tailieunhanh - Pediatric Laparoscopy - part 6

Tuy nhiên một lần này được chia đôi khi khó khăn hơn để làm việc trên các tàu hilar đặc biệt nếu chúng được cắt tỉa và chia. Các tùy chọn khác là để phân chia các mạch hilar tiếp theo để lại bộ phận của dây chằng splenorenal cho sau này. Các tàu hilar thường tuân theo phân chia cá nhân giữa clip. | Splenectomy 129 Figure . Harmonic scalpel dividing splenocolic legament as one blunt grasper elevates spleen and the other provides countertraction. Figure . Use of the harmonic scalpel to divide the gastrosplenic ligament. 14 130 Pediatric Laparoscopy 14 avoid thermal injury. After the short gastric vessels are divided it is often convenient to detach the attachments to the diaphragm. The splenorenal can be divided as the next step. However once this is divided it is occasionally more difficult to work on the hilar vessels particularly if they are to be clipped and divided. The other option is to divide the hilar vessels next leaving division of the splenorenal ligament for later. The hilar vessels are often amenable to individual division between clips. In this situation use of a dolphin nose forceps is often useful in the first assistant s right hand. Once the vessels are isolated a 5 mm clip-applying device Endo Clip US Surg Corp Norwalk CT is passed through port D. Two clips are placed on the pancreatic site one on the splenic side and the vessel divided with scissors. If the pancreas is intimately attached to the spleen the vessels must be handled in this fashion to avoid pancreatic injury. If however the pancreas is separated from the hilum by one centimeter or more a stapling device can be utilized to divide the hilar vessels. Once the surgeon has decided to use the stapler it is often preferable to divide the splenorenal ligament so the spleen can be lifted and rotated as needed to ease application of the stapler. At this point a 5 mm telescope is placed through a separate trocar usually left lower quadrant and the stapling device Endo GIA US Surgical Corporation Norwalk CT placed through the umbilical trocar Fig. . One and occasionally two applications of the device are utilized to divide the vessels. After the spleen is completely detached the area is inspected for bleeding. The spleen is positioned as high in the left upper quadrant