**Immunity**

The spleen richly contains T cells, B cells, K cells, macrophages/monocytes, natural killer cells, killer cells, lymphokine-activated killer (LAK) cells, dendritic cells and so forth, and in conjunction with a variety of immune factors to makes in vivo immune response. Tuftsin is a tetrapeptide produced by the spleen to stimulatepha- gocytosis through the activation of neutrophils, it is a typical anti-tumor substance in the spleen, and can reflect the spleen function. Spleen tyrosine kinase (SYK) is a non-receptor tyrosine kinase, initially expressed in the spleen hematopoietic cells. SYK plays an important role in the Fc-mediated phagocytosis, B cell receptor signal transduction, cytokine secretion, and integrin-mediated signal transduction.

### **Barrier function**

Weiss first proposed in 1986 that there is a blood-spleen barrier (BSB) between the artery and vein in the spleen, which is similar to blood-brain barrier and can filter Plasmodium falciparum-infected red blood cells. Jiang and Zhu et al respectively made their study on rat spleens and set up the concept and architecture of the BSB: The blood-spleen barrier (BSB) is located in the marginal zone of the spleen, which lies at the periphery of the white pulp;

Spleen Preserving Surgery and Related Laparoscopic Techniques 197

damages; so there is a need to make a revision and improvement according to actual

a)

b)

c) Fig. 1. a) spleen artery is divided four branches into different segment , b) the anatomic basis

of preseving spleen , c) model of spleen vessels

situation in clinical work to adjust the treatment.

This is a biological barrier containing sinus-lining endothelial cells, basement membrane, macrophages, reticular cells, reticular fibers (reticular tissue), and collagen fibers.

#### **Endocrine function**

As an important immune organ, the spleen also has an endocrine function, and is an important part of the immuno–neuro–endocrine modulation system in the body. Normal spleen may secrete erythropoietin, colony-stimulating factor, thyroid–stimulating hormone, gonadotropin, growth hormone, etc.

Through the nineteenth and twentieth century splenectomy had been successfully performed for trauma and hypersplenism. It was observed that the patients recovered to their usual pursuits but the life-long probability of the infection, augmented rate of long-term thromboembolic complications, enhanced arteriosclerosis, and late coronary artery disease could not be ignored and the long-term survival seemed skeptic. It's obvious that the knowledge of spleen function is getting more apparent and deep. Its importance in the host defense and immune function is absolutely undisputed. So the surgeons and researchers came up with the notion of preserving the spleen. To the matter of fact this conception didn't go in vain as it has been established now that that the preservation of at least 25% of the splenic parenchyma ensures an adequate short and long-term splenic function.

The anatomy of the spleen and its surrounding structures is indispensible. At the spleen hilum, all the vascular structures enter and divide to the related poles. Sometimes in patients the vessels divide into three branches thus any injury at the pedicle can result in the ischemia to the part supplied by the other branches(figure 1). Since, there is an ample amount of blood flow through the spleen. So, if the flow is interrupted to the part not being dissected "reperfusion injury" should be well thought-out. If the crisis is in the superior or inferior pole the dissection is not to difficult compared to the crisis at the hilum. The hilum also has the pancreatic tail landing on it; therefore, the activities at the hilum must be with care and precision so as not to injure pancreas. While draining the abscess there is an increased risk of the content to leak and reach the peritoneal cavity that is probable to cause sepsis around. Before starting the dissection of the splenic tissue, its abdominal adherence should be resected with care and after the surgery the remenant spleen should be place carefully to the left upper quadrantto avoid rotation, which further can re-open the cut surface and vessels. The size, location of cysts, abscess, hemangioma and trauma plays an essential role in the decision for choosing the best-suited technique.

#### **Spleen injury scale**

At present, there are dozens of methods for spleen injury scaling. Main methods include Schackford Grade V (1981), Feliciano Grade V(1985), Gall & Scheele Grade IV(1986), Uranus Grade V(1990), American Association for the Surgery of Trauma(AAST, 1994 Revision) Grade V, and Patcher Grade IV(1998) and so on. These methods have different characteristics, but sometimes cannot effectively guide clinical work and operation. The 6th National Symposium on Spleen Surgery of China held in September 2000 in Tianjin adopted the spleen injury scale criteria as below. Grade I: subcapsular splenic rupture whose length ≤ 5.0cm & depth ≤ 1.0cm shown in the surgery. Grade II: the length of the spleen laceration≥5.0cm & depth ≥ 1.0cm, but the splenic hilum is not involved, or segmental splenic vessels are injured. Grade III: splenic rupture involves into splenic hilum, or partial spleen is broken apart, or spleen trabecular vessels are injured. Grade IV: extensive rupture exists in the spleen, or there is an injury in splenic pedicle, and main veins and arteries. Such scaling method helps to quickly determine the injury condition, but cannot cover all

