This paper has been published in Journal of Laparoscopic Surgery, 2008, No.5 Chengpeng Zhang, Dongsheng Hou, Jinsong Ye (Department of General Surgery, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical College, Guangzhou 510230, China) [Abstract] Objective: to explore the management of the open splenorenal shunt branch during laparoscopic peripancreatic vascular dissections. METHODS: Three patients with portal hypertension combined with esophagogastric fundal varices underwent peripancreatic vascular dissections using total laparoscopic technique, and the proximal end of the dissected splenic vein was ligated and the spleen was preserved because of obvious splenic and renal shunts detected by preoperative CT. RESULTS: All three cases were successfully operated, the operation time was 125, 75, 105 min, the intraoperative bleeding was 80, 45, 65 ml, no blood transfusion, no intermediate openings, and the postoperative hospitalization time was 4-7 d. CONCLUSION: Laparoscopic pericardial vascular dissections of the open splenorenal shunt branch can be performed by clamping between the splenic vein and the mesenteric vein at the junction of splenic vein and mesenteric vein and the preservation of splenorenal shunt branch, then dissecting the proximal end of the splenic vein and preserving the spleen. The splenic vein can be clamped between the inferior mesenteric vein and the splenorenal shunt and then dissected to divert the spleen from the portal vein system to the body circulatory system, which is a more reasonable method of spleen preservation, preserving the spleen’s original function, reducing portal hypertension, and removing the cause of hypersplenism, and the effect is more satisfactory. Zhang Chengpeng, Department of Minimally Invasive General Surgery, The First Affiliated Hospital of Guangzhou Medical University 【Keywords】 Laparoscopy; Dissection; Splenic-kidney shunt; Portal hypertension Management of Spleen-kidney collateral shunt in laparoscopic esophagogastric devascularization Zhang Chengpeng, Hou Dongsheng, Ye Jinsong, et al. Department of General surgery, Minimally invasive surgery center, First Affiliated Hospital of Department of General surgery, Minimally invasive surgery center, First Affiliated Hospital of Guangzhou Medical college, Guangzhou 510230,China 【Abstract】 Objective: To study the feasibility and safety of Management of Spleen-kidney collateral shunt in laparoscopy. Objective: To study the feasibility and safety of Management of Spleen-kidney collateral shunt in laparoscopic esophagogastric devascularization. Methods: Three totally laparoscopic esophagogastric devascularization were applied, and we found in CT that the collateral shunt was not a problem. Methods: Three totally laparoscopic esophagogastric devascularization were applied, and we found in CT that a conspicuous splenorenal shunt was open in these cases, so we practice splenic vein disconnection to reserve spleen. Results: The operations were successfully completed in these three cases. The surgical time was 125 min,15 min,105min, the blood loss was 80ml, 45ml, 65ml, respectively. None of the patients required blood transfusion or conversion to open procedure. There were no serious postoperative complications. There were no serious postoperative complications. The postoperative hospital stay was 4-7 days. Conclusions: It is ideal to transfer spleen vein from portal vein to general circulation. It can retain function of spleen, degrade portal hypertension, and remove etiological factor of hypersplenism. [KeyWords] Laparoscopic; Devascularization; Spleen-kidney collateral shunt; Portal hypertension In recent years, the rapid development of laparoscopic technology and the continuous updating of equipment have begun to be combined with the surgical treatment of portal hypertension [1]. Due to this particular blood flow state of portal hypertension due to cirrhosis, the body spontaneously forms a series of portal shunts to reduce the pressure in the portal venous system, and splenorenal shunts are one of the more common conditions. The spontaneous formation of splenorenal shunt can partially reduce the pressure in the portal system, but there are still patients admitted to the hospital due to rupture and bleeding of portal hypertension combined with esophagogastric fundal varices. 3 patients with portal hypertension combined with esophagogastric fundal varices who had splenorenal shunt were treated by laparoscopic pericardial vascular dissections in our hospital from February 2004 to October 2005, and the results were satisfactory at the postoperative follow-up period of 24 months. 