Splenectomy

Indications

-       Trauma

-       Lymphoma/leukaemia

-       Haemolytic anaemias

-       ITP

-       Splenomegaly with hypersplenism

-       Cysts, abscess, haemangioma or splenic artery aneurysm

-       Part of other operations

o   Gastrectomy

o   Distal pancreatectomy

o   Conventional splenorenal shunt

-       Tumour

Contraindications

Preoperative preparation

-       Correction of anaemia, thrombocytopaenia and coagulopathies

-       Prophylactic antibiotics

-       Vaccinations - see notes re timing

-       X-match

Anaesthesia

-       General anaesthesia

Position of the patient

-       Supine on the operating table

Special equipment

-       IDC

-       NGT

-       1+ assistants

Incision

-       Midline laparotomy

-       For smaller spleens – some use a left upper paramedian or left subcostal incision

Exploration

-       First tie the splenic artery in continuity

o   Enter lesser sac by dividing 8 – 10cm of greater omentum between ligatures

o   Keep to the colic side of the gastroepiploic vessels

o   Divide the adhesions between back of stomach and front of the pancreas

o   Palpate along superior border of body of pancreas for arterial pulsation; corkscrew artery (vein here is inferior and always deep to pancreas, never tortuous)

o   Incised the peritoneum at this point, mobilising the vessel with right angled forceps and ligating it with 0 ties

The splenic artery may be exposed and ligated above the tail of the pancreas by opening the gastrocolic ligament outside the gastroepiploic arcade and opening the posterior peritoneum of the lesser sac over the vessel. Proximal ligation should be avoided to prevent ischemic pancreatic injury. Preliminary ligation reduces the risk of haemorrhage and allows a large spleen to decompress and shrink, making surgery easier and safer

-       Pass the left hand over the top of the spleen to draw it medially

-       Retract the left side of the abdominal wall

-       Coagulate and divide any adhesions between the convex surface of the spleen and the parietal peritoneum

-       Cut through the left/anterior leaf of the lienorenal ligament (peritoneum just lateral to the spleen), slitting it upwards and downwards
Restores anatomical position; do not go through the gastrosplenic ligament.

-       Gently mobilise the spleen forwards and medially using the fingers of the left hand

-       Identify the left colic flexure and free it from the spleen

-       Identify the tail of the pancreas as it turns forwards into the splenic hilum and dissect it gently free

-       Place a pack in the splenic bed while completing the splenectomy

-       Free the spleen from its attachments to the diaphragm (avascular) and greater curvature of the stomach
(contain the vasa brevia);

-       Incise the anterior peritoneal leaf of the gastrosplenic ligament
Mobilise off splenocolic ligament; may need to use haemostats and ties; no major or named vessels but can cause troublesome bleeding

-       Identify, ligate and divide the short gastric vessels (care not to include any of the stomach wall in the ligatures), using a right angled forceps and ties; 3-4 short gastric; highest shortest.

-       Approach the hilum from the posterior aspect of well-mobilized spleen
Control the vascular pedicle of the spleen between fingers and thumb, dissecting away fatty tissue to expose the splenic artery and vein

-       Doubly clamp, ligate and divide each branch of the vessels close to the spleen (to avoid pancreas); suture ligate large branches (avoid damage to tail of pancreas)

-       Divide remaining peritoneal attachments (right leaf of lienorenal ligament)

-       Haemostasis

-       Look for accessory spleens (splenunculi)

Options arising during surgery

-       Massive spleen

o   Adhesions to the diaphragm or parenchymal tear can cause bleeding

o   Enlarge the incision or ligate the splenic artery on top of the pancreas to improve control or otherwise mobilise the organ and bring up into the incision as soon as can safely be achieved

-       Ruptured spleen

o   Often possible to break down the left peritoneal leaf of the lienorenal ligament using finger dissection

o   Bring (medialize) spleen up into the wound

o   Compress vascular pedicle to control the bleeding

o   Inspect the organ to assess extent of damage

Drainage

-       Not routinely performed

Closure

-       Loop 0 Novafil

-       Staples to skin

Dressing

-       Comfeel

Post-operative instructions

-       NGT

-       Watch platelet count

-       Vaccinations

-       Physiotherapy

-       Thromboembolic prophylaxis.

Complications

-       Chonic vs acute
- Acute include bleeding, damage to adjacent structures, stomach at short gastrics, pancreatic leak at hilum (or distal pancreas necrosis as bld supply from splenic), colon at splenocolic ligament

- Residual bleeding at the retroperitoneum can be contained with a running lock-stitch; remember may have coagulation problem
- Chronic relates to hyposplenism and infections / OPSI - see notes.
Missed accessory spleens