Bloodless Laparoscopic Partial Splenectomy Assisted by Bipolar Radiofrequency Excision Hemostatic Device

With the development of modern medicine, especially immunology, there is a better understanding of the anatomical structure and function of the spleen. In the past, many benign and malignant spleen diseases were treated by total splenectomy due to the limitations of knowledge and surgical techniques. In 1992, Delaitre et al. first reported laparoscopic splenectomy, and laparoscopic techniques began to be gradually applied to spleen surgery¹⁴. However, studies have shown complications such as thromboembolism, hemorrhage, infections, congenital damage to adjacent organs, and dangerous postoperative infections occur after total splenectomy^2,3. Therefore, for patients with splenic diseases, the initial blind resection treatment has been gradually replaced by selective splenic preservation therapy, such as splenic repair suture, partial splenectomy, splenic artery embolization, and splenic transplantation. In 1995, Poulin et al. first reported LPS, which opened a new chapter in splenic surgery⁶. With a more comprehensive understanding of the function of the spleen, the anatomical relationship between the splenic lobules and segmental blood supply, and the application of various energy devices, LPS has been applied to patients in major centers^15,16,17,18. LPS can preserve as much normal tissue of the spleen as possible while removing the diseased tissue, reducing various complications after total splenectomy. Compared with open partial splenectomy (OPS), LPS requires a longer time and more intraoperative bleeding. However, it does not increase the incidence of postoperative complications and delay postoperative recovery. On the contrary, studies have shown that LPS has a significantly lower postoperative complication rate and a significantly shorter postoperative hospital stay than OPS^18,19,20.

The blood supply to each segment of the spleen is the anatomical basis of LPS. There are mainly two-lobe and four-segment types, i.e., the upper and lower segments of the spleen, the middle and upper segments of the spleen, the middle and lower segments of the spleen. It can also be divided into the splenic hilar, intermediate, and peripheral areas. The splenic artery divides into splenic lobular vessels at the splenic hilum, including 1, 2, 3, and multivessel types. The most common type is the 2- and 3-vessel type, in which the trunk of the splenic artery branches off 2 or 3 vessels of the splenic lobe and enters the spleen. In this regard, there are few arteriovenous anastomoses between adjacent splenic lobes (segments), forming an irregular plane with almost no vascular zone. This anatomical feature justifies the feasibility of partial splenic resection to a certain extent. Partial splenic separation can be performed in a relatively avascular zone to reduce the amount and rate of bleeding^21,22. Surgeons can choose different types of partial spleen resections depending on specific conditions and the anatomy of the splenic blood supply. In this case, the tumor was in the spleen's upper part. After releasing and ligating the branch vessels in the upper part of the spleen, a clear ischemic line appeared on the surface of the spleen, based on where partial splenectomy is performed.

The spleen is rich in blood supply, and many blood vessels in the spleen parenchyma need to be dealt with during resection, which results in long operation time, heavy bleeding, and high risk. Therefore, various hemostatic energy devices have emerged and are applied to LPS^{7,8,9,10,11,12,23,24,25}. A bipolar radiofrequency device is a bipolar radiofrequency electrode containing two pairs of 5 cm long reversed electrodes displayed in a rectangular array. The high-frequency alternating current generated by the radio frequency electrodes is transmitted to the surrounding tissues. After the alternating current passes through the tissue, molecules in the tissue rub against each other, generating heat along the current direction, resulting in ischemic necrosis of cells and forming a coagulated necrotic zone approximately 1 cm in width. In 2008, Professor Habib invented the Habib 4X bipolar radiofrequency cutting hemostatic electrode and used it in liver resection with promising results²⁶. Subsequently, the bipolar radiofrequency device was gradually promoted for hepatectomy in major centers. Wang et al. used a bipolar radiofrequency device for LPS for the first time in China and achieved the therapeutic result of bloodless splenectomy²⁷.

This patient underwent successful LPS using a bipolar radiofrequency device. Our experience is summarized as follows: (1) Strict indications, including trauma to the spleen, benign spleen tumors, splenic cysts, hematomas, and especially hematologic disorders of the splenic margins, required splenectomy. Partial splenectomy was contraindicated for tumors near the splenic gallbladder. In addition, some studies have shown that at least 25% to 30% of the residual spleen needs to be preserved to maintain normal spleen function^17,18. (2) Preoperative CT and intraoperative ultrasonography were used to clarify the anatomical relationship between the lesion, the splenic artery, and its branches. After dissecting the splenic artery trunk, an disposable single-cavity rubber catheter was placed as a pre-blocking band to block the splenic pedicle and reduce bleeding on time when there was massive bleeding during surgery. The splenic pedicle could be fully exposed by pulling the catheter to protect important vessels and expose the bleeding site. (3) The splenic artery was dissected along the main splenic artery toward the splenic hilum to avoid injury to the pancreas. Attention was paid to identifying the direction of the branch vessels of the secondary splenic pedicle. The vessels in the splenic lobe to be resected were accurately clamped. The ischemic borders of the spleen were observed. Because some patients have anatomic variations in the branches of the splenic artery, careful identification of the anatomical relationship was required, and the vessels need to be carefully released. Only when the ischemia line has been found, the vessels must be severed. To ensure the viability of the spleen, a partial splenectomy could be performed after confirming the resection surface at approximately 1 cm on the blood supply side of the ischemic line. (4) Intraoperative operations were handled elaborately with moderate freedom, and the collateral blood vessels of the spleen were preserved to protect the secondary blood supply system of the spleen. When preserving the upper pole of the spleen, the upper part of the spleen and the gastric ligament must not be cut to avoid damaging the short gastric vessels and the blood supply to the upper pole of the spleen. When preserving the lower pole of the spleen, the lower part of the gastrosplenic ligament (splenic colonic ligament) needs to be protected to avoid damaging the left gastrointestinal vessels and the blood supply to the lower pole of the spleen. (5) The appropriate power for the bipolar radiofrequency device must be selected, and deep ablation and coagulation must be performed. After ablation disconnection, the broken end of the vessel was clamped using non-absorbable polymer locking clips, or a thicker tube was ligated and sutured to the splenic portion to merge the seal. This patient underwent the procedure successfully with no complications, validating the safety and feasibility of bipolar radiofrequency device-assisted LPS, but further exploration and validation in multicenter, large sample size is still needed.

This surgical method mainly applies to young patients with benign splenic tumors. It is not suitable for large benign tumors of the spleen, malignant tumors of the spleen, and the following situations: the residual spleen is too small to lose function after partial resection, and the branches of the spleen vessel are difficult to be exposed because of serious adhesion or vascular anomalies.

In conclusion, bipolar radiofrequency device-assisted LPS is safe and effective. Under the premise of strictly mastering the indications and fully understanding the vascular anatomy of the spleen, the application of a bipolar radiofrequency device in LPS can reduce intraoperative bleeding and achieve the clinical effect of "bloodless spleen incision", which is worthy of clinical application.