Laparoscopic Unroofing of Splenic Cysts
Marco Decurtins, Duri Gianom
Indications and Contraindications
Indications
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Nonparasitic cyst >5cm with and without symptoms
Nonparasitic cyst <5cm with symptoms
Parasitic cyst
Cyst-related complications (spontaneous or traumatic rupture, abscess formation)
Neoplastic cysts
Preoperative Investigations/Preparation
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Serological testing for echinococcus
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SECTION 7
Spleen
Procedure
STEP 1
Access and insertion of trocars
The patient is positioned in a 45-degree right lateral position. The surgeon and the
camera assistant stand at the patient’s abdominal side, video-monitor on the opposite
site. The first trocar (umbilical, 12mm) is inserted in an open technique (T1) and the
pneumoperitoneum (14mmHg) is introduced.
Further trocars are inserted under visual control in the left lower abdomen (T2, 10mm)
and in the left midaxillary line just below the costal margin (T3, 10mm). If needed,
additional trocars are placed semicircularly in relation to the spleen (dotted line).
STEP 2
Aspiration of the cyst contents and resection of the cyst wall
The cyst is opened in an avascular region with electrocautery and the contents aspired.
The adhesions to the surrounding tissue are dissected and the spleen needs to be
completely mobilized as for a laparoscopic splenectomy. Care should be taken with the
diaphragmatic adhesions, which can be particularly dense.
Laparoscopic Unroofing of Splenic Cysts
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STEP 3
The cyst wall is unroofed using diathermy or harmonic shears until unaffected splenic
parenchyma is reached. During the resection of the cyst, meticulous hemostasis is
important to prevent impairment of the view. To minimize the risk of recurrence, the
largest possible amount of cyst wall should be resected.
The excised tissue is placed in an endoscopic plastic bag and removed.
When technically feasible, an omentum patch is placed in the remaining cyst cavity
and the trocar incisions are closed without drainage.
982
SECTION 7
Spleen
Postoperative Tests
See chapter “Open Splenectomy.”
Postoperative Complications
See chapter “Open Splenectomy.”
■ Cyst recurrence
Tricks of the Senior Surgeon
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Complete mobilization of the spleen prior to resection of the cyst wall is
imperative.
To reduce the risk of bleeding, use dissection with a stapler device in situations
where the cyst wall is covered with normal splenic parenchyma. This is especially
useful in the region of splenic hilus.
Use an open approach in parasitic and neoplastic cysts.