Fig. 26.1
Operating room setup
Port Placement
Five trocars are placed after induction of 12-mmHg pneumoperitoneum by the Veress needle inserted in the left flank (Fig. 26.2):
Fig. 26.2
Trocar position
1 × 10–12-mm placed supra-umbilically for the assistant
3 × 8-mm intuitive robotic trocars placed in the right upper quadrant, in the epigastrium, and in the left flank are the working ports
1 × 10-mm port inserted in the middle point between the left costal margin and the umbilicus is used for the robotic camera
1 × 5-mm accessory trocar can be inserted in the epigastrium, between the umbilical port and trocar number 1
Inspection of the Peritoneal Cavity
A thorough inspection of the peritoneal cavity for gross pathology and accessory spleens is performed. If identified, the accessory spleen should be removed before splenectomy.
Stage 2
Approach
RS can be performed from an anterior approach (i.e., vessel division without posterior mobilization of the spleen). The stomach is retracted to the right with the Cadiere forceps inserted through trocar number 1. The precise bipolar forceps is introduced through port number 2. Port number 3 is used to introduce alternatively the monopolar and the Harmonic scissors. Splenic flexure is mobilized only if necessary in order to expose and divide the splenocolic ligament and the left gastroepiploic vessels. Splenic flexure mobilization can be useful as well to dissect the pancreatic tail and identify the splenic vessels in obese patients.
Short Gastric Vessels
The short gastric vessels are divided using the Harmonic scissors till full exposition of the pancreatic tail and splenic vessels. Alternatively, the short gastric vessels can be clipped and divided with the monopolar scissors (Fig. 26.3).
Fig. 26.3
Section of the short gastric vessels with the Harmonic Ace
Pedicle Dissection
The pancreatic tail is exposed using the fourth robotic arm in trocar 1 to completely retract the stomach on the right side and atraumatic bowel grasper to retract caudally the transverse colon. The splenic artery is circumferentially dissected for a distance of 2–3 cm at the level of the distal portion of the pancreas. If the artery gives off long branches, they can be dissected separately (Fig. 26.4).