1 Clinical data and methods 1.1 General data The 3 cases in this group, 2 female and 1 male, aged 47, 56 and 59 years old. The preoperative diagnoses were: post hepatitis cirrhosis, portal hypertension, esophagogastric fundal varices and hypersplenism. All three patients underwent preoperative three-dimensional reconstruction of CT portal system, and all of them had cirrhosis, portal vein thickening, and severe lower esophageal varices. The spleens were enlarged, splenorenal shunts were open (as shown in the figure), and the Child ratings of liver function were grade A, B, and A. Selection criteria: ① Patients with cirrhosis and portal hypertension, Child ratings of liver function of grade A or B, CT shows: splenorenal shunts are open, and they have a history of previous upper gastrointestinal hemorrhage without a history of epigastric surgery. ② moderate or more varicose veins in the middle and lower esophagus, history of vomiting blood or the possibility of uncontrollable hemorrhage due to rupture of the venous vessels in the lower esophagus. Those with enlarged spleen with hypersplenism. ③ Those without severe ascites, obvious jaundice, or improvement of the above symptoms by medical treatment. Exclusion criteria: ① peri-splenitis, splenic phlebitis or splenic vein thrombosis; ② splenic hyperfunction with esophageal and fundic varices is serious and bleeding is occurring; ③ liver function Child C grade; ④ other conventional contraindications to laparoscopic surgery. 1.2 Methods The patients were put on gastric tube and urinary catheter before the operation, endotracheal intubation with general anesthesia, left side back elevated and right oblique position. Open pneumoperitoneum was established 1cm above the umbilicus as the observation hole of laparoscopy, and the CO2 pneumoperitoneum pressure was set at 13-15mm Hg (1mmHg=0.133kPa). Under the exploration, there was no obvious ascites in the abdominal cavity, and the livers were small, hard, and the surfaces were bumpy and concave with large spleens, and the vasculature was obvious in the lower part of the esophagus and the peripheral blood vessels of the cardia. According to the size of the spleen, a 10-mm trocar was placed under the rib margin of the left anterior axillary line, a 5-mm trocar was placed under the rib margin of the left midclavicular line, and a 5-mm trocar was placed under the rib margin of the right midclavicular line, and the position of the trocar was adjusted to meet the requirement of facilitating the conversion between the cardia and splenic hilums, which were the two main operating positions. After opening the gastrocolic ligament, the posterior peritoneum was opened at the upper edge of the pancreas, and the splenic artery and vein were separated and searched for. The splenic vein was separated below the splenic artery, and then clamped and disconnected between the splenic vein and the inferior mesenteric vein and the splenic vein with preserved splenic and renal shunts. Here, it is necessary to combine the results of preoperative CT 3D reconstruction to ensure that the inferior mesenteric vein returns to the portal vein smoothly and the splenorenal shunt branch is intact. After that, the PK knife was used upward to continue the separation and ligation of the gastrosplenic ligament, and the internal short gastric vein was closed with a titanium clip and separated until the esophageal hiatus. The hepatogastric ligament was opened, the left liver was retracted with a trefoil hook to expose the cardia, and the titanium clamp was used to ligate the trunk at the root of the left gastric artery and vein, and the vein was separated and ligated on the upper 2/3 surface of the lateral surface of the lesser curvature of the stomach until the esophageal hiatus was opened. The diaphragmatic esophageal hiatus was opened, and the lower esophageal vein was freed and ligated upward for about 6-8 cm, while the high esophageal branch was dissected by electrocoagulation. Afterwards, the left subphrenic artery can be separated along the plasma membrane in front of the esophageal cardia, and the left subphrenic artery can be dissected. A trefoil hook was placed to pull the stomach to the right side, and the gastro-pancreatic cleft was used to search for the posterior gastric vessels and the fundic vessels and the traffic branches of the pancreas and dissected them. After checking the vitality of the spleen, no bleeding in the operation field, spraying bioprotein adhesive on the trauma, placing a drainage tube under the right liver, and routinely closing the abdomen. 