OPEN SPLENECTOMY

Incision and entry into abdomen

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• The incision depends on the size of the spleen, the reason for splenectomy, and the preference of the surgeon. Generally, in emergency or trauma situations, an upper midline incision is preferable because it affords excellent exposure of the abdominal cavity, can be performed quickly, and provide access for the evaluation and management of other potential injured organs or structures.

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• In most patients undergoing splenectomy for a hematologic disorder, a left subcostal incision is employed, beginning to the right of the midline and proceeding obliquely to the left approximately two fingerbreadths below the costal margin. This incision yields excellent exposure

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• Left oblique abdominal incision

Mobilization and removal of spleen

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• Upon entry into the abdominal cavity, dissection is performed with blunt and sharp technique and with the surgeon's hand following the convex surface of the organ, leading to identification of the peritoneal attachments.

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• The spleen is gently grasped and displaced medially toward the incision. The avascular peritoneal attachments and ligaments are incised with an electrocautery or Metzenbaum scissors. These suspensory ligaments are avascular except for the gastrosplenic ligament, which contains the short gastric vessels. In patients with portal hypertension, any ligaments may have vessels that should be ligated.

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• Attention is then turned to the hilum, where the splenic artery and veins are identified, carefully dissected, doubly ligated with 0 nonabsorbable suture (eg, silk), and transfixed with 2-0 silk suture ligatures. To avoid injury to the pancreas, the dissection is carried out at the hilum in close proximity to the spleen.

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• Next, the short gastric vessels are identified and ligated. In hypotensive patients, the short gastric vessels usually do not bleed, nor does the splenic bed.

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• In the case of elective splenectomy, the first step is transection of the ligamentous attachments, including the splenophrenic ligament at the superior pole and the splenocolic and splenorenal ligaments at the inferior pole. This may be accomplished with blunt dissection, an electrocautery, or, in conditions where the ligaments are thickened, Metzenbaum scissors.

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• After the ligamentous attachments are transected, the gastric vessels that run from the spleen to the greater curvature of the stomach are ligated and divided. A Lembert suture is placed in the gastric wall in a seromuscular fashion to avoid the complication of gastric fistulization when one is unable to identify the source of bleeding from the stomach

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• After these maneuvers are completed, the spleen is delivered into the wound with blunt dissection of the posterior attachments. To keep from entering the splenic vein, care should be taken not to divide the posterior attachments too far medially. It is also important to avoid axial rotation of the spleen before securing the splenic vessels with vascular loop or clamps; such rotation may lead to disruption of the splenic artery or vein.

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• Dissection is carried out at the hilum in close proximity to the spleen to avoid injury to the pancreas. Individual ligation of the splenic artery or arterial branches and the splenic vein or venous branches is generally preferable. This is accomplished by means of double ligation and transfixion with nonabsorbable suture ligatures.

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• In the case of a markedly enlarged spleen (severe splenomegaly), it is often preferable to place a vascular loop or vascular clamp on the splenic vessels (see the image below) and double-ligate the vessels with heavy nonabsorbable suture. One may then proceed with suture ligation using a transfixed technique. This approach avoids slipped-off sutures and helps prevent postoperative bleeding.

PLACEMENT OF VASCULAR LOOPS

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• After removal of the spleen, hemostasis is obtained and confirmed in a systematic fashion through careful inspection of the left subphrenic area, the greater curvature of the stomach, and the short gastric vessel area, as well as the splenic hilum. Inspection of these areas is facilitated by proper retraction of the stomach and small bowel to allow clear visualization of the left upper quadrant and surgical bed

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• When splenectomy is performed for hematologic disease, a thorough abdominal exploration should be performed to look for any accessory spleens. Common locations of accessory spleens include the hilum, the gastrocolic and gastrosplenic ligaments, the greater omentum, the mesenteric region, and the presacral space. Any accessory spleen is removed to prevent the recurrence of idiopathic (immune) thrombocytopenic purpura (ITP)

COMPLETION AND CLOSURE

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• The abdominal incision is closed by approximating the linea alba with 1-0 polypropylene monofilament sutures in a continuous fashion. The left subcostal incision is approximated in layers with 1-0 absorbable sutures. The skin edges are approximated with staples. In injured patients, the abdomen should not be closed until the coagulopathy that is frequently associated with major trauma has been corrected.

COMPLICATIONS

INTRAOPERATIVE

• Intraoperative complications include pancreatic, vascular, colon, stomach, and diaphragmatic injuries. These are reported with both open and laparoscopic splenectomy.

EARLY POSTOPERATIVE

• Early postoperative complications include pulmonary complications (atelectasis to pneumonia), subphrenic abscess, ileus, portal vein thrombosis,[18]thrombocytosis, thrombotic complications, and wound complications (hematomas, seromas, and wound infections).

LATE POSTOPERATIVE

• Late postoperative complications include splenosis and overwhelming postsplenectomy sepsis(OPSS; or overwhelming postsplenectomy infection [OPSI].