introduced into the abdomen to improve depth perception, regain tactile sensation, aid in tissue extraction, and reduce operative time. There are two to three additional incisions for the trocars. The other hand operates the scalpel and suction. This technique can be considered as the hybrid of laparoscopic and open surgery. The surgery as delicate as spleen has a major hemostatic and technical issues. The direct introductions of hands in conjunction with the advanced laparoscopic instruments have yielded good results. For instance, the panic due to the uncontrolled hemorrhage can be stopped directly with the hands and the spleen remnant in case spillage can easily be obtained. The exact texture of the spleen can be felt and the desired amount retraction can be perfectly attained and not to forget the other hands actively dissecting through the laparoscopic ports. In this technique lap pads are used so

hemostasis, may negate these expenses.

on the mammillary line and a 12mm trocar positioned below the left costal arch on the anterior axillary linea. The surgery by this technique is quite efficient owing to the excellent view of abdominal anatomical landmarks. The resection is very clean and efficient with outstanding hemostasis from the cut surfaces. The 12 mm left umbilical trocar sometimes is replaced by 15mm ones for the introduction of the linear staplers. Surgical adhesives and meshes can be equally used with perfection if required. The surgery with spleen is technically challenging, thus, the electro cautery must be used efficiently with minimizing over use, because its overuse can cause the destruction of splenic parenchyma. The manipulation of the instruments should be with care at the pedicle, which may permanently disrupt the blood flow to the remenant spleen. The camera must be used in conjunction with the operator's maneuvers. The electro cautery can control the hemorrhage to some extent but if the cut surface becomes large then many surgeries are probable of becoming total. The eschar of electrocautery is a clinical concern as it may disrupt after surgery and cause future complications. The eschars at the hilum are more prone to disrupt because of the pressure in the blood vessels and rotation. The control of the suction is equally important as it may sometimes disturb the meshes and eschar.

The use of harmonic scalpel has improved the lapraroscopic surgery, and because of the greater precision near the vital structures it has bought wonders to the spleen preserving surgeries. It has become an important tool in the surgical armamentarium. It doesn't produce noxious smoke plume, which makes the surgeons view even clearer. It also has the additional benefit of minimal, if any, lateral thermal tissue damage that reduces the postoperative sepsis and necrosis. It causes minimal charring and desiccation. The reduced need for ligatures has contributed to the excellent recovery. There is no escharformation, which makes this technique very advantageous as it clearly prevents its disruption, thus preventing postoperative hemorrhage. The introduction of high definition cameras has made the surgeries more vivid.

There is also a new widely adapted plasma scalpel and its use provides excellent results. Its use has the benefit of giving a better precision, which makes this technique highly promising. The comfort and ease with which it dissects the tissues is overwhelming. It nearly gives the surgeon a blood less view of the surgery field. It causes minimum scarring and has the advantage of faster healing which reduces the operating room time. Using plasma scalpel minimizes the instrument changes that are good aspects for surgeons to consider.

Radiofrequency (RF) ablation has recently evolved as a boon to the surgical world. It has advantage over other techniques because it makes the surgery merely bloodless; hence lesser post-operative complication, sepsis, and minimal hospital stay. Recently it was stated that RF is used to coagualate not the tumor itself, but a thin zone of normal organ parenchyma surrounding it, in order to achieve near bloodless division of the parenchyma. However, only case reports and small series have been reported regarding RF-assisted partial splenectomy. It is already successful on liver, brain and lungs and needs more effort, trial and expertise corresponding spleen. The preservation of splenic parenchyma is the requisite in spleen preserving surgeries and hemorrhage is yet another factor governing the success of surgery. The use of laparoscope already has minimized the bleeding, scar, pain and hospital stay and when used in symbiosis with RF ablation will undoubtedly bring better outcome to spleen preserving surgeries.

The argon beam coagulator has good effect on solid organ surfaces such as the spleen. Smoke is minimal as argon gas surrounds the target site. In a laparoscopic adaptation, 5 and

on the mammillary line and a 12mm trocar positioned below the left costal arch on the anterior axillary linea. The surgery by this technique is quite efficient owing to the excellent view of abdominal anatomical landmarks. The resection is very clean and efficient with outstanding hemostasis from the cut surfaces. The 12 mm left umbilical trocar sometimes is replaced by 15mm ones for the introduction of the linear staplers. Surgical adhesives and meshes can be equally used with perfection if required. The surgery with spleen is technically challenging, thus, the electro cautery must be used efficiently with minimizing over use, because its overuse can cause the destruction of splenic parenchyma. The manipulation of the instruments should be with care at the pedicle, which may permanently disrupt the blood flow to the remenant spleen. The camera must be used in conjunction with the operator's maneuvers. The electro cautery can control the hemorrhage to some extent but if the cut surface becomes large then many surgeries are probable of becoming total. The eschar of electrocautery is a clinical concern as it may disrupt after surgery and cause future complications. The eschars at the hilum are more prone to disrupt because of the pressure in the blood vessels and rotation. The control of the suction is equally important as it may

