Laparoscopic Partial Splenectomy Assisted by Fluorescence in a 13-Year-Old Girl

Abstract

Partial splenectomy allows preserving immune function in benign splenic lesions such as epidermoid cysts. Determining the plane of resection and perfusion of the spleen remnant can be difficult, especially in centrally located lesions. We present a 13-year-old girl with a symptomatic splenic cyst of 6 cm in diameter located next to the splenic hilum. Laparoscopic partial splenectomy was performed through a 10-mm umbilical approach and three accessory 5-mm ports. Intraoperative intravenous injection of indocyanine green (ICG) at 0.2 mg/kg guided the careful dissection of the splenic hilum and checked the spleen perfusion once the upper arterial branch was clamped. The subsequent wash-out of the ICG allowed inspection of the peripheral vascular return of the splenic remnant through polar veins. Surgery was uneventful with minimal blood loss. Follow-up ultrasound scan revealed a well-perfused small splenic remnant with no signs of recurrence. Laparoscopic partial splenectomy is feasible in benign splenic tumors, especially in those cases of peripheral location. Fluorescence facilitates the safe dissection of the splenic hilum, the visualization of the transection plane of the spleen and the perfusion of the remnant in cases of anatomically and technically complicated partial splenectomies.

Keywords: fluorescence; indocyanine green; laparoscopy; partial splenectomy; pediatric.

Fig. 1

Computed tomography with intravenous contrast. Axial ( A ) and coronal ( B ) sections in venous phase. A hypodense 48.8 × 55.2-mm lesion with a rounded morphology was observed in the anterior, cranial, and lateral region of the spleen, intimately related to the hilum.

Fig. 2

Intraoperative image before beginning dissection. To the left of the image, the left hepatic lobe is seen covering the upper pole of the spleen. The spleen presents a large cyst on the superolateral aspect with diaphragmatic adhesions.

Fig. 3

Intraoperative image after arterial clamping. Image under near infrared light. To the right of the dotted line, inferolateral pole of the spleen. It shows fluorescence since arterial vascularization in this portion is preserved. To the left of the dotted line, supero-medial pole. It does not show fluorescence as the superior splenic artery, which supplies arterial irrigation to this portion, has been clamped.

Fig. 4

Intraoperative image after venous clamping. ( A ) Image under LED light. ( B ) Image under near infrared light. No fluorescence is observed in the inferolateral pole of the spleen, reflecting adequate ICG wash-out through a permeable venous system. Some ICG rests can be seen in the omentum (lower part of the image) and stomach (left edge). ICG, Indocyanine green.

Fig. 5

Intraoperative image. Division of the lateral pole from the medial pole using Caiman forceps.

Fig. 6

Intraoperative image. Postoperative aspect.