- Email: [email protected]
Partial splenectomy with the CO2 laser: An alternative technique
JOURNAL
OF SURGICAL
RESEARCH
41,580-586
Partial Splenectomy
(1986)
with the CO2 Laser: An Alternative
Technique
MARLETA REYNOLDS, M.D., JOSEPH LOCICERO III, M.D., STEPHANIE YOUNG, M.D., ANDLAWRENCEL.MICHAELIS,M.D. Department of Surgery, Northwestern Childrens Memorial Hospital,
University Medical School, Chicago, Illinois 60614
Submitted for publication November 27, 1985 Because total splenectomy has been shown to alfect immunocompetence in children, partial splenectomy is advocated as an alternative to total splenectomy in traumatic injury as well as in treatment of benign cysts.Present techniques include elaborate hemostatic techniques and extensive suture repair which has led to the development of massive abdominal adhesions. We have investigated CO2 laser sealing of splenic wounds to obviate the need for extensive repair and to minimize intraabdominal reaction. Five dogs underwent partial splenectomy with a scalpel. Hemostasis was obtained with CO2 laser coagulation; a defocused laser beam at 8 W (power density 30-50 W/cm*). After 3 weeks, the laser sealed splenic tissue was amputated and, on this occasion, hemostasis was obtained using a standard suture technique of Teflon pledget-bolstered chromic sutures. Three weeks later the dogs were explored and the sutured splenic tissue was removed. Gross findings on the first exploration demonstrated no signs of hemorrhage and minimal adhesions of the laser sealed spleens. In contrast, exploration after suture repair revealed dense adhesions containing the spleen, omentum, mesentery, and small and large bowel. Microscopic examination of the laser sealed spleen showed a zone of injury only 2-3-mm thick. Excellent hemostasis of the cut surface of the spleen can be accomplished using the CO* laser. In addition, the minimal depth of injury and the absence of foreign material in the peritoneal cavity make this an attractive alternative t0 COIIVentiOnd methods. 0 1986 Academic Press, Inc.
INTRODUCTION
MATERIALS
Techniques of splenic salvage have been developed in an attempt to conserve the immunologic function of the spleen [ 11. A variety of surgical techniques, and, more recently, nonoperative management and observation have become popular [ 151. Occasionally, an elective partial splenectomy is indicated for diagnosis or for resection of a benign cyst. However, with the current available techniques there is fear that patients may suffer delayed rupture of the spleen with significant hemorrhage or develop massive intra-abdominal adhesions from the repair. At our institution, laparotomies in two children who had previously undergone splenic repair using Teflon bolsters were complicated and prolonged by massive adhesions of the omentum, mesentery, and small bowel to the Teflon pledgets. This clinical experience has led to the investigation of another salvage technique that might prove useful in such patients. 0022-4804/86
$1.50
Copyright 0 1986 by Academic Press, Inc. All rights of reproduction in any form reserved.
AND
METHODS
Five mongrel dogs were anesthetized using intravenous sodium pentobarbitol (3 mg/kg) and allowed to ventilate spontaneously after endotracheal intubation. An upper midline abdominal incision was made and the spleen elevated into the wound. The lower pole (approximately one-third) of the spleen was resected with a scalpel. Using manual compression of the splenic hilum, the cut surface of the spleen was sealed using the defocused beam of a CO2 laser’ at 8 W (power density 30-50 W/cm2). Large vessels were suture-ligated with a figure-of-eight chromic suture. After hemostasis was obtained using this method, the spleen was returned to the abdomen and the abdomen was closed with running nylon suture. The animals were treated in accordance with the National Academy of Science guidelines for the care and use of laboratory animals. ’ Sharplan, Inc., Israel. 580
REYNOLDS
ET
AL.:
PARTIAL
After 3 weeks, the dogs were again anesthetized and explored through the same incision. Extent of intraabdominal adhesions was noted and the portion of the spleen that had been coagulated with the laser was excised. The spleen was then repaired using Teflon bolsters and running chromic sutures. Again the abdomen was reexplored after 3 weeks and the portion of the spleen that had been repaired with Teflon was excised. The CO* laser was used again to obtain a seal on the remaining spleen. All splenic tissue was examined microscopically with hematoxylin and eosin staining. RESULTS
The COZ laser was successful in sealing the cut surface of the transected spleen. This technique could be performed with great ease and speed when the splenic hilum was controlled. Splenic parenchyma and blood vessels less than 5 mm in diameter were sealed with the laser. It was necessary to ligate only a few large
581
SPLENECTOMY
blood vessels with individual suture ligation technique. No more than three vessels per spleen required this approach. Examination of the abdomen 3 weeks following COZ laser sealing revealed minimal abdominal adhesions (Fig. 1). No blood or clot was found at reexploration. A single piece of omentum was adherent to the splenic surface. There was no evidence of infection. By contrast, splenic repair using Teflon bolstered sutures was technically more difficult than the laser procedure. Even with compression of the splenic hilum, more bleeding was encountered during this type of repair. In one case, the splenic parenchyma cracked, requiring an additional bolster to prevent hemorrhage. Three weeks later, extensive intraabdominal adhesions were found (Fig. 2). Mesentery, omentum, small bowel, and colon were adherent to each other and to the Teflon bolsters as well as to the spleen surface. Purulent material was identified in all five specimens. One dog died from a perforated viscus and
FIG. 1. Splenic repair with CO2 laser coagulation results in a thin film of fibrin A single piece of omentum is adherent to the fibrin surface.
