Robot-assisted Partial Splenectomy

We present a case report of a Robot-assisted Partial Splenectomy. Partial splenectomy has emerged as a viable alternative for the management of benign splenic lesions, aiming to preserve immunological function. Robotic-assisted surgery facilitates it by providing three-dimensional visualization, precise dissection, leading to improved hemostatic control.

This case involves a 38-year-old woman whose splenic lesion gradually increased in size on ultrasound over two years. It was later identified as a SANT on CT during follow-up with no associated symptoms. Preoperative imaging revealed an exophytic lesion on the anterior surface of the spleen measuring 4.0 centimeters.

Written informed consent was obtained. All procedures complied with human welfare guidelines, including the Declaration of Helsinki. The patient is placed in a right lateral decubitus position with the left arm abducted to optimize exposure of the surgical field.

After interflation, four robotic trocars of 8 millimeters and two assistant trocars are placed as shown in the image. Surgery begins. R1 holds a bipolar forceps, R2 the camera, R3 a cautery hook, and R4 are cadiere forceps.

A1 holds a laparoscopic harmonic scalpel and A2 a laparoscopic forceps. Spleen mobilization begins with detachment of the hepatic flexor of the colon using the robotic cautery hook on arm 3 and the laparoscopic harmonic scalpel controlled by the tableside surgeon. We continue with the division of the splenic colic, gastrosplenic and phrenosplenic ligaments in order to provide access to the splenic hilum.

During the division of the gastrosplenic ligament, the short gastric vessels are carefully transected to fully mobilize the spleen. Finally, the phrenosplenic ligament is divided to complete the mobilization of the spleen and allow unobstructed access to the hilum. A 10 centimeters long length vessel loop is placed around the splenic hilum to have complete in and out flow control.

At this time, all vascular connections between spleen and stomach have already been transected. After complete mobilization of the spleen, the lesion is identified at its inferior pole. An intraoperative ultrasonography is performed by introducing the ultrasound probe through an assistant port and identify the splenic lesion.

The tumor margins are demarcated using the cautery hook. Three splenic pedicles were identified as noticed previously on the CT.Before proceeding with dissection, the pancreatic tail is identified to avoid inadvertent injury. The inferior splenic pedicle is then dissected and its vascular branches are selectively isolated using the robotic cautery hook on arm 3 and the laparoscopic harmonic scalpel.

The splenic vein of the inferior pedicle is carefully dissected and isolated. Once adequately exposed, it is ligated using Hem-o-lok clips to ensure secure vascular control. The splenic artery of the inferior pedicle is isolated and exposed.

After clear identification, it is clipped using Hem-o-lok clips to achieve effective arterial control and minimize the risk of intraoperative bleeding. The remaining vascular elements of the inferior splenic pedicle are carefully isolated. Once adequately exposed, they are ligated using Hem-o-lok clips to ensure secure vascular control.

The area of macroscopic splenic ischemia is demarcated using the cautery hook. A bulldog clamp is applied to the splenic hilum before parenchyma transection by the tableside surgeon. Due to incomplete splenic ischemia following hilar clamping, the lesser sac is accessed to expose the splenic artery.

Although optional, this step provides enhanced vascular control in cases of incomplete ischemia and helps anticipate potential bleeding complications. The splenic parenchyma is transected with a tumor free margin using the laparoscopic harmonic scalpel controlled by the tableside surgeon. The hemostasis is achieved using a bipolar forceps on robotic arm 1.

During parenchymal transection, the surgeon follows the demarcated ischemic line with precision to avoid injury to adjacent vascular structures. This step is crucial to preserve as much viable splenic parenchyma as possible, maintaining sufficient tissue volume to support immunological function postoperatively. A dry hemostatic patch is placed over the splenic parenchymal transection site.

One wet 10 x 10 centimeters gauze is placed on top and remove the gauzes after the 3rd of minutes. The resected splenic specimen is carefully extracted through the assistant trocar using an endoscopic retrieval bag. After removal of both bulldog clamps, adequate perfusion of the remaining spleen is confirmed.

The remaining spleen is fixed in position using an absorbable 4-0 polyglactin suture to prevent rotation or ischemia. The postoperative course was uneventful and was discharged in good condition on postoperative day three. Histology revealed angiomatoid nodular structures.

Immunohistochemistry was positive for Factor VIII and showed low Ki67 expression. Findings consistent with SANT. In conclusion, robotic-assisted PS emerges as a safe and effective surgical strategy for the management of benign splenic tumors, such as SANT.

It integrates the benefits of minimally invasive surgery with the precision and dexterity of robotic technology. However, further studies and long-term follow-up are warranted to validate the adoption of this approach in clinical practice.