The use of harmonic scalpel has improved the lapraroscopic surgery, and because of the greater precision near the vital structures it has bought wonders to the spleen preserving surgeries. It has become an important tool in the surgical armamentarium. It doesn't produce noxious smoke plume, which makes the surgeons view even clearer. It also has the additional benefit of minimal, if any, lateral thermal tissue damage that reduces the postoperative sepsis and necrosis. It causes minimal charring and desiccation. The reduced need for ligatures has contributed to the excellent recovery. There is no escharformation, which makes this technique very advantageous as it clearly prevents its disruption, thus preventing postoperative hemorrhage. The introduction of high definition cameras has

There is also a new widely adapted plasma scalpel and its use provides excellent results. Its use has the benefit of giving a better precision, which makes this technique highly promising. The comfort and ease with which it dissects the tissues is overwhelming. It nearly gives the surgeon a blood less view of the surgery field. It causes minimum scarring and has the advantage of faster healing which reduces the operating room time. Using plasma scalpel minimizes the instrument changes that are good aspects for surgeons to

Radiofrequency (RF) ablation has recently evolved as a boon to the surgical world. It has advantage over other techniques because it makes the surgery merely bloodless; hence lesser post-operative complication, sepsis, and minimal hospital stay. Recently it was stated that RF is used to coagualate not the tumor itself, but a thin zone of normal organ parenchyma surrounding it, in order to achieve near bloodless division of the parenchyma. However, only case reports and small series have been reported regarding RF-assisted partial splenectomy. It is already successful on liver, brain and lungs and needs more effort, trial and expertise corresponding spleen. The preservation of splenic parenchyma is the requisite in spleen preserving surgeries and hemorrhage is yet another factor governing the success of surgery. The use of laparoscope already has minimized the bleeding, scar, pain and hospital stay and when used in symbiosis with RF ablation will undoubtedly bring

The argon beam coagulator has good effect on solid organ surfaces such as the spleen. Smoke is minimal as argon gas surrounds the target site. In a laparoscopic adaptation, 5 and

sometimes disturb the meshes and eschar.

made the surgeries more vivid.

better outcome to spleen preserving surgeries.

consider.

10mm diameter (disposable) probes are employed. It provides an optimum hemostasis. Argon beam coagulator uses a no-touch technique, and the stream of argon gas, as it conducts the electrical energy, simultaneously has a" blast" effect on the target tissues, momentarily blowing away blood, fluid, and debris for more efficient coagulation. The electrical generator is inexpensive but the electrode tips are relatively expensive, requiring frequent replacement. However, the efficacy of the argon beam coagulator, with its potential for a reduction of operating room time and its efficient achievement of (otherwise tedious) hemostasis, may negate these expenses.

The laparoscopic techniques have bought about essential changes in the surgery and have given a different vision and most importantly precision. The innovative robotic technologies at some centers are used in conjunction with laparoscopy. The use of robotic cameras have added the function of zoom in and zoom out and the 180 degree view have provided surgeons with the desired angle to see splenic pedicle and surrounding landmarks. Robotic cauteries, cameras can also be used with joysticks and voice activation so in delicate moments like achieving hemostasis during pedicle dissection, The surgeons just have to give a command to get the exact view thus saving time manpower and with ease. There are many centers using the davinci system to perform procedures asdelicate as splenectomies. Although, it will need more trial for this technique to be worldwide adopted.

Not only the tools to obtain optimum results during the surgeries are evolving but also the laparoscopic surgery have also evolved. The minimal invasive is on a path of becoming even more minimal. The technique like SILS (single incision laparoscopic surgery) has bought revolution in the laparoscopic world. There are many literatures world wide showing the use of SILS for partial splenectomies. This technique in particular draws lot of attention owing to the fact that it's used through single trocar introduced through a small umbilical incision. From a single port three to four instruments as camera, scalpel, suction can be introduced and operated. The instruments have a multiple operating and viewing angles so the surgery doesn't need many ports. The tips of the instruments are available with multiple degree of rotation, which is the basic tenet of SILS. Partial splenectomies can be done with intricate surgical maneuvers made easy. The reduced operating room time and the nearly invisible scar also improve the pain, hospital stay and post operative complications.