over the cut splenic surface.
582
JOURNAL OF SURGICAL RESEARCH: VOL. 41, NO. 6, DECEMBER
1986
FIG. 2. The omentum, small bowel, and small bowel mesentery are densely adherent to each other and to the suture repaired splenic surface.
small bowel obstruction adhesions.
secondary to these
Microscopic jindings. Light microscopic examination of the splenic tissue excised 3 weeks following laser sealing of the splenic surface demonstrated an injury measuring 2-3 mm in greatest depth (Figs. 3,4). The underlying spleen was normal and sharply demarcated from the obviously damaged tissue. Within this area of damage, four discrete zones were noted. The outermost zone was a hypocellular band of fibrous tissue. This zone may correspond to the omental adhesion. Next was a zone of well organized granulation tissue formed by capillaries and fibroblasts, denatured protein (orange pigment), foreign body giant cells, and macrophages. Below this zone was a second dense band of hypocellular to acellular fibrous tissue. Finally, there was a subadjacent zone of hemorrhage followed by normal appearing but somewhat congested splenic tissue. In one specimen there was an infarction, measuring 3 cm in depth, of the
underlying spleen. One specimen showed evidence of thrombi within the recanalized vessels of the injured zone. In comparison, the splenic tissue 3 weeks after repair with Teflon pledgets revealed evidence of an acute inflammatory exudate on both sides of a band of fibrous tissue at the margin of resection (Figs. 5, 6). This exudate varied in depth but extended deep into the splenic red pulp. In some specimens the red pulp was replaced by this dense, extensive suppurative process and, in others, the red pulp was only focally and superficially invaded. No microorganisms could be identified in this exudate. The size of this injury at its smallest depth was 3 cm. DISCUSSION
Methods of hemisplenectomy or splenic repair have been described in the past, but it was not until the reports of compromised immunocompetence and postsplenectomy pneu-
FIG. 3. A zone of granulation tissue containing foreign body giant cells and denatured protein (to the right) constitutes the depth of injury following CO2 laser coagulation. The subadjacent normal appearing splenic tissue (to the left) is rather sharply demarcated from the granulation tissue. (2 1X, H & E)
FIG. 4. The zone of granulation tissue contains irregular foci of denatured protein (black) surrounded and engulfed by foreign body giant cells. (2 10X, H & E)
583
584
JOURNAL OF SURGICAL RESEARCH: VOL. 41, NO. 6, DECEMBER
1986
nc. 5. Acute inflammatory exudate containing numerous polymorphonuclear leukocytes lies at the margin of resection of splenic tissue repaired with Teflon pledgets. (2 1X, H & E)
FIG. 6. Dense clusters of polymorphonuclear
leukocytes and fibrinous exudate are seen. (2 10X, H & E)
REYNOLDS
ET AL.: PARTIAL
mococcal sepsis that splenic salvage was recommended [ 151. A critical mass of spleen (more than one-third) was reported by Van Wicht to be important in host resistance to pneumococcal challenge [ 171. Grosfeld and Ronachak reported that following hemisplenectomy in traumatized rats, a normal response to a pneumococcal challenge could be expected [8]. When compared with splenic reimplantation, a partial splenectomy in rats was found to be superior in producing a response to pneumococcal challenge [2]. Since splenic immunologic function seems to be maintained with partial splenic salvage, splenorrhaphy has become the preferred method of handling splenic injury at operation. Buntain and Lynn extensively reviewed the state of the art for splenic repair in 1979 and added two of their own techniques [ 11. Since that time, management of children with suspected splenic injury by noninvasive splenic evaluation and observation has changed the operative indications and reduced the number of spleens at risk. There are still indications for partial splenectomy, including excision of benign cysts and for diagnosis in suspected intraabdominal malignancy. Recent advances in technology have provided an even greater number of choices in the technique of splenic repair. Gottlob et al. reported using cyanoacrylate adhesives in the form of a grid