This operative video demonstrates a robotic splenectomy with intraoperative ultrasound performed for FDG-avid splenic lesions suspicious for hematologic malignancy.

The patient is a 64-year-old woman with a complex medical history, including thalassemia, insulin-dependent diabetes mellitus, chronic kidney disease, antiphospholipid syndrome requiring chronic anticoagulation, and idiopathic thrombocytopenic purpura. She previously experienced hemorrhagic shock due to splenic hemorrhage, which was treated with transarterial splenic artery coil embolization.

The patient later presented with sepsis, hypercalcemia, and enlarging FDG-avid splenic lesions, raising strong suspicion for an underlying hematologic malignancy versus infectious process. Prior bone marrow biopsies were nondiagnostic, and percutaneous biopsy of the splenic lesions was considered prohibitively high risk due to the patient’s complex comorbidities and prior splenic artery embolization.

After multidisciplinary evaluation, the patient was offered diagnostic and therapeutic splenectomy.

The patient underwent robotic staging laparoscopy followed by robotic splenectomy with intraoperative ultrasound.

Intraoperative findings included:

• Inflammatory adhesions

• Splenomegaly with a large splenic mass

• Evidence of prior splenic artery coil embolization

The spleen was mobilized by dividing the gastrocolic ligament and short gastric vessels, allowing entry into the lesser sac and exposure of the splenic hilum. The splenocolic ligament was divided and the splenic flexure mobilized to facilitate complete splenic mobilization.

Careful dissection was performed to identify and preserve the tail of the pancreas, which was separated from the splenic hilar vessels prior to vascular division.

The splenic artery and splenic vein were divided using a robotic vascular stapler, and the specimen was retrieved in an EndoCatch bag through a Pfannenstiel extraction incision.

The patient tolerated the procedure well without intraoperative complications.

Final pathology demonstrated:

• Diffuse large B-cell lymphoma involving the spleen

• High proliferative index (Ki-67 >90%)

Fluorescence in situ hybridization analysis did not demonstrate MYC, BCL2, or BCL6 rearrangements, excluding high-grade double-hit lymphoma.

This case illustrates the role of robotic splenectomy in the diagnosis and management of suspected splenic lymphoma, particularly in medically complex patients in whom bone marrow biopsy is nondiagnostic and percutaneous splenic biopsy is unsafe.