The spleen lies intraperitoneally between the stomach, diaphragm, left kidney, and colon. Due to the close positional relationship, splenomegaly can impair the function of these organs. Directly opposite the splenic hilum lies the tail of the pancreas. In untargeted clamping of the splenic pedicle to stop profuse bleeding, the pancreas is always at risk!
Except in the hilum and the area where the pancreatic tail attaches, the spleen is covered by peritoneum. This results in peritoneal duplications, which are to be considered as part of the omental bursa:
- The phrenicosplenic ligament stretches from the underside of the diaphragm to the splenic hilum. It contains the pancreatic tail (pancreaticosplenic ligament), all splenic vessels, and the trunk of the left gastroepiploic artery. Caudally, it connects with the splenocolic ligament.
- The gastrosplenic ligament inserts at the greater curvature of the stomach as well as at the splenic hilum. It carries the short gastric arteries/veins and the left gastroepiploic artery.
- The splenocolic ligament connects the left colonic flexure with the lower pole of the spleen.
In addition, numerous secondary adhesions to neighboring structures form over the course of life. Here, the splenic capsule tends to tear during preparation. Therefore, extreme caution must be exercised when exposing the organ. A capsule tear leads on the one hand to unnecessary blood loss with diffuse bleeding, which impairs visibility. On the other hand, in diseases of the hematopoietic system, the splenic capsule must remain intact to exclude dissemination of splenic tissue into the peritoneal cavity (“peritoneal splenosis”).
In hematological diseases, it is furthermore obligatory, as the first step of the elective operation, to search for accessory spleens, which are found in about 25% of cases. They can grow to considerable size after splenectomy and thus nullify the success of the operation. For ontogenetic reasons, the additional, fully functional organs are always on the left. It is therefore recommended in such cases to always search the splenic hilum, pancreatic tail, gastrosplenic ligament, greater omentum, mesentery, and left lower abdomen in this order!