to repair the injured spleen [7]. The microwave coagulating scalpel has been successfully used in experimental animals for partial splenectomy [ 161. Ultrasonic welding of the splenic surface after pretreatment with liquid cyanoacrylate monomers was considered successful in experimental animals [lo]. More recently, Delaney and associates described a technique for splenorrhaphy using woven polyglycolic acid mesh in dogs [3]. Millikan treated 49 of 72 patients with injured spleens by splenorrhaphy using electrocautery and microfibrillar collagen application to capsular tears, augmented by Teflon pledgeted sutures for deeper injuries [ 111. “Fibrin seal,” a combination of fibrinogen, cold and soluble globulin factor VIII, bovine antiplasmin, and platelet growth factor with calcium-thrombin
SPLENECTOMY
585
solution, was shown to be more efficacious than microfibrillar collagen cryoprecipitate in obtaining hemostasis in experimental splenic injuries [4]. Scheele reported successful use of fibrin tissue adhesive with and without collagen fleece in 100 of 108 patients with splenic injury [ 141. The question of blood product antigenicity makes these techniques less attractive. The laser has been used as a surgical tool by many surgical subspecialists, but its application in general surgery has been mostly limited to the animal laboratory. Dickson reported the use of the neodymium-doped ytrium aluminum garnet (Nd:YAG) laser for partial splenectomy in dogs [5]. Orda and Ellis compared the COZ laser with diathermy and scalpel in splenic wound healing in rats [ 131. The CO* laser used in this experiment seals the cut parenchyma by coagulation. Blood vessels less than 5 mm can be sealed in a similar fashion. A study similar to ours has recently been published by Dr. Goldenberg and associates [6]. This study suggests that tissue damage induced by the CO;! laser is confined to a fairly discrete superficial zone without affecting the normal appearing underlying tissue. In one specimen, presence of adjacent infarction was due to a variation in technique. It appears that the COZ laser-treated splenic tissue forms a well delineated mature scar. In contrast to Teflon bolstered sutures, the present standard therapy, there was no acute inflammation or exudative process. In addition, there was a marked difference in the formation of surrounding intraabdominal adhesions. Although the procedure does not reduce overall operative time, there were no untoward sequelae resulting from the use of this technique. The CO* laser is now available in many operating rooms. Although its use in surgery of solid organs remains in its infancy, adequate laboratory studies have been conducted to allow clinical trials. Our study supports the idea that the CO* laser can be used to obtain hemostasis and to provide a means of splenic repair. The splenic tissue response to CO2 laser injury is minimal, thus the use of prosthetic
586
JOURNAL OF SURGICAL RESEARCH: VOL. 41, NO. 6, DECEMBER
materials and their associated problems may be avoided. REFERENCES 1. Buntain, W. L., and Lynn, H. B. Splenorrhaphy: Changing concepts for the traumatized spleen. Surgery 86: 748, 1979. 2. Cooney, D. R., Dearth, J. C., Swanson, S. E., Dewanjie, M. D., and Telander, R. L. Relative merits of partial splenectomy, splenic reimplantation and immunization in preventing postsplenectomy infection. Surgery 86: 561, 1979. 3. Delaney, M., Porreca, F., Mitsudo, S., et al. Splenic capping: An experimental study of a new technique for splenorrhaphy using woven polyglycolic acid mesh. Ann. Surg. 196: 187, 1982. 4. DeRisi, D., Petrelli, N. S., Cohen, H., et al. Attempts to bypass the need for splenectomy in splenic injury. J. Surg. Oncol. 19: 74, 1982. 5. Dixon, J. A., Miller, F., McCloskey, D., and Siddoway, J. Anatomy and techniques in segmental splenectomy. Surg. Gynecol. Obstet. 150: 516, 1980. 6. Goldenberg, A., Goldenberg, S., Neto, J. G., and Chacon, J. P. CO2 laser and suture in splenic parenchyma: An experimental study. Lasers Surg. Med. 5: 405, 1985. I. Gottlob, R., Zinner, G., Donas, P., and Lechner, G. Grid adhesion: A new type of tissue union. ht. Surg. 65: 139, 1980. 8. Grosfeld, J. L., and Ranochak, J. E. Are hemisple-
9. 10. 11.
