SPLENIC ARTERY ANEURYSMECTOMY WITH COMBINED LAPAROSCOPIC-ROBOTIC TECHNIQUE: OUR PRELIMINARY EXPERIENCE AND LITERATURE REVIEW

ANTICO, A., VESCE, G., IOB, G. PARINI, U.
Correspondence address: U.O. Chirurgia Vascolare ed Angiologia. Ospedale Regionale della Valle d’Aosta
Viale Ginevra, 3 11100 Aosta. Email: antico.antonio@uslaosta.com

Antico, A.; Vesce, G.; Iob G.; Parini, U. Splenic artery aneurysmectomy with combined laparoscopic-robotic technique: our preliminary experience and literature review. Seclaendosurgery.com (en línea) 2006, nº 15. Disponible en Internet .
http://www.seclaendosurgery.com/seclan15/articulos/art01eng.htm
ISSN: 1698-4412

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ABSTRACT

Objectives. To assess the feasibility and effectiveness of the combined laparoscopic-robotic tecnique (CLRT) in the treatment of splenic artery aneurysms (SAAs).
Material & Methods. The dimensions of the SAAs were 2,5 and 3 cm, which were incidentally found during the abdominal CT scan. Neither of the 2 SAAs were treatable with an endovascular approach because ofthe tortuousness of the proximal splenic artery.
Results. The post-operative colour-Doppler ultrasound control underlined the patency of the splenic artery and the normal aspect of the spleen in both cases (100%). Mobilization and the resumption of alimentation began in the first post-operative day.In all cases the post-operative pain was controlled with mild analgesic. The average hospitalization time was 5 days without complications. The follow-up was performed by colour-Doppler ultrasound 3, 6 and 12 months after the procedure; the good result was confirmed in 2/2 cases (100%).
Conclusions. The authors consider that, in selected cases of SAAs, there are benefits in the CLRT. To the advantages of the laparoscopy, the robot adds the magnification of the anatomical structures and the precision of the surgical gesture, benefits which allow to perform vascular anastomosis of structures of small dimensions as that of the splenic artery.

Key words: splenic artery, aneurysm, laparoscopic, robot.

INTRODUCTION

Surgical therapy for splenic artery aneurysms (SAAs) has traditionally consisted of a laparotomy with resection of the aneurysm and possibly a splenectomy. A review of literature and our early experience of two cases of SAAs treated with Combined Laparoscopic Robotic Technique (CLRT) to treat SAAs, are reported.

MATERIAL AND METHODS

Material & Methods. The dimensions of the SAAs were between 2,5 and 3 cm, which were incidentally found during the abdominal CT scan (Photo n. 1).

Photo 1. CT scan image with 3D reconstructions.		Photo 2. Angiography image.

Neither of the 2 SAAs were treatable with an endovascular approach because ofthe tortuousness of the proximal splenic artery (Photo n. 2).

Procedure description: the patients were placed in a 45-degree right semidecubitus (right-side down) position. Four trocars were used in both cases, one 12-mm trocar and a combination of 5 and 10-mm trocars. A 10-mm, 30-degree laparoscope was used (Photo n. 3).

Photo 3 . Trocars position.		Photo 4 . The aneurysm.

In both patients, the gastrocolic ligament was opened using Ultracision, thereby accessing the lesser space. The splenic artery was subsequentely visualized. To get a larger view of the splenic artery, the stomach was pulled up. The splenic artery was subsequentely dissected proximally and distally to the aneurysm necks. Aneurysm exclusion was realized by laparoscopic clips on each end. The aneurysm was then totally dissected to look for a collateral arterial branch and removed in an impermeable nylon bag (Photo n. 4).

Subsequentely the proximal and distal splenic artery was prepared for the anastomosis. Anastomosis was performed with the aid of the robot da Vinci (Photo n. 5). A drain was placed next to the anastomosis.

Photo 5 . Robot position.

RESULTS

The post-operative colour-Doppler ultrasound control underlined the patency of the splenic artery and the normal aspect of the spleen in both cases (100%). Mobilization and the resumption of alimentation began in the first post-operative day. In all cases the post-operative pain was controlled with mild analgesic. The average hospitalization time was 5 days without complications. The follow-up was performed by colour-Doppler ultrasound 3, 6 and 12 months after the procedure and subsequently once a year; the good result was confirmed in 2/2 cases (100%).

DISCUSSION

The aneurysms of visceral arteries are more commonly found in the splenic artery (60%). They are rarely discovered (1,6-10,6%), but with a mortality risk of 36% in cases of rupture (2% of the cases). The therapeutic options are: classical open-surgery, laparoscopy or endovascular treatment. Clinical and anatomical criteria have been set to indicate the treatment in programmed or urgent operations. In the I° group: young fertile women, aneurysms with diameter ≥2 cm or in rapid growth; in the II° group: symptomatic cases with abdominal pain, hemodynamics instability or shock. Management of SAAs still remains controversial. Laparoscopic SAA ligation repair appears to be optimal and useful for aneurysms protruding from the pancreas and it is gaining interest because clinical recovery is rapid with a poor morbidity and economic and cosmetic advantages. Transcatheter embolization too offers a temporary control in urgency to stop haemorrhage and go back at later date to make much better elective operation. Endovascular interventions as percutaneous embolization has recently gained popularity: it offers a safe alternative or adjunctive therapy to traditional surgery (3). Chiesa et al. believe that an aggressive surgical approach is justified, even in the case of asymptomatic visceral artery aneurysms, because of the low morbidity and mortality rates; endovascular treatment should be reserved for selected cases (1). Lagana et al. consider that using different techniques, endovascular treatment is feasible in nearly all SAAs; it ensures good immediate and long term results and no doubt presents some advantages in comparison to surgical treatment, as it is less invasive and allows the preservation of splenic function (4). In the present review of the literature, to date, we have not identified any cases of SAAs treated with the Combined Laparoscopic Robotic Technique (CLRT).

CONCLUSIONS

After their preliminary experience, we consider that, in selected cases of SAAs, there are benefits in the CLRT. To the advantages of the laparoscopy, the robot adds the magnification of the anatomical structures and the precision of the surgical gesture, benefits which allow to perform vascular anastomosis of structures of small dimensions as that of the splenic artery. It ensures good immediate and long term results, and no doubt presents some advantages in comparison to classical surgical treatment, as it is less invasive and allows the preservation of splenic function.

REFERENCES

1. Chiesa R. et al. Visceral artery aneurysms. Ann Vasc Surg. 2005 Jan;19(1):42-48.
   
2. Reardon PR. et al. Laparoscopic resection of splenic artery aneurysms.
   Surg Endosc. 2005 Apr;19(4):488-93. Epub 2005 Feb 3.
   
3. Nincheri Kunz M. et al. Management of true splenic artery aneurysms. Two case reports and review of the literature.Minerva Chir. 2003 Apr;58(2):247-256.
   
4. Lagana D. et al. Endovascular treatment of splenic artery aneurysms. Radiol Med (Torino) 2005 Jul-Aug;110(1-2):77-87.