SPLEEN

Question 1

open splenectomy

Answer 1

pack colon downward with warm sponges; retractor under left rib margin

• Search for accessory spleen in following order:
hilar region;
splenorenal ligament;
greater omentum;
retroperitoneal region surrounding tail of pancreas;
splenocolic ligament;
mesentery of large and small bowel

Incise gastrosplenic ligament by pulling stomach medially and going through avascualar plane and entering lesser sac; ligate vessels encountered in ligament

• If want to take splenic artery first, palpate for tortuous course of splenic artery along upper margin of pancreas, incise peritoneum over it, and isolate with right-angle dissector and ligate with 2-0 silk ties

remainder of gastrosplenic ligament divided between small clamps taking care to avoid injury to stomach wall (make sure uppermost vein in ligament secure)

• take down any adhesions between spleen and peritoneum of abdo wall or left diaphragm
• as spleen mobilized, pass finger over its margin to expose splenorenal (SR) ligament and incise carefully to avoid tearing capsule
• mobilize spleen outside wound and then divide splenocolic (SC) ligament between clamps and either suture ligating with 2-0 silk or absorbable suture
• spleen then retracted medially with surgeon’s left hand and tail of pancreas is separated from splenic hilum by careful blunt dissection
• spleen then held up so pedicle visible and vessels individually clamped and ligated at base of pedicle proximal to bifurcation of splenic vessels; should tie proximally and ligate distally; same principle of double ligature for splenic vein
• check all fields and vessels for bleeding
• alternate method is to divide lateral ligaments first, bring up spleen, divide splenocolic ligament and then take splenic pedicle and gastrosplenic vessels together, thereby obliterating lesser space with same clamps. Still preferable to ligate and tie vessels individually though with this method