12. 13.
14. 15.
16.
17.
1986
nectomy and/or primary splenic repair feasible? J. Pediatr. Surg. 11: 419, 1976. King, R., Lobe, T. E., Haase, G. M., and Boles, E. T. Selective management of injured spleen. Surgery 90: 677, 1981. Kuhne, W., Richter, J., and Martens, H. Wound healing of spleen ruptures by ultrasonic welding in animal experiments. Exp. Puthol. 24: 167, 1983. Millikan, J. S., Moore, E. E., Moore, G. E., and Stevens, R. E. Alternatives to splenectomy in adults after trauma: Repair, partial resection, and reimplantation of splenic tissue. Amer. J. Surg. 144: 711, 1982. Oakes, D. Splenic trauma. In M. M. Ravitch, (Ed.), Current Problems in Surgery. Chicago: Year Book Med. Publ. 1981. Vol. XVIII, pp. 341-401. Orda, R., and Ellis, H. H. Experimental study of hepatic, renal and splenic wound healing following laser, diathermy, and scalpel incisions. Amer. Surg. 47: 447, 1981. Scheele, J., Gentsch, H. H., and Matteson, E. Splenic repair by fibrin tissue adhesive and collagen fleece. Surgery 95: 6, 1984. Sherman, R. Perspectives in management of trauma to the spleen: 1979 Presidential Address, American Association for the Surgery of Trauma. J. Trauma 20: 1, 1980. Toy, F. K., Reed, W., and Taylor, L. S. Experimental splenic preservation employing microwave surgical technique: A preliminary report. Surgery 96: 117, 1984. Van Wyck, D. B., Witte, M. H., Witte, C. L., et al. Critical splenic mass for survival from experimental pneumococcemia. J. Surg. Res. 78: 14, 1980.
OF SURGICAL
RESEARCH
41,580-586
Partial Splenectomy
(1986)
with the CO2 Laser: An Alternative
Technique
MARLETA REYNOLDS, M.D., JOSEPH LOCICERO III, M.D., STEPHANIE YOUNG, M.D., ANDLAWRENCEL.MICHAELIS,M.D. Department of Surgery, Northwestern Childrens Memorial Hospital,
University Medical School, Chicago, Illinois 60614
Submitted for publication November 27, 1985 Because total splenectomy has been shown to alfect immunocompetence in children, partial splenectomy is advocated as an alternative to total splenectomy in traumatic injury as well as in treatment of benign cysts.Present techniques include elaborate hemostatic techniques and extensive suture repair which has led to the development of massive abdominal adhesions. We have investigated CO2 laser sealing of splenic wounds to obviate the need for extensive repair and to minimize intraabdominal reaction. Five dogs underwent partial splenectomy with a scalpel. Hemostasis was obtained with CO2 laser coagulation; a defocused laser beam at 8 W (power density 30-50 W/cm*). After 3 weeks, the laser sealed splenic tissue was amputated and, on this occasion, hemostasis was obtained using a standard suture technique of Teflon pledget-bolstered chromic sutures. Three weeks later the dogs were explored and the sutured splenic tissue was removed. Gross findings on the first exploration demonstrated no signs of hemorrhage and minimal adhesions of the laser sealed spleens. In contrast, exploration after suture repair revealed dense adhesions containing the spleen, omentum, mesentery, and small and large bowel. Microscopic examination of the laser sealed spleen showed a zone of injury only 2-3-mm thick. Excellent hemostasis of the cut surface of the spleen can be accomplished using the CO* laser. In addition, the minimal depth of injury and the absence of foreign material in the peritoneal cavity make this an attractive alternative t0 COIIVentiOnd methods. 0 1986 Academic Press, Inc.
