Robotic Assisted Laparoscopic Splenic Artery Aneurysm Resection

Summary

Splenic artery aneurysms (SAA) are recognized as the most common type of visceral artery aneurysms, comprising approximately 60% of such cases. Historically, the management of SAA has included open surgical, endovascular, or non-operative management. This paper describes a robotic-assisted laparoscopic surgical technique for splenic artery aneurysm resection.

Abstract

Splenic artery aneurysms (SAA) are the most common visceral aneurysm and may develop significant risk for rupture and life-threatening complications when more than 3 cm, in pregnancy, or if resembling pseudoaneurysms. Traditional treatment options of open surgical repair and endovascular repair have been extensively studied, but the role of robotic-assisted laparoscopic surgery in definitively managing SAA is emerging as a promising minimally invasive alternative in select pathology. This case aims to present the technical details, challenges, and outcomes of an SAA in a young woman treated with robotic-assisted laparoscopic resection, highlighting the feasibility and efficacy of this approach. A 38-year-old woman with no significant past medical history was incidentally found to have a distal third splenic artery aneurysm measuring 2.2 cm in diameter and was referred to a vascular surgery clinic for further evaluation. Although she was not pregnant at the time, she was undergoing fertility treatments with plans for assisted pregnancy. She requested definitive aneurysm treatment, wished to avoid multiple interventions, and intended to become pregnant via IVF within the coming year, making repeated axial imaging unsuitable for follow-up. Imaging evaluation revealed the aneurysm sac contained one prominent feeding artery and two highly tortuous draining branches. After providing informed consent, the patient underwent successful robotic-assisted laparoscopic excision of the splenic artery aneurysm. Robotic-assisted laparoscopic surgery represents a valuable approach for the definitive management of distal splenic artery aneurysms or aneurysms involving highly tortuous vessels, conditions historically requiring open surgical ligation, resection, or vascular reconstruction. This paper illustrates how challenging aneurysms can be precisely visualized, dissected, and managed using robotic-assisted laparoscopy with the DaVinci surgical system, highlighting key minimally invasive techniques for optimal exposure and vascular control in splenic artery aneurysm repair.

Introduction

Splenic artery aneurysms (SAA) are recognized as the most common type of visceral artery aneurysms (VAAs), comprising approximately 60% of such cases¹. These aneurysms can carry a significant risk of rupture when meeting size criteria (more than 3 cm) or in pregnancy with an increased plasma volume and cardiac output, leading to potentially life-threatening hemorrhage². Historically, the management of SAA has included open surgical repair and conservative management (non-operative management for patients not meeting size criteria, pseudoaneurysm morphology, or not young fertile women)^3,....

Protocol

The patient provided informed consent to the report of her case details and imaging studies. This study was conducted, and the protocol was written in accordance with the ethical guidelines and regulations of the Houston Methodist Hospital Ethics Committee.

1. Pre-operative planning

1. Obtain complete written informed consent from the patient. Consent should discuss the following: Robotic-assisted laparoscopic splenic artery aneurysm ligation and/or resection, splenic artery reconstruction, conversion to open splenic artery aneurysm resection (laparotomy), splenectomy (total or partial), pancreatic injury repair, b....

Results

The procedure was carried out by a vascular surgeon trained in robotic surgery. The surgical team consisted of the Attending surgeon, a Circulator nurse, a Scrub nurse, and a Surgical Resident. The total operative time was 233 min. The estimated blood loss was 20 mL. There were no intraoperative complications or transfusions. The patient was transferred from the recovery room to the surgical floor with normal range hemodynamics and controlled pain.

Discussion

Laparoscopic and robotic treatments of visceral artery aneurysms (VAA) are described in the literature^12,13,14,15. Still, they historically are limited in daily clinical practice mainly due to limited expertise amongst vascular surgeons and the facility cost of the surgical robots. In addition, endovascular repair continues to represent first-choice management in most cases^16<.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
2-0 Vicryl V-Lock Suture		VLOCM0115
8m endoscope plus, 30 degree	Intuitive Surgical	470057
8mm blunt obturator	Intuitive Surgical	470008
8mm cannula	Intuitive Surgical	470002
BD Bard All-Purpose Red Rubber Unisex, 16FR, Straight	Bard	277716
Bipolar energy instrument cord	Intuitive Surgical	470384
Cadiere Forceps	Intuitive Surgical	471049
Da Vinci Xi surgical robot	Intuitive Surgical	380662-21	Robotic assisted surgical platform
Endo catch specimen retrieval bag	Medtronic	173050G
Fenestrated Bipolar Forceps	Intuitive Surgical	471205
Hot Shears (Monopolar Curved Scissors)	Intuitive Surgical	470179
Laparoscopic 5mm x 100mm Trocar	Ethicon	2B12LT
Laparoscopic Suction Irrigator	Pilling	728145
Large Clip Applier	Intuitive Surgical	470230
Large SutureCut Needle Driver	Intuitive Surgical	471296
Monopolar energy instrument cord	Intuitive Surgical	470383
Permanent Monopolar Cautery Hook	Intuitive Surgical	470183
Snake Liver Retractor 5mm 80mm End	Artisan Medical Devices	SNK-100
Tip-Up Fenestrated Grasper	Intuitive Surgical	470347
Vessel Loop McKesson Mini Red Silicone Radiopaque	McKesson	487858
Vessel Sealer Extend	Intuitive Surgical	480422