This is a biological barrier containing sinus-lining endothelial cells, basement membrane,

As an important immune organ, the spleen also has an endocrine function, and is an important part of the immuno–neuro–endocrine modulation system in the body. Normal spleen may secrete erythropoietin, colony-stimulating factor, thyroid–stimulating hormone,

Through the nineteenth and twentieth century splenectomy had been successfully performed for trauma and hypersplenism. It was observed that the patients recovered to their usual pursuits but the life-long probability of the infection, augmented rate of long-term thromboembolic complications, enhanced arteriosclerosis, and late coronary artery disease could not be ignored and the long-term survival seemed skeptic. It's obvious that the knowledge of spleen function is getting more apparent and deep. Its importance in the host defense and immune function is absolutely undisputed. So the surgeons and researchers came up with the notion of preserving the spleen. To the matter of fact this conception didn't go in vain as it has been established now that that the preservation of at least 25% of the splenic

The anatomy of the spleen and its surrounding structures is indispensible. At the spleen hilum, all the vascular structures enter and divide to the related poles. Sometimes in patients the vessels divide into three branches thus any injury at the pedicle can result in the ischemia to the part supplied by the other branches(figure 1). Since, there is an ample amount of blood flow through the spleen. So, if the flow is interrupted to the part not being dissected "reperfusion injury" should be well thought-out. If the crisis is in the superior or inferior pole the dissection is not to difficult compared to the crisis at the hilum. The hilum also has the pancreatic tail landing on it; therefore, the activities at the hilum must be with care and precision so as not to injure pancreas. While draining the abscess there is an increased risk of the content to leak and reach the peritoneal cavity that is probable to cause sepsis around. Before starting the dissection of the splenic tissue, its abdominal adherence should be resected with care and after the surgery the remenant spleen should be place carefully to the left upper quadrantto avoid rotation, which further can re-open the cut surface and vessels. The size, location of cysts, abscess, hemangioma and trauma plays an

At present, there are dozens of methods for spleen injury scaling. Main methods include Schackford Grade V (1981), Feliciano Grade V(1985), Gall & Scheele Grade IV(1986), Uranus Grade V(1990), American Association for the Surgery of Trauma(AAST, 1994 Revision) Grade V, and Patcher Grade IV(1998) and so on. These methods have different characteristics, but sometimes cannot effectively guide clinical work and operation. The 6th National Symposium on Spleen Surgery of China held in September 2000 in Tianjin adopted the spleen injury scale criteria as below. Grade I: subcapsular splenic rupture whose length ≤ 5.0cm & depth ≤ 1.0cm shown in the surgery. Grade II: the length of the spleen laceration≥5.0cm & depth ≥ 1.0cm, but the splenic hilum is not involved, or segmental splenic vessels are injured. Grade III: splenic rupture involves into splenic hilum, or partial spleen is broken apart, or spleen trabecular vessels are injured. Grade IV: extensive rupture exists in the spleen, or there is an injury in splenic pedicle, and main veins and arteries. Such scaling method helps to quickly determine the injury condition, but cannot cover all

macrophages, reticular cells, reticular fibers (reticular tissue), and collagen fibers.

parenchyma ensures an adequate short and long-term splenic function.

essential role in the decision for choosing the best-suited technique.