INTRODUCTION
MATERIALS
Techniques of splenic salvage have been developed in an attempt to conserve the immunologic function of the spleen [ 11. A variety of surgical techniques, and, more recently, nonoperative management and observation have become popular [ 151. Occasionally, an elective partial splenectomy is indicated for diagnosis or for resection of a benign cyst. However, with the current available techniques there is fear that patients may suffer delayed rupture of the spleen with significant hemorrhage or develop massive intra-abdominal adhesions from the repair. At our institution, laparotomies in two children who had previously undergone splenic repair using Teflon bolsters were complicated and prolonged by massive adhesions of the omentum, mesentery, and small bowel to the Teflon pledgets. This clinical experience has led to the investigation of another salvage technique that might prove useful in such patients. 0022-4804/86
$1.50
Copyright 0 1986 by Academic Press, Inc. All rights of reproduction in any form reserved.
AND
METHODS
Five mongrel dogs were anesthetized using intravenous sodium pentobarbitol (3 mg/kg) and allowed to ventilate spontaneously after endotracheal intubation. An upper midline abdominal incision was made and the spleen elevated into the wound. The lower pole (approximately one-third) of the spleen was resected with a scalpel. Using manual compression of the splenic hilum, the cut surface of the spleen was sealed using the defocused beam of a CO2 laser’ at 8 W (power density 30-50 W/cm2). Large vessels were suture-ligated with a figure-of-eight chromic suture. After hemostasis was obtained using this method, the spleen was returned to the abdomen and the abdomen was closed with running nylon suture. The animals were treated in accordance with the National Academy of Science guidelines for the care and use of laboratory animals. ’ Sharplan, Inc., Israel. 580
REYNOLDS
ET
AL.:
PARTIAL
After 3 weeks, the dogs were again anesthetized and explored through the same incision. Extent of intraabdominal adhesions was noted and the portion of the spleen that had been coagulated with the laser was excised. The spleen was then repaired using Teflon bolsters and running chromic sutures. Again the abdomen was reexplored after 3 weeks and the portion of the spleen that had been repaired with Teflon was excised. The CO* laser was used again to obtain a seal on the remaining spleen. All splenic tissue was examined microscopically with hematoxylin and eosin staining. RESULTS
The COZ laser was successful in sealing the cut surface of the transected spleen. This technique could be performed with great ease and speed when the splenic hilum was controlled. Splenic parenchyma and blood vessels less than 5 mm in diameter were sealed with the laser. It was necessary to ligate only a few large
581
SPLENECTOMY
blood vessels with individual suture ligation technique. No more than three vessels per spleen required this approach. Examination of the abdomen 3 weeks following COZ laser sealing revealed minimal abdominal adhesions (Fig. 1). No blood or clot was found at reexploration. A single piece of omentum was adherent to the splenic surface. There was no evidence of infection. By contrast, splenic repair using Teflon bolstered sutures was technically more difficult than the laser procedure. Even with compression of the splenic hilum, more bleeding was encountered during this type of repair. In one case, the splenic parenchyma cracked, requiring an additional bolster to prevent hemorrhage. Three weeks later, extensive intraabdominal adhesions were found (Fig. 2). Mesentery, omentum, small bowel, and colon were adherent to each other and to the Teflon bolsters as well as to the spleen surface. Purulent material was identified in all five specimens. One dog died from a perforated viscus and
FIG. 1. Splenic repair with CO2 laser coagulation results in a thin film of fibrin A single piece of omentum is adherent to the fibrin surface.
over the cut splenic surface.
582
JOURNAL OF SURGICAL RESEARCH: VOL. 41, NO. 6, DECEMBER
1986
FIG. 2. The omentum, small bowel, and small bowel mesentery are densely adherent to each other and to the suture repaired splenic surface.
small bowel obstruction adhesions.
