The American Journal of Surgery 186 (2003) 164 –166
How I do it
How we do a bloodless partial splenectomy Nagy A. Habib, Ch.M.*, Duncan Spalding, Giuseppe Navarra, M.D., Joanna Nicholls, M.Sc. Department of Gastrointestinal Surgery, Hammersmith Hospitals NHS Trust, Du Cane Rd., London W12 0HS, United Kingdom Manuscript received August 23, 2002; revised manuscript December 12, 2002
Abstract Partial splenectomy and Tru-cut biopsy are not routinely practiced because of the lack of vascular control to arrest bleeding. Using radiofrequency energy to coagulate the resection margin and biopsy tract, a 74-year-old woman with a tumor in the lower pole of the spleen underwent partial splenectomy and Tru-Cut biopsy of the spleen. Hemostasis was excellent. Blood loss was minimal and the patient was discharged with a functioning spleen. This new technique may allow safe and bloodless partial splenic resection and Tru-cut biopsy of the spleen, which might reduce the number of splenectomies performed and the consequent difficulties for the patient that can arise. © 2003 Excerpta Medica, Inc. All rights reserved. Keywords: Splenectomy; Radiofrequency energy; Coagulative desiccation
Partial splenectomy is not routinely practiced because of the lack of vascular control to arrest bleeding once the tissue is cut. For the same reason Tru-cut biopsy of the spleen, which can assist in the diagnosis of hematological malignancies, is not usually performed. Radiofrequency (RF)-generated heat has been used successfully to ablate liver tumors , and recently we have developed a new technique for liver resection using RF, which leads to a virtually bloodless liver resection . Here, RF-generated heat was used to perform a virtually bloodless partial splenectomy and a biopsy of the spleen.
Surgical technique The procedure was performed in a 74-year-old woman who had a solitary metastatic tumor 4 cm in diameter in the lower pole of the spleen. Previously she had had an oophrectomy, followed by chemotherapy for ovarian cancer. Under general anesthesia a modified left subcostal incision was performed. First the peritoneal cavity was exam-
* Corresponding author. Tel.: ⫹44-20-8383-8574; Fax: ⫹44-20-83833212. E-mail address: [email protected]
ined for evidence of disseminated disease and then the spleen was mobilized by dividing the splenorenal ligament. Fig. 1 shows a computed tomography scan image of the tumor occupying the lower pole of the spleen. Coagulative desiccation of the proposed resection margin was performed 1 cm away from the tumor edge using a “cooled-tip” radiofrequency (RF) probe (Ct-2530; obtained from Tyco Healthcare, Gosport, Hants, UK), and a 500 kHz RF generator (Model RFG-3D; Radionics Europe, N.V., Wettdren, Belgium), which produces 100 W of power and allows measurements of generator output, tissue impedance, and electrode tip temperature. The probe contains a 3-cm exposed electrode, a thermocouple on the tip to monitor temperature and impedance, and two coaxial cannulas through which chilled saline is circulated during RF energy application to prevent tissue boiling and cavitation immediately adjacent to the needle. Each application of RF energy along the resection margin was applied for about 60 seconds, which was sufficient to create a “zone of desiccation” in a core of tissue measuring 1 cm in radius and 3 cm in depth. Application of RF energy began with the area deepest and furthest from the upper surface of the spleen. The middle finger of the left hand was used to feel the tip of the probe piercing the capsule of the inferior surface of the spleen, while the right hand held the probe Fig. 2. Just prior to each probe removal the saline infusion was stopped to increase the temperature close to the electrode, resulting in
0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/S0002-9610(03)00170-3
N.A. Habib et al / The American Journal of Surgery 186 (2003) 164 –166
Fig. 3. Resection of the tumor with the scalpel. Note complete hemostasis at the resection edge. Fig. 1. Computed tomography scan showing the ovarian metastasis occupying the lower pole of the spleen.
coagulation of the needle tract during withdrawal and reduced the possibility of bleeding from the probe tract and spleen capsule. Once an area was coagulated, the probe was withdrawn completely and placed 1 cm away from the previous application. That allowed complete coagulation of a band of parenchyma in the interface between tumor and spleen. The spleen tissue was then divided with a scalpel Fig. 3. The plane of the division was performed in such a way to leave a 1-cm resection margin away from the tumor and leave in situ 1 cm of coagulated surface. A Tru-cut biopsy of the spleen was taken from the remaining spleen and sent for frozen section to rule out micrometastasis. After removal of the biopsy needle the Cooled-tip probe was inserted into the biopsy tract to stop bleeding Fig. 4 from it.
rapidly and was discharged home with a functioning spleen. At 3-week follow-up platelet count, as well as gamma globulins, CD3⫹, CD4⫹, CD8⫹, and NK cells, were all within normal limits.
Blood loss was minimal during the surgery and no bleeding was observed postoperatively. The patient recovered
The spleen is an important component of the body’s defenses against many infections, and the adverse consequences of its removal have become increasingly apparent over the last 4 to 5 decades. Death rates from overwhelming postsplenectomy sepsis have been reported to be up to 600 times greater than in the general population, with an estimated lifetime risk for postsplenectomy sepsis of 5% . There is some evidence that splenic reticuloendothelial function can be preserved by partial splenectomy, provided that at least 25% of splenic tissue is preserved [4,5]. To our knowledge this is the first report of a technique to describe a controlled partial splenectomy in an adult with virtually no blood loss. We believe that this simple technique deserves to be used more widely as it probably could be used to stem bleeding from a ruptured spleen after
Fig. 2. Radiofrequency probe inserted along a line 1 cm proximal to the tumor edge.
Fig. 4. Insertion of the radiofrequency probe at the site of the Tru-Cut biopsy.
N.A. Habib et al / The American Journal of Surgery 186 (2003) 164 –166
trauma and iatrogenic injuries, and if that proves to be the case, it may save patients from the risks of undergoing a total splenectomy. References  Jiao LR, Hansen PD, Havlik R, et al. Clinical short-term results of radiofrequency ablation in primary and secondary liver tumors. Am J Surg 1999;177:303– 6.
 Weber J-C, Navarra G, Jiao LR, et al. New technique for liver resection using heat coagulative necrosis. Ann Surg 2002;236:560 –3.  Lynch AM, Kapila R. Overwhelming post splenectomy infection. Dis Clin North Am 1996;10:693–707.  Malagoni MA, Dawes LG, Droege EA, et al. Splenic phagocytic function after partial splenectomy and splenic autotransplantation. Arch Surg 1985;120:275– 8.  Traub A, Giebink GS, Smith C, et al. Splenic reticuloendothelial function after splenectomy, spleen repair, and spleen autotransplantation. N Engl J Med 1987;317:1559 – 64.