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Open splenectomy - general and visceral surgery
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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
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
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
Inspecting the surgical field and inserting a drain
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
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.