Management of a splenic hemorrhage during mobilization of the left colon

Bleeding-related complications during the mobilization of the splenic flexure via a laparoscopic approach during left colon and rectum surgery are rare. This video shows how to manage a bleeding due to a decapsulation of the inferior pole of the spleen.

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Management of a splenic hemorrhage during mobilization of the left colon

Authors

J Leroy, F Costantino, J Marescaux

Abstract

Bleeding-related complications during the mobilization of the splenic flexure via a laparoscopic approach during left colon and rectum surgery are rare. This video shows how to manage a bleeding due to a decapsulation of the inferior pole of the spleen.

Classification

tips and tricks

Keywords

Management, splenic hemorrhage during mobilization, left colon

Media type

Surgical video

Duration

07'50''

Publication

2009-09

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E-publication

WeBSurg.com, Sept 2009;9(09).
URL: http://www.websurg.com/doi-vd01en2729.htm

Management of a splenic hemorrhage during mobilization of the left colon

1. Introduction 00'08''

As various articles in the literature suggest, it is rare for bleeding-related complications to occur during the mobilization of the splenic flexure via a laparoscopic approach during left colon and rectum surgery. In this video, we see a mobilization of the splenic flexure being performed through a medial approach.

2. Medial approach for transverse mesocolon dissection 00'27''

The first step is to dissect the transverse mesocolon’s root off the anterior aspect of the pancreas at the level of the body and tail of the pancreas. This is performed after dividing the inferior mesenteric vessels and opening the lesser omental sac.

3. Dissection of the left transverse colon insertion 00'44''

As we can see on these pictures, the anterior traction on the mesocolon, the transverse colon and the descending colon allows to get good exposure of the left transverse colon’s root insertion point. The root is divided and, as we can see here, this division can be continued via a posterior approach up to the insertion point onto the diaphragm, an approach that allows to visualize the spleen.

4. Lateral dissection 01'12''

However, it is unwise to continue this dissection without a complete view of the lateral attachments; this is why the mobilization is continued through a lateral approach and the phrenicocolic attachments are divided on the descending portion of the splenic flexure. Using a cephalad approach, the omental attachments on the transverse colon are then divided: this allows to perform a division of the colo-omental attachments. This division is performed with a monopolar electrode using ValleyLab current in order to achieve an elective dissection of the splenic flexure.

5. Dissection of the omental attachments 02'45''

We continue the division of the omental attachments on the external aspect of the left transverse colon.

6. Spleen decapsulation 02'52''

Once the splenic flexure has been entirely freed of its posterior and anterior attachments, we check the splenic region and we are surprised to see a decapsulation of the spleen’s inferior pole accompanied by a hemorrhagic oozing. We first use a dry gauze to control the bleeding as it allows to clean the area and find out just how important the bleeding is.

7. Hemostasis using the Tachosil mesh 03'30''

After a few minutes, the gauze is full of blood and we decide to perform a hemostasis by using a hemostatic absorbable mesh, in this case the Tachosil®, that was rolled into a dry gauze to be applied easily in the abdominal cavity: this is a very convenient tip in laparoscopic surgery. To avoid detachment during the manipulation, it is preferable to cover the Tachosil® by a wet gauze as is done here, which allows a more anatomical application on the organ to cauterize. Here we see the Tachosil®, which is being applied on the lower pole of the spleen where the decapsulation had caused the bleeding. We then wait for several minutes, and realize that the bleeding has stopped and maintain the Tachosil® as it is for 15 minutes.