secondary to these
Microscopic jindings. Light microscopic examination of the splenic tissue excised 3 weeks following laser sealing of the splenic surface demonstrated an injury measuring 2-3 mm in greatest depth (Figs. 3,4). The underlying spleen was normal and sharply demarcated from the obviously damaged tissue. Within this area of damage, four discrete zones were noted. The outermost zone was a hypocellular band of fibrous tissue. This zone may correspond to the omental adhesion. Next was a zone of well organized granulation tissue formed by capillaries and fibroblasts, denatured protein (orange pigment), foreign body giant cells, and macrophages. Below this zone was a second dense band of hypocellular to acellular fibrous tissue. Finally, there was a subadjacent zone of hemorrhage followed by normal appearing but somewhat congested splenic tissue. In one specimen there was an infarction, measuring 3 cm in depth, of the
underlying spleen. One specimen showed evidence of thrombi within the recanalized vessels of the injured zone. In comparison, the splenic tissue 3 weeks after repair with Teflon pledgets revealed evidence of an acute inflammatory exudate on both sides of a band of fibrous tissue at the margin of resection (Figs. 5, 6). This exudate varied in depth but extended deep into the splenic red pulp. In some specimens the red pulp was replaced by this dense, extensive suppurative process and, in others, the red pulp was only focally and superficially invaded. No microorganisms could be identified in this exudate. The size of this injury at its smallest depth was 3 cm. DISCUSSION
Methods of hemisplenectomy or splenic repair have been described in the past, but it was not until the reports of compromised immunocompetence and postsplenectomy pneu-
FIG. 3. A zone of granulation tissue containing foreign body giant cells and denatured protein (to the right) constitutes the depth of injury following CO2 laser coagulation. The subadjacent normal appearing splenic tissue (to the left) is rather sharply demarcated from the granulation tissue. (2 1X, H & E)
FIG. 4. The zone of granulation tissue contains irregular foci of denatured protein (black) surrounded and engulfed by foreign body giant cells. (2 10X, H & E)
583
584
JOURNAL OF SURGICAL RESEARCH: VOL. 41, NO. 6, DECEMBER
1986
nc. 5. Acute inflammatory exudate containing numerous polymorphonuclear leukocytes lies at the margin of resection of splenic tissue repaired with Teflon pledgets. (2 1X, H & E)
FIG. 6. Dense clusters of polymorphonuclear
leukocytes and fibrinous exudate are seen. (2 10X, H & E)
REYNOLDS
ET AL.: PARTIAL
mococcal sepsis that splenic salvage was recommended [ 151. A critical mass of spleen (more than one-third) was reported by Van Wicht to be important in host resistance to pneumococcal challenge [ 171. Grosfeld and Ronachak reported that following hemisplenectomy in traumatized rats, a normal response to a pneumococcal challenge could be expected [8]. When compared with splenic reimplantation, a partial splenectomy in rats was found to be superior in producing a response to pneumococcal challenge [2]. Since splenic immunologic function seems to be maintained with partial splenic salvage, splenorrhaphy has become the preferred method of handling splenic injury at operation. Buntain and Lynn extensively reviewed the state of the art for splenic repair in 1979 and added two of their own techniques [ 11. Since that time, management of children with suspected splenic injury by noninvasive splenic evaluation and observation has changed the operative indications and reduced the number of spleens at risk. There are still indications for partial splenectomy, including excision of benign cysts and for diagnosis in suspected intraabdominal malignancy. Recent advances in technology have provided an even greater number of choices in the technique of splenic repair. Gottlob et al. reported using cyanoacrylate adhesives in the form of a grid to repair the injured spleen [7]. The microwave coagulating scalpel has been successfully used in experimental animals for partial splenectomy [ 161. Ultrasonic welding of the splenic surface after pretreatment with liquid cyanoacrylate monomers was considered successful in experimental animals [lo]. More recently, Delaney and associates described a technique for splenorrhaphy using woven polyglycolic acid mesh in dogs [3]. Millikan treated 49 of 72 patients with injured spleens by splenorrhaphy using electrocautery and microfibrillar collagen application to capsular tears, augmented by Teflon pledgeted sutures for deeper injuries [ 111. “Fibrin seal,” a combination of fibrinogen, cold and soluble globulin factor VIII, bovine antiplasmin, and platelet growth factor with calcium-thrombin
SPLENECTOMY
585
