Minimally invasive surgical techniques have been widely carried out at home and abroad for the treatment of splenic diseases, such as laparoscopic splenectomy, laparoscopic partial splenectomy, and partial splenic artery embolization.
I. Laparoscopic splenectomy
1.Surgical indications
(1) Blood diseases.
(i) Idiopathic thrombocytopenic purpura.
(ii) hereditary spherocytosis, hereditary oval erythropoiesis.
(3) autoimmune hemolytic anemia.
④Pearlybumin-producing disorder anemia.
⑤ thrombotic thrombocytopenic purpura.
(vi) Evans syndrome.
(vii) Hodgkin’s lymphoma.
(8) Chronic lymphocytic leukemia.
(2) Benign diseases of the spleen.
(i) Splenic malformation tumor.
(ii) Splenic cysts.
(3) Splenic granulomatous lesions.
(2) Traumatic splenic rupture.
3.Secondary hypersplenism (e.g. portal hypertension).
4.Wandering spleen.
II. Laparoscopic partial splenectomy
Laparoscopic partial splenectomy is divided into two types: regular and irregular, the former being splenic segmental resection, lobectomy and hemi-splenectomy performed according to the distribution of blood vessels in the spleen; in practice, irregular splenectomy is mostly chosen; the advantage of LPS is that part of the spleen is preserved and the patient’s immune function is basically not destroyed after surgery.
III. Laparoscopic giant splenectomy
The difficulty of laparoscopic giant splenectomy lies in the narrowing of the perisplenic space, the heavy adhesions around the spleen due to pathological spleen, the complicated condition of the splenic tissues, and the possible existence of lateral circulation, which greatly increases the chance of intraoperative hemorrhage and intermediate open surgery. In the early stage of laparoscopic splenectomy, it is generally believed that the size of the spleen has a greater relationship with the success or failure of laparoscopic splenectomy. The indications for simple laparoscopic splenectomy are generally agreed by domestic scholars to be a spleen of basically normal size or less than 15 cm in length under ultrasound.
IV. Partial splenic artery embolization
Partial splenic artery embolization is performed by blocking the splenic lobe artery or splenic segment artery to cause atrophy or necrosis of splenic tissue in the blood supply area to treat splenomegaly. It has gradually surpassed surgery as the method of choice for the treatment of splenomegaly due to various causes.
It is suitable for all indications for surgical splenectomy, including secondary and primary hypersplenism due to various causes (cirrhosis hypersplenism, hepatocellular carcinoma combined with hypersplenism, hepatic venous obstruction syndrome, idiopathic standing venous hypertension, etc.), hematologic diseases with splenic indications, lymphoma, myelofibrosis, splenic rupture, etc.
V. Splenic ablation
Commonly used splenic ablation procedures include ultrasound-guided percutaneous anhydrous alcohol intrasplenic injection, radiofrequency ablation of the spleen, and non-invasive splenic ablation with high-intensity focused ultrasound.
1.Ultrasound-guided intrasplenic injection of percutaneous anhydrous alcohol etc.
Ultrasound-guided transdermal ethanolamine oleate injection, intrasplenic injection of sodium cod liver oil acid or anhydrous alcohol etc. cause local splenic necrosis, thrombosis and fibrosis, and have certain efficacy in the treatment of hypersplenism. However, some scholars believe that this method can cause significant bleeding at the puncture site and should not be advocated until the bleeding cannot be effectively resolved; in addition, the anhydrous alcohol injected into the spleen is diluted by blood and then the destruction is limited.
2.Radiofrequency ablation of the spleen
(1) Treatment route and mode selection
(1) Percutaneous puncture splenic ablation: for those with simple hypersplenism, no history of upper gastrointestinal bleeding, no severe esophageal varices, severe cirrhosis, liver function Child B or C grade, poor coagulation function and unable to tolerate major surgery, percutaneous splenic puncture radiofrequency treatment can be chosen.
② Trans-laparoscopic splenic ablation: Trans-laparoscopic radiofrequency ablation can be chosen for those who have no history of upper gastrointestinal bleeding, whose liver function Child B or C grade is elevated to grade B or above after hepatoprotective support therapy, and who can tolerate general anesthesia. The operation is performed under direct vision, the possible bleeding from the needle tract can be dealt with in a timely manner, the scope of destruction can be easily grasped, and the combined laparoscopic dissection of the gastric coronary vein or peripancreatic vessels can also be considered for patients with complicated moderate to severe esophageal varices.
Splenic ablation in open surgery: It is suitable for patients with history of upper gastrointestinal bleeding, severe varices of esophageal veins, possibility of rupture and bleeding, or concurrent primary hepatocellular carcinoma, who can first undergo peripancreatic vascular dissection or hepatectomy or radiofrequency ablation of hepatocellular carcinoma, and then undergo splenic ablation with ligation or blockage of splenic artery. Radiofrequency ablation in open surgery for hypersplenism is clear, easy to control the scope of destruction, effective protection of surrounding organs and tissues, and the time of radiofrequency ablation is significantly shortened after blocking the splenic artery, and the puncture needle tract does not bleed. tion, PSE), radiofrequency ablation, etc.