2. Results All three cases were successfully operated, the operation time was 125, 75, 105 min, the intraoperative bleeding was 80, 45, 65 ml, no blood transfusion, no intermediate opening, and the postoperative hospitalization ranged from 4 to 7 d. The postoperative recovery was good, with no serious complication, and there was no recurrence of hemorrhage. All of them went down to the ground on the first postoperative day, the drains were removed 2-3d after the operation, and they ate 2-3d after the operation. All of them had outdoor activities 3 days after surgery. Hypersplenism was corrected, and on the next day of surgery, the white blood cell and platelet counts were restored to normal levels from below 2.0×109/L before surgery and continued to rise; they reached a peak on the 5th day after surgery, with platelet counts averaging 365×109/L and white blood cell counts averaging 24.5×109/L. The counts were restored to normal levels on the 14th day after surgery. The lower esophageal varices disappeared at 3 and 6 months after surgery by gastroscopy, and there was no recurrence of bleeding at 24 months of follow-up. The spleen was reduced from palpable to nonpalpable 2 cm below the left costal margin before the operation. 3. Discussion The surgical treatment of cirrhotic portal hypertension has entered the era of minimally invasive, and the development of laparoscopic surgical technology has led to the consideration of the use of laparoscopic technology to perform peripancreatic vascular dissections for this complex surgery, and some scholars have conducted a series of animal experiments to prove the feasibility of using laparoscopic technology to perform this surgery [3]. Currently, laparoscopic peripancreatic vascular dissections are still predominantly performed using a hand-assisted laparoscopic approach [4], whereas total laparoscopy is less frequently performed, mainly because traditional surgery requires removal of the spleen. In patients with spontaneous splenorenal shunts, surgical diversion of the spleen into the circulatory system makes it possible to perform a “minimally invasive” total laparoscopic peripancreatic vascular dissection. 3.1 Feasibility of retaining the spleen In 1970, Najjar in the United States firstly discovered that a kind of tetrapeptide produced by the spleen, macrophage-enhancing peptide (tuftsin), has the effect of enhancing the activity of neutrophils and mononuclear phagocytes, promoting their chemotaxis and phagocytosis, and enhancing the phagocytosis of lymphocytes, thus exerting the ability of anti-infection. It also enhances the phagocytosis of lymphocytes, thus exerting anti-infective ability. After splenectomy, tuftsin disappears. This explains the unique immune-enhancing properties of the spleen. The value and feasibility of splenectomy for “pathologic spleens” under conditions of portal hypertension has long been a controversial topic. It has been reported that simple splenectomy can reduce portal blood flow in portal hypertension by 40%, which seems to be a good way to reduce portal hypertension. Xu Q [5] et al. found that there was no significant change in free portal pressure after splenectomy compared with ligation of the splenic artery by measuring free portal pressure during surgery. It has also been reported that after splenectomy, portal vein thrombosis after laparoscopic splenectomy is a relatively common complication because of the tendency to form eddies in the splenic vein and the sharp rise in platelet counts after splenectomy, which increases the chances of splenic vein stump and portal vein thrombosis [6].Orozco et al. found that the intra-operative bleeding and postoperative portal venous thrombosis rates were significantly higher in splenectomy than in splenic artery ligation by testing the intra-operative bleeding and postoperative portal venous thrombosis rates of the splenectomy group. The incidence of portal vein thrombosis was significantly higher in the splenectomy group than in the spleen-preserving group, but there was no difference in the rate of recurrent bleeding, operative time, and postoperative complications [8]. We believe that patients with cirrhosis and portal hypertension can be preserved because of the adhesions around the spleen and the coagulation disorders in cirrhotic patients, as well as the substantial connections between the spleen and the surrounding tissues and organs, such as the splenodiaphragmatic ligament, splenorenal ligament, splenocolonic ligament, etc., and the vascular traffic, and the spleen can partially shunt the portal blood flow through these structures in portal hypertension. In addition, laparoscopic management of these anatomical structures undoubtedly increases the technical difficulty of surgical operation. In terms of immune function, preservation of the spleen makes more sense in a cirrhotic state where the patient is immunocompromised. 