How to Preserve the Spleen: Laparoscopic Partial Splenectomy as a Treatment for Splenic Hemangioma

Summary

The surgical protocol describes a laparoscopic partial splenectomy protocol in a 30-year-old female with a splenic hemangioma. The minimally invasive, organ-preserving procedure resulted in minimal blood loss, no complications, and preserved residual spleen perfusion, offering a reproducible approach for benign splenic lesions.

Abstract

Advances in understanding splenic function and the implementation of precision medicine and enhanced recovery after surgery (ERAS) have established laparoscopic partial splenectomy (LPS) as the preferred surgical approach for benign splenic diseases, hematologic diseases involving the spleen, and minor splenic trauma. This technique not only preserves splenic function but also offers advantages, including safety, reduced postoperative pain, and accelerated recovery. The widespread adoption of LPS represents an evolving trend in splenic surgery. A case of a 30-year-old female patient with a splenic hemangioma is presented. Computed tomography (CT) angiography revealed a bifurcated splenic artery. This protocol demonstrates the key steps of a laparoscopic partial splenectomy, with a detailed focus on approach selection, vascular management, parenchymal transection, and wound closure, all performed uneventfully with minimal intraoperative blood loss. Follow-up ultrasonography demonstrated a well-perfused residual spleen. This case highlights the importance of precise preoperative vascular imaging and careful hilar dissection to ensure adequate perfusion of the residual spleen. The stepwise protocol presented here may serve as a practical reference for surgeons performing spleen-preserving laparoscopic procedures.

Introduction

Splenic hemangioma is a common benign tumor of the spleen, predominantly of the cavernous type, followed by capillary hemangioma¹. It has a female predominance, potentially associated with hormonal changes during pregnancy or oral contraceptive use². Splenic hemangiomas exhibit slow growth, yet 2%–10% have a predisposition to spontaneous rupture, potentially leading to massive intra-abdominal hemorrhage and hemorrhagic shock¹. Consequently, precise diagnosis and appropriate management are essential to reduce the risk of rupture and prevent serious complications. With advancements in laparoscopic techniques, laparoscopic splenectomy has undergone significant technical refinement^3,4,5.

Compared with open surgery, laparoscopic splenectomy is associated with reduced surgical trauma, less postoperative pain, and faster recovery^4,5. LPS is primarily indicated for benign focal lesions confined to the upper or lower splenic pole with well-defined vascular boundaries, select hematologic disorders requiring splenic preservation (e.g., hereditary spherocytosis), and localized splenic trauma, whereas contraindications include lesions highly suspicious for malignancy, diffuse or centrally located growth (particularly with hilum involvement that compromises safe vascular dissection), and complex vascular anatomy or tumor blood supply identified on preoperative three-dimensional CT angiography that would preclude preservation of a sufficient functional splenic volume (typically >25%–30%)^4,6,7,8. In these scenarios, total splenectomy is recommended as a more anatomically definitive and procedurally controlled alternative^9,10.

Historically, total splenectomy was the standard approach despite the high risk of overwhelming post-splenectomy infection (OPSI)¹¹. Greater recognition of splenic immune function has shifted the clinical preference toward partial splenectomy, particularly for lesions localized to the poles. In patients with a Type I (distributed) arterial pattern and limited intersegmental anastomoses, ligating a segmental branch creates a distinct ischemic demarcation line, providing the anatomical basis for precise, parenchyma-preserving resection⁶. Therefore, laparoscopic partial splenectomy is a viable surgical option for benign splenic tumors located at the superior or inferior poles of the spleen^7,8. Several studies have reported favorable outcomes of laparoscopic partial splenectomy compared with total splenectomy^9,10.

