Open splenectomy

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  • Praxis für Handchirurgie und Handgelenkchirurgie Frankfurt

    Dr. med. Kirsten Beyermann

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  • Surgical anatomy

    The spleen is an intraperitoneal organ, located between the stomach, diaphragm, left kidney, and colon. Because of its close relationships, splenomegaly may impair the functioning of these organs. The tail of the pancreas directly faces the splenic hilum. Trying to stop splenic hemorrhage by uncontrolled clamping of the splenic hilum always puts the pancreas at risk!

    The spleen is invested by peritoneum except for the hilum and the region in juxtaposition with the tail of the pancreas. This results in duplications of the peritoneum, which are considered to be part of the lesser sac:

    • The phrenicosplenic ligament extends from the inferior aspect of the diaphragm to the splenic hilum. It comprises the tail of the pancreas (pancreaticosplenic ligament), all of the splenic vessels, and the trunk of the left gastroepiploic artery. Caudad, it attaches to the splenocolic ligament.
    • The gastrosplenic ligament inserts on the greater curvature of the stomach and the splenic hilum. It comprises the short gastric arteries and veins and the left gastroepiploic artery.
    • The splenocolic ligament attaches the left colonic flexure to the inferior pole of the spleen.

    In addition, numerous secondary adhesions with adjacent structures will arise over the years. It is here where the capsule of the spleen is liable to tear during dissection. Therefore, extreme caution should be exercised when exposing the organ. On the one hand, a torn capsule results in unnecessary blood loss with diffuse bleeding, thereby impairing exposure of the field. On the other hand, in patients with hematopoietic disorders the capsule of the spleen must remain intact to prevent seeding of the peritoneal cavity with splenic tissue (“peritoneal splenosis”).

    In patients with hematological disorders, the first step in elective surgery mandates the search for accessory spleens, which are seen in approximately 25% of cases. They may grow to considerable size after splenectomy, thereby negating the benefit of the procedure. For ontogenetic reasons, the fully functional accessory organs are always located on the left side. It is therefore always advisable in such cases to carry out the search in the following order: Splenic hilum, tail of the pancreas, gastrosplenic ligament, greater omentum, mesentery, and left lower quadrant!

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  • Indication

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  • Contraindication

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments

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  • Postoperative management

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date of publication: 27.02.2012

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  • Incision

    Access: In elective splenectomy a transverse left upper quadrant incision. Optionally, access may also be gained via a left subcostal incision.

    In trauma, a midline upper quadrant incision is actually the only acceptable option to gain access to the abdomen. This is the only access ensuring sufficient exposure of the entire abdomen.

    In the procedure presented here, the incision is determined by the previous laparotomy for primary tumor resection.
    Make a midline incision from the xiphoid process to below the umbilicus. Transect the subcutaneous tissue and expose the fascia. Transect the fascia along the midline with electrocautery and open the peritoneum.

    Tip: In coagulopathy, avoid transecting any of the major muscles of the abdominal wall, as this may trigger massive hemorrhage!

    Insert the retractor system and explore the entire abdominal cavity to rule out accessory spleens!

    Tip: In trauma, you may only see blood at first when opening the peritoneum and will not have any exposure at all. In particular, the source of the bleeding is rarely apparent at first glance. It is recommended to first pack all four quadrants with abdominal towels instead of suctioning off blood for several minutes. The surgeon should not hesitate to firmly grasp the spleen from behind with the left hand, dislocate it anteriad, and pack the perisplenic and splenocolic recess with one or two abdominal towels. This allows proper exposure and evaluation of the spleen, while the compression from posteriad decreases the bleeding.

    In principle, the spleen may be mobilized from either the anterior or posterior aspect. The posterior variant is the standard technique employed in splenectomy, especially in emergency situations. As presented here, in some tumors and very large spleens the anterior technique is preferred. In principle, both approaches are possible and should be decided on a case-by-case basis. During the dissection it is often necessary to alternate between the anterior and posterior aspects.

  • Entering the lesser sac

    Transect the gastrocolic ligament and enter the lesser sac Completely mobilize the left colonic flexure from here. Transect the splenocolic ligament between ligatures.

    Tip: Leave intact the phrenicocolic ligament, which supports the inferior pole of the spleen like a hammock. This prevents the left colonic flexure from slipping into the free space of the perisplenic and splenocolic recess, which could lead to kinking of the large intestine and gastrointestinal transit disorders.

  • Transecting the short gastric vessels

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    Transect the gastrosplenic ligaments, including the short gastric vessels, between ligatures.

    Tip: Usually, the distance between the superior pole of the spleen and the greater curvature of the stomach at the gastrosplenic ligament is quite short. For this reason, there is a tendency to transect the short gastric vessels immediately at the gastric wall. This may result in wall necrosis with subsequent gastric leakage. Repair any deserosalized areas of the gastric wall with seroserous sutures.

  • Transecting the splenic vessels

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    Separate the splenic vessels in the splenic hilum after identifying its border with the tail of the pancreas. Then transect these vessels and secure their central stumps with suture ligatures.

    Tip: Do not ligate the artery too far centred, as branches extend here into the tail of the pancreas, and necrosis of the tail of the pancreas may otherwise occur.

  • Dissecting the tail of the pancreas and removing the spleen

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    After posterior incision of the peritoneum on the diaphragm, dislocate the spleen anteriad. Expose the hilar border of the spleen with the tail of the pancreas and complete the hilar dissection. Remove the spleen.

  • Inspecting the surgical field and inserting a drain

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    Oversew any minor bleeding/injuries at the tail of the pancreas. Thoroughly inspect the entire field. Oversew any deserosalized areas of the stomach and colon; cauterize or ligate any bleeders. Then thoroughly lavage the field.

    Tip: It has proven effective to assess the following danger points in the order shown: 1-hilar vessels, 2-tail of the pancreas, 3-colon, 4-stomach (most common source of bleeding, short gastric arteries/veins), 5-diaphragm, 6-perisplenic/splenocolic recess, left kidney, adrenal gland, 7-retroperitoneal veins

    Draining the former perisplenic/splenocolic recess is optional but should be considered mandatory if the pancreas is also involved.

  • Closing the laparotomy

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    Close the abdominal wall with a running suture PDS 2 encompassing the fascia and peritoneum. Spare the muscle as much as possible because otherwise this will only result in muscular necrosis and subsequent infections. After optional closure of the subcutaneous layer with, e.g.,Vicryl 2/0, close the skin. For this we recommend a rapidly absorbable subdermal running suture with, e.g., Monocryl 4/0. Optionally, close the skin with a standard subcuticular suture, interrupted sutures or skin staples.

    Send the specimen for pathology.

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  • Intraoperative complications

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  • Postoperative complications

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