3.2 Superiority of laparoscopic management of the open splenorenal shunt: The current surgical treatment of portal hypertension is only a curative approach, whose main goal is to control or reduce the incidence of upper gastrointestinal hemorrhage, and which does not cure the lesions of the liver itself. Patients with post-hepatitis cirrhosis often require antiviral therapy due to the presence of hepatitis viruses. As the current commonly used anti-hepatitis B and C virus drugs such as interferon have more cases of bone marrow suppression [9], there is a possibility of causing a further decrease in leukocytes, for portal hypertension hypersplenism caused by leukocyte lowering is a contraindication to this time to relieve hypersplenism becomes more urgent. In portal hypertension, a series of portal shunts are spontaneously formed in the human body, and the most common of them is the splenic-renal shunt, with a chance of occurrence close to 20% [10], which is not uncommon. Combining laparoscopic techniques and utilizing these shunts can be a win-win situation for all parties involved. The inherent advantages of magnified images and fine dissection of laparoscopic techniques are fully realized in this procedure. While open pericardial vascular dissections generally have a large abdominal incision and a large impact on the patient’s internal environment, laparoscopic techniques are inherently less invasive and quicker to recover from the trauma of an open abdomen, and the spleen is preserved in this procedure, which makes it possible to perform the procedure fully laparoscopically. In our patient, preoperative CT examination revealed the presence of an open splenorenal shunt branch, and three-dimensional reconstruction of the portal system was then performed (see Figure) to specifically localize the location of the splenorenal shunt branch. The locations of the splenorenal shunts were all located in the splenic vein near the splenic hilum, connecting to the confluent left renal vein. After exiting the splenic hilum, the splenorenal shunt branch was sent out from the splenic vein and merged with the inferior mesenteric vein to flow into the portal vein, and the location of the surgical clamping and dissection could be identified between these two branches based on the imaging. We adopted the idea of splenic vein diversion of Jiang hc et al [11], i.e., without affecting the inflow of the inferior mesenteric vein into the portal vein, the open splenorenal shunt branch can be used to divert splenic vein blood into the left renal vein, which is actually to divert the spleen from the original portal vein system to the body vein system (left renal vein), which is in accordance with the idea of Warren’s surgery (selective distal splenorenal vein shunt), and it is a more reasonable method. It is a more reasonable method, which not only preserves the original function of the spleen, but also reduces the portal hypertension, removes the cause of hypersplenism, and the result is more satisfactory. References: [1] Helmy A,Abdelkader Salama I,Schwaitzberg SD.Laparoscopic esophagogastric devascularization in bleeding varices.Surg Endosc.2003,17( Surg Endosc. 2003,17( 10):1614-1619 [2] Liu Yu. Periportal vascular dissection for the treatment of portal hypertension hemorrhage in cirrhosis. Western Med. 2006,18(3):330-331 [3] Salama IA, Helmy A, Connolly R, et al. Laparoscopic devascularization of the lower esophagus and upper stomach: experimental study in the pig. experimental study in the pig.Laparoendosc Adv Surg Tech A.2003, 13(1):59-63. [4] Yamamoto J, Nagai M, Smith B,et al.Hand-assisted laparoscopic splenectomy and devascularization of the upper stomach in the management of gastric varices. World J Surg. 2006,30(8):1520-1525. [5] Xu Q,Hua,R. Effects of spleno-renal shunt conbined with devascularization and devasculariz- ation alone on hemodynamics of the portal venous system.J Surg Concepts Pract 2004,9(4): 286- 290 [6] Comar KM,Sanyal AJ.Portal hypertensive bleeding.Gastroenterol Clin North Am,2003,32(4):1079- 1105 [7] Harris,William,Marcaccio,Michael.Incidence of portal vein thrombosis after laparoscopic splenectomy.Canadian Journal of Surgery.2005,48(5): 352-354. [8] Orozco H,Mereado MA,Martinez R, et al. Is splenectomy necessary in devascularization procedures for treatment of bleeding portal hypertension[J].Arch 50172 practolol [9] Zhang B,Xu Q,Du JX. Clinical study on 30 cases of interferon myelosuppression treated by acupuncture. Jiangsu Traditional Chinese Medicine.2006,27(9):58-59. [10] Pan WD,Xu RY,Relationship between portal hypertensive gastropathy and existence of spontaneous spenorenal shunts. China Journal of Endoscopy,2005,11(5):481-483. [11] Jiang HC, Liu C. Problems related to spleen preservation in portal hypertension. Chin J Hepatobiliary Surg,2003,9(10):577-580. Note: Spleen-kidney collateral shunt: splenorenal bypass shunt Superior mensenteric vein: superior mesenteric vein Left gastric vein-dialated and tortuous: dilated and tortuous. Left gastric vein-dialated and tortuous: dilated tortuous left gastric vein Dialated left ovarian vein: dilated left ovarian vein