This protocol presents a case of a 30-year-old female patient in whom a splenic space-occupying lesion was incidentally discovered during routine examination six months prior. CT findings suggested a diagnosis of splenic hemangioma at the inferior pole of the spleen, measuring approximately 3.5 × 3.5 × 3.0 cm (Figure 1). Given the documented interval enlargement of the lesion, surgical intervention was recommended after multidisciplinary evaluation, and informed consent was obtained. CT angiography indicated a bifurcated splenic artery (Figure 2). After completing the preoperative evaluation, a laparoscopic partial splenectomy was performed on the patient. Intraoperative blood loss was 300 mL (hemodynamically stable), and postoperative pathology confirmed splenic cavernous hemangioma.

Protocol

Informed consent was obtained from the patient. All procedures performed were in accordance with the ethical standards of the People's Hospital of Ningxia Hui Autonomous Region committee.

1. Pre-surgical steps

1. Anesthesia and positioning
   1. Administer general anesthesia with endotracheal intubation and position the patient supine.
2. Surgeon positioning
   1. Position the surgeon and camera operator on the patient's right side.
   2. Position the assistant on the patient's left side.
3. Trocar placement (A five-port approach)
   1. Place a 12 mm trocar left paramedian to the umbilicus as the observation port.
   2. Place a 5 mm trocar below the xiphoid process, slightly left.
   3. Position a 12 mm trocar at the midpoint between the xiphoid and umbilicus, with left deviation.
   4. Place a 12 mm trocar near the umbilical level along the left midclavicular line as the main operating port.
   5. Place a 5 mm trocar near the umbilical level along the left anterior axillary line as an auxiliary port.

2. Exposure of the surgical field

1. Retraction of the left hepatic lobe and gastric body
   1. Utilize purse-string sutures to retract the left hepatic lobe.
   2. Suture the purse-string suture into the resilient tissue at the edge of the left hepatic lobe to avoid laceration of the liver parenchyma.
   3. Utilize a urinary catheter to constrain the gastric body. Achieve optimal exposure of the surgical field (Figure 3).
2. Suspension of the gastric body for deep exposure
   1. Incise the hepatogastric ligament at the inferior border of the left lateral liver lobe.
   2. Suspend the gastric body using a self-adjustable band fashioned from a urinary catheter, looped around the stomach and tightened to achieve upward traction.
   3. Introduce a straight needle with suture through a selected point on the right upper abdominal wall into the peritoneal cavity.
   4. Externalize the suture tail through a corresponding point on the left upper abdominal wall.
   5. Secure the suspension suture by fixing the externalized suture to the hepatic side of the divided hepatogastric ligament using a clip.
   6. Place a small gauze roll under the suture on the abdominal wall to facilitate external adjustment and fixation.
   7. Gather the two suture ends externally.
   8. Apply appropriate tension to achieve adequate upward traction.
   9. Tie the suture ends securely to the skin.
      ​NOTE: This maneuver provides optimal exposure of the superior pancreatic border, portal vein, and splenic vein while avoiding excessive traction that could cause iatrogenic liver injury.

3. Mobilization and control of the splenic artery

1. Dissection of the splenic artery
   1. Dissect the main trunk of the splenic artery at the upper border of the pancreatic tail.
   2. Open the retroperitoneum at the avascular area superior to the pancreas with blunt dissection.
   3. Identify and isolate the splenic artery (located posterior-superior to the splenic vein) by carefully freeing it from adjacent tissues.
2. Placement of vascular control
   1. Place a blocking band (vascular loop) around the splenic artery (Figure 4) to establish immediate proximal control in case of hemorrhage.

4. Hilar dissection and identification of target vessels

1. Dissection of the splenic hilum
   1. Dissect the splenic hilum to identify the course and distribution of the splenic vessels.
      ​NOTE: Keep all dissections immediately adjacent to the splenic capsule to preserve the pancreatic tail.
2. Establishment of the initial ischemic line
   1. To establish the initial ischemic line, first control and divide the lower-pole vascular pedicle to the target segment.
   2. A clear ischemic line will become evident within 3–5 min of vascular division, appearing as a dusky purple demarcation against the normal red-brown parenchyma.
3. Division of target branches
   1. Meticulously dissect the target branch arteries and veins along the splenic parenchyma and divide them separately (Figure 5).

