After the induction of anesthesia, a Foley catheter and a nasogastric tube are placed. The patient is then placed in right lateral decubitus position and a beanbag may be utilized (Fig. 44.2). The ideal position is a 45–75° elevation of the left side, with additional padding beneath the right flank or operative table break to allow maximization of the distance between the left flank and the left anterior superior iliac spine. The surgeon then gains access to the peritoneal cavity either with a spring-loaded (Veress) needle or by open technique (Hasson). The umbilical port should be typically 12–15 mm to accommodate a 12 mm endoscopic stapler and a 10 mm or 15 mm endoscopic retrieval bag. Additional working ports are then placed under direct visualization; we recommend two 5 mm working ports in the left upper quadrant to facilitate traction and dissection and one additional working port in the left lower quadrant which will serve as the principle working port through which the endoscopic dissection device will be used, either an ultrasonic scalpel (Harmonic) or vessel sealer (LigaSure) (Fig. 44.3).

An initial search for accessory spleens, especially in the splenic hilum, is undertaken. The operative bed is then positioned to allow the left flank to be elevated, thus allowing the spleen to “hang” from its lateral attachments.

The splenocolic ligament is divided, followed by the gastrosplenic ligament (Fig. 44.4). Attention should be paid to adequate hemostasis of the short gastric vessels, which are in close proximity to the stomach. Medial traction is then placed on the spleen to allow division of the splenorenal ligament. The hilar splenic vessels can be divided using clips, vascular staplers or energy devices (LigaSure), or a combination of these. Many surgeons staple the splenic artery and the splenic vein separately to minimize the risk of an arteriovenous fistula between those vessels, although this may not be evidenced based (Figs. 44.5 and 44.6).

The spleen is then placed in an endoscopic retrieval bag (Fig. 44.7). In the case of massive splenomegaly, removal of the spleen may be challenging. Large enforced retrieval bags, which can be placed through a 15 mm trocar, are available. Additional techniques for removal include careful finger fracturing or morcellation with a ringed forceps. Occasionally, a minilaparotomy or Pfannenstiel incision may be required. Care must be taken to avoid spillage of splenic fragments within the abdomen, which may lead to splenosis. The abdomen is inspected for hemostasis and an additional cautious search for accessory splenic tissue is completed. Port sites are closed in a standard fashion. The patient is awoken from anesthesia and admitted for observation.

Benefits of the lateral approach to splenectomy include improved exposure due to dissection technique, thus less need to grasp and manipulate the spleen, leading to faster dissection and less risk of injury to the splenic capsule [17, 19]. This results in decreased operative time compared to the anterior approach [12] and, therefore, decreased operative cost and general anesthetic time.

The anterior approach may be beneficial in situations where a concomitant laparoscopic cholecystectomy will be performed. In contrast to the lateral approach, this technique involves initial control of the vascular pedicle [20] and may provide a benefit of reduced arteriovenous fistula formation when the vessels are individually ligated [20]. After induction of general anesthesia, a Foley catheter and a nasogastric tube are placed. Pneumoperitoneum is established at the umbilicus via similar techniques as mentioned above. Additional ports are placed under direct visualization along the left costal margin medially and laterally and an additional port site at the xiphoid process. Modification in port site placement may be necessary for concomitant procedures.