Partial Splenic Resection Using the TA-Stapler Selman Urantis, MD, Leo Kronberger, MD, FRSM, Julius Kraft-Kine, MD, Graz, Austria Since 1987, we have used the TA-stapler for 15 partial resections of the spleen. The cases included 5 second- to third-degree traumatic ruptures, 4 splenic cysts, 3 injuries resulting from accidents during upper-abdominal surgery, 2 diagnostic re- sections, and 1 intralienal pancreatic cyst. The TA-55 stapler was used 14 limes and the TA-90 once. No patient developed postoperative bleedlns or required further surgery. Postoperative labora- tory chemistry and scintigraphy findings were within the limits indicative of normal function in all cases. The TA-stapler expands the technical possibilities for organ-conserving splenic surgery. T he indications for operations on the spleen fall into three categories: (1) traumatic (exogenic or acciden- tal), (2) elective therapeutic (splenic cysts and intralienal pancreas cysts), and (3) diagnostic (splenomegaly with un- clear hematological findings and normal marrow punc- ture). 1.2 Because the spleen tears easily and the sinus is prone to diffuse bleeding, hemostasis in traumatic lesions and after resection can be difficult. Segmental resection of a traumatized spleen is frequently infeasible, as lesions often extend beyond segmental boundaries. Or, excessive parenchyma may be removed. When partial resection is possible, the resulting parenchy- mal surface can be closed with various sutures, coagula- tion, and fibrin glue. While these techniques are suitable, however, they are difficult and time-consuming. For some years, the TA-stapler has been available for partial splenic resection.3-5 We use this method to treat splenic injuries and for diagnostic and therapeutic resec- tions as well. PATIENTS AND METHODS Between May 1987 and December 1992, we performed 69 organ-conserving procedures on the spleen (Table I). In 15, both elective and posttraumatic, we used the TA- stapler for partial resection. Our classification of splenic trauma, which we have used since 1987, generally conforms with the 1989 standards of the Organ Injury Scaling (OIS) Committee.6 Five of our patients had Grade-II to Grade-IU traumatic ruptures (cor- responding to OIS Grades III and IV) (Table II). In three, the etiology was accidental injury in the course of upper- abdominal surgery. These lesions were limited to one pole or to half of the spleen. We treated them with pole resec- tion or hemisplenectomy (Figure 1). From the Departmentof Surgery, UniversitySurgical Clinic, Karl- Franzens University, Graz, Austria. Requests for reprints should be addressed to Selman Uraniis, MD, Associate Professor,Universi~tsklinikfiir Chirurgie,Auenbruggerplatz 29, A-8036Graz, Austria. Manuscript submittedOctober 1, 1992,and acceptedin revisedform April 1, 1993. We performed five therapeutic resections for isolated splenic cysts. These included a mesothelial cyst, an epi- dermoid cyst (Figure 2), an intralienal pancreas cyst, and two (presumably) posttraumatic pseudocysts. Two patients underwent partial resection after showing isolated splenomegaly. Hematological studies and marrow puncture could not confirm the diagnosis of a hematologic disorder. Partial resection for histological examination was therefore indicated. In all elective resections, prior to mobilization of the spleen, we opened the bursa omentalis via the gastrocolic ligament, followed by prehilar presentation and snaring of the splenic artery. We used a tourniquet to interrupt the blood supply during the resection and released it immedi- ately upon application of the staples. In the trauma cases, we omitted the time-consuming procedure of preparing and snaring the splenic artery. Instead, the surgeon com- pressed the vessels digitally on the hilus until hemostasis was achieved. In all cases, the spleen was mobilized all around and placed on the abdominal wall. The splenic tissue was com- pressed digitally across normal parenchyma adjacent to the injury after ligature and severing of the respective vessels. This maneuver pushed the parenchyma toward the dam- aged segment that would later be removed. Only two lobes of the capsule and vascular cords of connective tissue re- mained between the surgeon's fingers. Here the stapler and the staples were applied. In trauma cases, the extent of the injury determined the extent of the resection. After digital compression of the parenchyma and application of the stapler, the vessels sup- plying the tissue that was to be removed were tied off. The cystic lesions were opened before resection and a sample was removed. To prevent accidental contamina- tion of the abdominal cavity, the contents were then suc- tioned off. Cysts were removed bluntly with the finger- fracture technique, taking care to remove all remnants of cystic epithelium. Finally, the tourniquet was loosened, the spurting vessels tied off, and the stapler and the sta- ples applied (Figure 3). This technique prevents af- terbleeding and regrowth of the cyst. If necessary, fibrin glue (Tissucol, Immuno AG, Vienna, Austria) can be ap- plied to the resected edges with a compressed-air sprayer (Tissomat, Immuno AG) and sealed with collagen fleece. We used the TA-55 stapler (Auto Sttture Instruments, Norwalk, Connecticut) 14 times and the TA-90 stapler once. The choice of staple unit always depended on the thickness of the splenic parenchyma. We used 3.5 nonre- sorbable stapler units (height of closed staple, 1.5 mm) twice, and the Polysorb 55 disposable unit (United States Surgical Corporation, Norwalk, Connecticut) with ab- sorbable staples 13 times. In three cases, these were #170 staples with a height of 4.3 mm when closed. In the re- maining resections we used #200 staples with a height of 5 mm when closed. To save as much of the organ as pos- sible, we made a V-shaped resection with the TA-55 THE AMERICAN JOURNALOF SURGERY VOLUME 168 JULY 1994 49