Trauma Splenectomy

Acute/Open splenectomy

• Wear a headlight

• Abx

• Midline/ subcostal – fixed subcostal retraction

• If trauma – generous midline, 4 quadrant packing, control obvious haemorrhage, anaesthetist time to catch-up

• If get major bleeding from spleen at any stage – compress hilum

• Large & elective

  • Consider embolising artery on way to theatre

• Step 1

  • With left hand gently retract spleen to midline
  • Right hand - Divide lateral attachments (Splenophrenic and Splenorenal ligaments)
    • Can often break splenophrenic ligament with hand, both should be avascular unless portal hypertension

• Step 2

  • Mobilize spleen and tail of pancreas as a unit from lateral to medial, by placing fingernails of right hand against the kidney and dissecting in the plane between kidney and tail of pancreas

• Step 3

  • Assistant elevates spleen – deal to gastrosplenic ligament
  • Serially clamp, tie, and cut short gastrics
  • Greater curvature of stomach may get caught in clamps
  • If concerned - oversew stomach side with seromuscular stitches to prevent subsequent gastric leak
  • Try to preserve gastroepiploic arcade

• Step 4

  • Divide Splenocolic ligaments/ Adhesions to omentum
  • NB: Don’t need to mobilise splenic flexure

• Step 5

  • Draw spleen out of wound
  • Inspect splenic bed and look for other injuries in LUQ - diaphragm, tail of pancreas, kidney, stomach, left lobe of liver
  • Place pack in splenic bed
  • Decide if splenectomy needed
  • Other options include hemostatic agents, splenorrhaphy, and partial splenectomy

• Step 6

  • Serially ligate (double) (or transfix) and divide the splenic vessels (usually several branches present), arteries and veins separately, if possible (dissect & isolate with right angles), and remove spleen
  • Identify & preserve pancreatic tail – ligating vessels close to hilum will do so

• Step 7

  • Check hemostasis
  • Check for splenules
    • Role of autotransplantation controversial
    • Cut spleen into pieces and place them in omental pouches
  • No drains unless there is an associated pancreatic or kidney injury
  • Anterior & posterior layer closure