During the laparoscopic surgeries there are many instances where accidents causes oozing of blood and a condition of momentary panic because of either the unsuccessful clamping of vessels or the spillage of resected spleen from the bag and also due to the deprived view of the surgical site. The new idea of HALS (hand assisted laparoscopic surgery) prevents momentary panic and also is an efficient and clever choice. In HALS there is a umbilical incision where lap pad is fixed through which gloved hands are introduced into the abdomen to improve depth perception, regain tactile sensation, aid in tissue extraction, and reduce operative time. There are two to three additional incisions for the trocars. The other hand operates the scalpel and suction. This technique can be considered as the hybrid of laparoscopic and open surgery. The surgery as delicate as spleen has a major hemostatic and technical issues. The direct introductions of hands in conjunction with the advanced laparoscopic instruments have yielded good results. For instance, the panic due to the uncontrolled hemorrhage can be stopped directly with the hands and the spleen remnant in case spillage can easily be obtained. The exact texture of the spleen can be felt and the desired amount retraction can be perfectly attained and not to forget the other hands actively dissecting through the laparoscopic ports. In this technique lap pads are used so that minimal incision is enough to introduce the hand in the abdominal cavity.

Spleen Preserving Surgery and Related Laparoscopic Techniques 203

liquids should not be used in the area where the laser is used. All dry materials in or near the operative field must be dampened with saline or water that makes the process more

The argon beam coagulator has its advantages of its own in giving a competent hemostasis with its "blast effect" which blows away the debris and coagulated blood for excellent hemostasis. It has very good results for splenic abscess as it has a large oozing surface. The major concern in this technique is the potential of gas embolism during the laparoscopic surgery. So the ultrasonography and ECG is constantly needed to check if the embolism has

The minimal invasive surgery has become more minimal with SILS. The cameras,suction and cutting shears all fit through one trocar. The single port for the trocar has laparosonic cutting shears (LCS) and the cameras also have all round vision, which makes this method promising. It has single small incision, therefore less invasive and traumatic. Like every technique has its advantage and disadvantages. SILS is not very efficient if the tumor size is large. It is a good option only for the spleens with normal size or only slightly enlarged. Because of the single small incision the macerated spleen is liable to spillage. In case of sudden bleeding it is difficult to control the hemostasis and still needs ergonomic improvement. The fulcrum effect should be minimized to make this technique better so robotic zoom in and zoom out cameras can be a good replacement. The hybrid technique as HALS has eliminated many shortcomings from the laparoscopic surgery. Since, one hand is inside the abdominal cavity it gives perfect retraction and uninterrupted view. The margin of tumor can be felt so dissection margin can be precise without hampering the normal spleen parenchyma. The bleeding site can be actively clamped with just a move of a finger. The splenic parenchyma is frail and the use of hands directly to retract can certainly circumvent bleeding and improper traction. There are many instances in spleen preserving surgeries when the macerated spleen within the bag gets spilled in the abdominal cavity so its recovery is quicker as the spleen gets implanted very soon. This technique can be very efficient in blunt trauma cases when laparotomy is urgently required. The camera in the other hand can work in conjunction with the hand to explore the abdominal cavity. This technique is irrespective of the size of spleen because even the bigger spleen can be handled with care and taken out without spillage and optimum safety. The pitfalls of HALS are the

air leakage from the lap pads and the hands getting tired in 20% of the surgeons.

adherence, eschar formation, sepsis, and necrosis should be employed.

A laparoscopic spleen preserving surgery as aforementioned is a technically demanding procedure. The spleen parenchyma is frail and the tears or the parenchymal bleeding can occur. Thus, from a surgeon's point of view it requires exquisite care and control to avoid parenchymal rupture and cell spillage. There are many techniques available to do the same procedure in a logical and proficient way. The surgeons must be familiar with all the details and complications before choosing for one. Every technique has a virtue of its own over the other, so it is vital to discriminate techniques to choose the ideal one. The need of the laparoscopic surgery must be understood with the operative time and cost in mind. The postoperative outcome is the most important part of perioperative care and in the abdominal surgeries as spleen; adhesion is serious complication that affects the motility of abdominal structures later on. The complication as eschar formation, which may disrupt postoperatively is capable of causing bleeding. Thus, the technique that offers minimum

reached the heart and lungs to prevent further damages.

tedious.

**6. Conclusion** 
