巨脾4例に対する脾門部先行処理仰臥位腹腔鏡下脾臓摘出術の経験

Laparoscopic splenectomy in the supine position using the internal approach technique

◆要旨：腹腔鏡下脾臓摘出術の際に，脾臓の脱転や良好な視野の確保が難しい場合があり,偶発症では出血が最も多いとされる．とりわけ，巨脾症例は難易度が高くなる．脾臓外側からアプローチし授動する手技が多く報告されている．当科で，膵尾部および脾門部を十分に授動させ，脾門の先行処理を行った後，脾腎間膜も右側からアプローチし，切離する方法を4症例に行った．いずれも600gを超える巨脾症例であったが，腹腔内で脾臓を遊離するまでに平均115分，出血は平均10gであり，比較的速く安全に施行できた．脾臓を脱転することなく脾腎間膜の処理ができ，脾臓の大きさや体型によらず行える安全でストレスの少ない手技と考えられた．

Laparoscopic splenectomy is widely performed in the right（semi） lateral position and the lienorenal ligament is dissected laterally before the splenic pedicle ligation. However it is difficult to ensure a satisfactory operative field especially in patients with splenomegaly. We developed laparoscopic splenectomy by internal approach technique. We don't touch the spleen almost until the splenic pedicle is divided. This method provides a satisfactory surgical view and less operative blood loss. ［method］ After ligation of the gastrosplenic ligament, the pancreatic capsule is divided just below the pancreas. Toldt' fusion fascia is widely divided between pancereas and left kidney, and tunneling procedure is done from the pancreatic tail to the splenic hilum. The splenic pedicle is clumped and divided by linear stapler. By moderate lifting of the spleen using forceps, the lienorenal ligament between the spleen and retroperitoneal tissue is exposed, then incision of the ligament can be done easily and the spleen is isolated. ［Results］ We perfomed laparoscopic splenectomy using this approach in four patients. The weight of the spleen was more than 600g in all cases. The mean time until isolation of the spleen and amount of blood loss during operation were 115min and 10g, respectively. No intraoperative complication occurred. ［Conclusion］ Laparoscopic splenectomy by internal approach technique is a safe and useful procedure regardless of the size of the spleen.