In this video, we will discuss the proper technique to expose the spleen and perform a splenectomy.
Segment:1 Objectives .
We will begin by discussing the relevant anatomy, the instruments and positioning, the exposure and techniques, and, finally, the tips and pitfalls of this exposure.
Segment:2 Anatomy .
The spleen is located in the left upper quadrant of the abdomen and in close proximity to several organs, to which the spleen is attached by four ligaments. Knowledge of these attachments is key to mobilization of the spleen for exposure and, if necessary, splenectomy.
Inferior to the spleen is located the splenic flexure of the colon. The spleen is attached to the colon by the splenocolic ligament. Posterolaterally is located the left kidney, and the splenorenal ligament. Superiorly located is the left hemidiaphragm and the splenophrenic ligament, which is not shown here. Medially is the greater curvature of the stomach and the splenogastric ligament. The splenogastric ligament is unique in that it is the only vascular ligament containing the short gastric vessels.
Care must be taken to ligate these vessels during division of the splenogastric ligament. Note that during an emergent splenectomy for trauma, the avascular ligaments, including the splenocolic, splenorenal, and splenophrenic ligaments can often be mobilized bluntly. However, if preservation of the spleen is anticipated, forceful traction of the spleen may cause injury to the spleen during blunt mobilization. The splenic hilum, which is located along the medial border, is in close proximity to the tail of the pancreas, and care must be taken to avoid inadvertent injury to the pancreas during exposure of the hilum.
Segment:3 Instrumentation and Positioning .
The patient should be positioned supine, with the arms abducted at 90 degrees, and a standard trauma laparotomy prep of the abdomen from the nipples to the knees is utilized. A standard laparotomy tray is sufficient, although inclusion of surgical staplers and electrothermal bipolar or harmonic sealing devices, such as a LigaSure or harmonic scalpel, may be useful for ligation and division of the short gastric vessels and the splenic hilum.
A midline laparotomy incision is made in the skin from the xiphoid process to the pubis symphysis using a scalpel. The incision is carried through the subcutaneous fat using a Bovie electrocautery. Upon entry to the peritoneal cavity, a fixed self-retaining retractor, such as the Bookwalter retractor, is very useful. Next, the surgeon's hand is placed deep in the left upper quadrant of the abdomen, gently cradling the spleen along its posterolateral surface.
And several laparotomy pads are placed behind the spleen, thus medializing the spleen and providing excellent exposure for inspection. Note the locations of the ligamentous attachments, including the splenocolic ligament, the splenogastric ligament, the splenorenal ligament, and the splenophrenic ligament.
Gentle downward traction is placed on the splenic flexure of the colon, and the splenocolic ligament is put on tension and then divided with the Bovie electrocautery. The spleen is gently retracted medially, and division of the splenic attachments is continued along its posterolateral border. The splenorenal ligament is next divided, followed by the splenophrenic ligament.
With the posterolateral attachments of the spleen divided, the spleen is easily retracted medially, revealing the posterior aspect of the spleen and the tail of the pancreas. Next, the spleen is retracted laterally, revealing the splenogastric ligament and the short gastric vessels located between the greater curvature of the stomach and the medial aspect of the spleen.
The splenogastric ligament is carefully dissected in order to expose the short gastric vessels. The short gastric vessels may then be ligated and divided serially. Here, they are ligated with sutured ties. However, an alternative is to divide the splenogastric ligament and the short gastric vessels on block, using an electrothermal sealing device like the LigaSure.
Once the splenogastric ligament is divided, the hilum of the spleen is easily accessible. Note the close proximity of the tail of the pancreas. Any attachments between the tail of the pancreas and the splenic hilum are carefully dissected and divided in order to provide adequate exposure to the splenic vessels and to prevent inadvertent injury to the pancreatic tail. The splenic vessels are dissected close to the spleen in order to avoid injury to the pancreas.
At the splenic hilum, note that the splenic vessels consist of several branches, which should be identified and carefully dissected. Here, the splenic vessels are ligated using silk ties and divided with the Metzenbaum scissors. Alternative methods to ligate and divide the splenic hilum include the GIA stapler with a vascular load, or the LigaSure device. Once the splenic hilum is completely divided, the spleen is then removed.
The vascular pedicles to the spleen, including the short gastric vessels and the hilar vessels, should be reexamined to ensure hemostasis. Nonoperative management of severe splenic injuries
Segment:4 Tips and Pitfalls.
in patients with traumatic brain injury or coagulopathy is generally not recommended. The short gastric vessels should be ligated close to the spleen in order to prevent injury to the greater curvature of the stomach. Similarly, the splenic vessels should be ligated close to the spleen in order to prevent injury to the tail of the pancreas.
The most common sites of persistent bleeding postoperatively are at the tail of the pancreas from the superior pancreatic artery and at the insertion sites of the short gastric vessels into the stomach. Remember to vaccinate patients post-splenectomy against encapsulated organisms. In hemodynamically stable patients, alternatives to splenectomy include splenic salvage, including partial splenectomy and splenorrhaphy, and angioembolization.