Laparoscopic management of a splenic injury during redo bariatric surgery

Gastric bypass for morbid obesity is a well standardized procedure but in case of previous surgery, perioperative challenging complications may occur. This is the case of a female patient who benefited from a gastric band removal 2 months ago because of band’s failure. The video shows the management of a splenic injury.

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Laparoscopic management of a splenic injury during redo bariatric surgery

Authors

V Podelski, M Vix, J Marescaux

Abstract

Gastric bypass for morbid obesity is a well standardized procedure but in case of previous surgery, perioperative challenging complications may occur. This is the case of a female patient who benefited from a gastric band removal 2 months ago because of band’s failure. The video shows the management of a splenic injury.

Classification

tips and tricks

Keywords

Laparoscopic management, splenic injury, redo bariatric surgery

Media type

Surgical video

Duration

05'45''

Publication

2011-05

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E-publication

WeBSurg.com, May 2011;11(05).
URL: http://www.websurg.com/doi-vd01en3291.htm

Laparoscopic management of a splenic injury during redo bariatric surgery

1. Introduction 00'22''

This is the case of a female patient who benefited from a gastric band removal 2 months ago because of band’s failure.

2. Dissection of adhesions 00'30''

Access is made back into the operative field in order to perform a Roux-en-Y gastric bypass. The usual gastro-hepatic adhesions are found again. They join the anterior aspect of the stomach with the inferior aspect of the liver. This region is dissected and adhesions are taken down in order to identify the left crus of the diaphragm. This dissection is carried out cautiously rather in contact to the inferior surface of the liver so as to avoid any serosal or muscular injury to the stomach.

3. Dissection of cardial region 01'14''

The region of the cardia is approached slowly. As can be seen here, the spleen lies closely to the left crus. Once the left crus has been identified, the opening of the lesser sac is initiated after controlling the area of the stomach where the staple lines will be applied. The lesser omentum is opened as close to the lesser curvature as possible. This opening is made cautiously as it is meant to keep as much vascularization as possible at the internal part of the stomach. Dissection is performed at the posterior part of the stomach in order to achieve a retrogastric tunnelization through the lesser sac. A few adhesions may be observed here. They may originate from previous procedures.

4. Creation of gastric pouch 02'15''

Once the tunnelization has been achieved, division of the stomach is begun using an Endo-GIA linear stapler, blue cartridge, 60mm. The objective is to create a relatively small pouch about 45 to 50 cc. The first Endo-GIA stapler is applied. A small bleeding is cauterized through the application of a bipolar forceps. Dissection is then pursued towards the cardia and a second Endo-GIA linear stapler (60mm) is applied. Dissection is continued until reaching the superior portion of the stomach. A second row of staples is applied vertically and there remains a small gastric tunnel at the superior part. It will be divided using the Endo-GIA linear stapler. One may be surprised to find such a massive bleeding in this region.

5. Bleeding observation 03'12''

Naturally, one may observe some oozing at the level of the different staple lines, but the problem seems to originate either from the anterior aspect of the liver, or from the spleen. No direct splenic laceration can be found. The liver is retracted and shows no massive bleeding. Aspiration is pursued so as to search for the cause of this bleeding. It can be found on an omental fold that is stuck to the inferior surface of the spleen. Bipolar coagulation hemostasis is decided upon instinctively. The quality of the hemostasis is poor, as there is too much blood in the area for bipolar cautery to work appropriately. Decision is made to use the same swab that had been previously used for retraction purposes so as to achieve compression in the region. Aspiration is then carried out in contact to this region. The swab is left in place for 20 minutes and then removed.

6. Identification and control of splenic laceration 04'17''

The splenic laceration is now well identified. It has been almost coagulated. Hemostasis is achieved almost spontaneously. The bipolar forceps is applied, and a new swab is placed for compression purposes until the end of the procedure. The procedure is carried on back in the same region in order to control that the hemostasis is definitive. The bipolar forceps is used again so that the region is completely dry. No other hemostasis technique is required in this patient, since compression and bipolar forceps have allowed for a satisfactory hemostasis. There is no risk of subcapsular splenic hematoma in this case, as the capsule has been opened and hemostasis has been carried out inside the parenchyma. The gastrojejunal anastomosis can be seen here in the foreground. A drainage is left in place. The postoperative period is uneventful. An ultrasonography is carried out a few days after the procedure. No subcapsular splenic hematoma is found.