solution, was shown to be more efficacious than microfibrillar collagen cryoprecipitate in obtaining hemostasis in experimental splenic injuries [4]. Scheele reported successful use of fibrin tissue adhesive with and without collagen fleece in 100 of 108 patients with splenic injury [ 141. The question of blood product antigenicity makes these techniques less attractive. The laser has been used as a surgical tool by many surgical subspecialists, but its application in general surgery has been mostly limited to the animal laboratory. Dickson reported the use of the neodymium-doped ytrium aluminum garnet (Nd:YAG) laser for partial splenectomy in dogs [5]. Orda and Ellis compared the COZ laser with diathermy and scalpel in splenic wound healing in rats [ 131. The CO* laser used in this experiment seals the cut parenchyma by coagulation. Blood vessels less than 5 mm can be sealed in a similar fashion. A study similar to ours has recently been published by Dr. Goldenberg and associates [6]. This study suggests that tissue damage induced by the CO;! laser is confined to a fairly discrete superficial zone without affecting the normal appearing underlying tissue. In one specimen, presence of adjacent infarction was due to a variation in technique. It appears that the COZ laser-treated splenic tissue forms a well delineated mature scar. In contrast to Teflon bolstered sutures, the present standard therapy, there was no acute inflammation or exudative process. In addition, there was a marked difference in the formation of surrounding intraabdominal adhesions. Although the procedure does not reduce overall operative time, there were no untoward sequelae resulting from the use of this technique. The CO* laser is now available in many operating rooms. Although its use in surgery of solid organs remains in its infancy, adequate laboratory studies have been conducted to allow clinical trials. Our study supports the idea that the CO* laser can be used to obtain hemostasis and to provide a means of splenic repair. The splenic tissue response to CO2 laser injury is minimal, thus the use of prosthetic
586
JOURNAL OF SURGICAL RESEARCH: VOL. 41, NO. 6, DECEMBER
materials and their associated problems may be avoided. REFERENCES 1. Buntain, W. L., and Lynn, H. B. Splenorrhaphy: Changing concepts for the traumatized spleen. Surgery 86: 748, 1979. 2. Cooney, D. R., Dearth, J. C., Swanson, S. E., Dewanjie, M. D., and Telander, R. L. Relative merits of partial splenectomy, splenic reimplantation and immunization in preventing postsplenectomy infection. Surgery 86: 561, 1979. 3. Delaney, M., Porreca, F., Mitsudo, S., et al. Splenic capping: An experimental study of a new technique for splenorrhaphy using woven polyglycolic acid mesh. Ann. Surg. 196: 187, 1982. 4. DeRisi, D., Petrelli, N. S., Cohen, H., et al. Attempts to bypass the need for splenectomy in splenic injury. J. Surg. Oncol. 19: 74, 1982. 5. Dixon, J. A., Miller, F., McCloskey, D., and Siddoway, J. Anatomy and techniques in segmental splenectomy. Surg. Gynecol. Obstet. 150: 516, 1980. 6. Goldenberg, A., Goldenberg, S., Neto, J. G., and Chacon, J. P. CO2 laser and suture in splenic parenchyma: An experimental study. Lasers Surg. Med. 5: 405, 1985. I. Gottlob, R., Zinner, G., Donas, P., and Lechner, G. Grid adhesion: A new type of tissue union. ht. Surg. 65: 139, 1980. 8. Grosfeld, J. L., and Ranochak, J. E. Are hemisple-
9. 10. 11.
12. 13.
14. 15.
16.
17.
1986
nectomy and/or primary splenic repair feasible? J. Pediatr. Surg. 11: 419, 1976. King, R., Lobe, T. E., Haase, G. M., and Boles, E. T. Selective management of injured spleen. Surgery 90: 677, 1981. Kuhne, W., Richter, J., and Martens, H. Wound healing of spleen ruptures by ultrasonic welding in animal experiments. Exp. Puthol. 24: 167, 1983. Millikan, J. S., Moore, E. E., Moore, G. E., and Stevens, R. E. Alternatives to splenectomy in adults after trauma: Repair, partial resection, and reimplantation of splenic tissue. Amer. J. Surg. 144: 711, 1982. Oakes, D. Splenic trauma. In M. M. Ravitch, (Ed.), Current Problems in Surgery. Chicago: Year Book Med. Publ. 1981. Vol. XVIII, pp. 341-401. Orda, R., and Ellis, H. H. Experimental study of hepatic, renal and splenic wound healing following laser, diathermy, and scalpel incisions. Amer. Surg. 47: 447, 1981. Scheele, J., Gentsch, H. H., and Matteson, E. Splenic repair by fibrin tissue adhesive and collagen fleece. Surgery 95: 6, 1984. Sherman, R. Perspectives in management of trauma to the spleen: 1979 Presidential Address, American Association for the Surgery of Trauma. J. Trauma 20: 1, 1980. Toy, F. K., Reed, W., and Taylor, L. S. Experimental splenic preservation employing microwave surgical technique: A preliminary report. Surgery 96: 117, 1984. Van Wyck, D. B., Witte, M. H., Witte, C. L., et al. Critical splenic mass for survival from experimental pneumococcemia. J. Surg. Res. 78: 14, 1980.