5. Parenchymal transection

1. Transection along the ischemic line
   1. Transect the splenic parenchyma approximately 1 cm inside the ischemic demarcation line using an ultrasonic scalpel (Figure 6 and Figure 7).
   2. Advance the ultrasonic dissector with its active blade facing the resection side.
2. Technique for hemostasis during transection
   1. Employ a deliberate, slow-paced coagulation-before-transection sequence to achieve reliable hemostasis, allowing gradual sealing of smaller vessels before division.
3. Management of larger vessels
   1. Ligate larger vessels encountered within the splenic parenchyma for secure hemostasis (Figure 8).

6. Hemostasis of the resection surface

1. Bipolar electrocoagulation
   1. Achieve complete hemostasis of the splenic resection surface using bipolar electrocoagulation (Figure 9).
   2. Apply bipolar electrocautery in a focal and precise manner to individual bleeding points.
      ​CAUTION: Avoid prolonged or broad-area coagulation to prevent eschar formation and delayed hemorrhage, ensuring a dry resection surface with minimal thermal damage to the preserved parenchyma.

7. Drain placement

1. Place a latex drainage tube with a specific size of 9.3 mm (18F) in the splenic fossa.
2. Confirm proper positioning before concluding the procedure.

8. Postoperative management

1. Monitoring
   1. Monitor vital signs and drain output closely to detect early complications.
   2. The patient had an estimated blood loss of 300 mL during the 230 min procedure.
   3. Remove the drain on postoperative day (POD) 4 following an uncomplicated course.
2. Thromboprophylaxis
   1. Administer low-molecular-weight heparin subcutaneously beginning 24–48 h postoperatively for thromboprophylaxis.
3. Platelet monitoring
   1. Track platelet counts serially.
   2. Platelet count on POD 1 was 170 × 10⁹/L.
   3. Platelet count on POD 4 was 187 × 10⁹/L.
   4. Values remained physiologic.
4. Diet advancement
   1. Advance diet as tolerated (achieved on POD 2).
5. Postoperative imaging
   1. Confirm uncomplicated recovery and residual splenic perfusion with cross-sectional imaging (CT on POD 6, Figure 10), which permitted discharge.
6. Histopathological confirmation
   1. Histopathological confirmation ultimately revealed a cavernous hemangioma of the spleen (Figure 11).

Results

Preoperative contrast-enhanced CT revealed a well-defined lesion located at the inferior pole of the spleen (Figure 1). Intraoperatively, the splenic artery and its branches were successfully identified and selectively ligated (Figure 2).

Following vascular control, parenchymal transection was performed. The total operative time was 230 min, with an estimated intraoperative blood loss of 300 mL. The patient resumed oral intake on post...

Discussion

As an indispensable organ, the spleen participates in vital functions such as regulating circulating blood volume, filtering blood, producing various immunoglobulins, and modulating the endocrine system¹¹. Historically, due to limited understanding of splenic function and anatomy, clinicians frequently performed total splenectomy for benign splenic tumors and splenic trauma. Postoperative patients face significantly increased risks of thrombocytosis, pylephlebitis, intra-abdominal abscesses, OPSI,...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
3D laparoscope	KARL STORZ SE & Co. KG	26605BA	Visualization system
Absorbable ligation clips	Hangzhou Sunstone Technology Co.,Ltd	K12	Vessel ligation
Laparoscopic instruments	Tonglu Youshi Medical Equipment Co., Ltd		Includes graspers, scissors, etc.
Latex T-shape Catheter	Zhenjiang Star Enterprise Co.,Ltd	16 Fr	Drainage catheter
Reusable Laparoscopic Bipolar Electrosurgical Forceps	Hangzhou Kangji Medical Instrument Co., Ltd.		Electrosurgical instrument
Ultrasound knife	Johnson & Johnson		Energy device for tissue dissection