**Endocrine function** 

**Spleen injury scale** 

gonadotropin, growth hormone, etc.

damages; so there is a need to make a revision and improvement according to actual situation in clinical work to adjust the treatment.

a)

b)

c)

Fig. 1. a) spleen artery is divided four branches into different segment , b) the anatomic basis of preseving spleen , c) model of spleen vessels

Spleen Preserving Surgery and Related Laparoscopic Techniques 199

Carroll et al reported the laparoscopic splenectomy for the first time in 1992. Since then, the laparoscopic surgery has extended to the traditional fields covered by laparotomy, e.g. spleen adhesion, splenorrhaphy, artery ligation, partial splenectomy and the like, and has been combined with such new techniques as LigaSure, splenic arterial embolization, CUSA, radiofrequency ablation, thus adding a new vitality to the spleen-preserving surgery. The laparoscopic spleen-preserving surgery is somehow difficult, time-consuming, and costly. However, when compared to laparotomy, this surgery has more advantages, for example,

Laparoscopic inspection: To determine the extent and scope for splenic injuries or lesions; to understand injuries or lesions in the surrounding tissues or organs of spleen; to judge the extent for the bleeding area and vascular injuries; to carry out the pathological examination

The laparoscopic spleen-preserving surgery has the following indications: Grade I-II splenic injuries with hemodynamic and vital sign stability; local benign lesions in the spleen, e.g. splenic cyst, splenichemangioma, echinococcosis, and etc.; hypersplenia, e.g. portal vein hypertension, hereditary spherocytosis and etc.; perisplenic tumors, e.g. pancreatic tumor, gastric cancer and etc.; splenic congenital diseases, e.g. splenectopia, accessory spleen and so on. Contraindications: Grade IVsplenic injuries; severe portal hypertension; splenomeglia;

1. For Grade I spleen injuries, the bleeding can be controlled by electric coagulation, biological glue, fibrin and the like. For Grade II spleen injuries, the following methods are adopted: splenorrhaphy, partialsplenectomy, splenic artery ligation and the like. For Grade III spleen injuries, the following methods are adopted: partialsplenectomy, and

4. The spleen can be conserved through laparoscopic resection for perisplenic tumors. 5. For splenectopia, the laparoscopic fixation can be conducted. For accessory spleen, the

In the laparoscopic spleen-preserving surgery, the complications include hemorrhage,

The laparoscopic spleen-preserving surgery is still in trial stage, and its efficacy is uncertain. Clinically, we should not blindly pursue new technology ignoring its efficacy; instead, we should never forget the damage control principles for splenic surgery, always save life first,

In the current study, the spleen function is not very clear, but we begin to know it can play an important role in human body. Spleen-preserving surgeries have been widely implemented. Moreover, the extensive laparoscopic application has brought new

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

opportunities, making the future splenic surgery more scientific and reasonable.

clear operative field, minimal invasion, rapid recovery, and short hospital stay.

for the spleen or the surrounding tissues and organs under direct vision biopsy.

**3. Laparoscopic surgery in spleen-preserving surgery** 

The spleen-preserving surgery is similar to the laparotomy:

2. For splenic benign lesions, the laparoscopic resection is conducted. 3. For hypersplenia, the laparoscopic partial splenectomy is conducted.

severe coagulopathy.

splenic artery ligation etc.

and then deal with the injury.

**4. Techniques** 

laparoscopic resection can be conducted.

visceral injury, infection, splenic vein thrombosis and so on.

The spleen preserving surgeries of course was the remedy for many complications but with the open nature of surgery came handful of post operative complication like infection, delayed healing which at times altered the well being of the patients and "yes" the recovery. It's evident that the spleen preserving surgeries have been evolving through decades (figure2). It's apparent that the advents of novel laparoscopic techniques have opened new gates to the spleen preserving surgeries. The dawn of nineteenth century could see the concept of laparoscopic partial splenectomy blooming and by late nineties many centers around the world adapted it as a routine procedure. Surgery is an evolving science and in recent times there are several pioneering techniques that have minimized the technical flaws and surgical outcomes.

a)

b)

Fig. 2. a) remnant spleen section after partial splenectomy , b)conservation of the spleen with distal pancreatetomy

The spleen preserving surgeries of course was the remedy for many complications but with the open nature of surgery came handful of post operative complication like infection, delayed healing which at times altered the well being of the patients and "yes" the recovery. It's evident that the spleen preserving surgeries have been evolving through decades (figure2). It's apparent that the advents of novel laparoscopic techniques have opened new gates to the spleen preserving surgeries. The dawn of nineteenth century could see the concept of laparoscopic partial splenectomy blooming and by late nineties many centers around the world adapted it as a routine procedure. Surgery is an evolving science and in recent times there are several pioneering techniques that have minimized the technical flaws

a)

b) Fig. 2. a) remnant spleen section after partial splenectomy , b)conservation of the spleen

and surgical outcomes.

with distal pancreatetomy
