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.