Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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STEP 5: PEARLS AND PITFALLS

As stated before, we advocate several precepts in arriving at the decision to proceed to intervention.

We particularly point out the significance of time since development of the pseudocyst. The literature on nonoperative modalities often describes interventions earlier than 4 weeks after the initial event. The reason to avoid such a decision early is that the texture of the pseudocyst will be unsuitable for holding a suture. We further believe that a percentage of these patients will have complete resolution of the pseudocyst if given enough time to do so.

Once the decision is made to proceed to intervention, we advocate obtaining pancreatic ductal anatomy defined by either endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP). We have developed a system to categorize the ductal changes seen in patients with pseudocyst; and type II (stricture), type III (complete obstruction), and type IV (chronic pancreatitis) are likely best managed by surgery, whereas type I (normal duct) is ideally suited to nonoperative interventions.

We advocate cystojejunostomy and infrequently use cystoduodenostomy.

Be prepared that some pseudocysts will be difficult to locate during operation. Intraoperative ultrasound can be very helpful in this situation. If in doubt, always aspirate with a fine needle before attempting to incise the wall of the presumed pseudocyst.

We have published the observation that persistent fluid collections after acute necrotizing pancreatitis are often rigid-walled and irregular in contour. These have been called “organized pancreatic necrosis,” although the terminology is still evolving. Because of the rigid wall, these fluid collections will not collapse when drained. In our experience, this has resulted in a higher frequency of postoperative infection and in a prolonged period before all symptoms resolve. If you are managing such patients, the radiographs will always be read as pseudocyst, and the surgeon must be prepared to make that distinction based on the history of each individual patient.

SELECTED REFERENCES

1. Nealon WH, Walser E: Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery vs. percutaneous drainage). Ann Surg 2002;235:751-758.

2. Nealon WH, Walser E: Duct drainage alone is sufficient in the operative management of pancreatic pseudocysts in patients with chronic pancreatitis. Ann Surg 2003;237:614-622.

3. Nealon WH, Bhutani M, Riall TS, et al: A unifying concept: Pancreatic ductal anatomy both predicts and determines the major complications resulting from pancreatitis. J Am Coll Surg 2009;208:790-799.

C H A P T E R 52

SPLENECTOMY/SPLENIC REPAIR

William J. Mileski

STEP 1: SURGICAL ANATOMY

The vascular supply of the spleen is composed primarily of the splenic artery and vein and the short gastric vessels. Primary anatomic consideration in treating spleen injuries is related to mobilization of the retroperitoneal attachments of the spleen, the splenocolic, splenorenal, and splenophrenic ligaments (Figures 52-1 and 52-2).

STEP 2: PREOPERATIVE CONSIDERATIONS

Nonoperative management of spleen injuries is applicable to most patients who present in hemodynamically stable condition, and the diagnosis of injury is most often made as a result of computed tomographic (CT) scanning. Under these conditions the success rates for nonoperative therapy is very high, more than 80% in most modern series. Bed rest in the intensive care unit (ICU) should be prescribed, serial complete blood counts obtained, and serial abdominal examinations performed in an ICU for 24 to 48 hours. Hemodynamic deterioration or the development of peritonitis is typically considered indications to alter to an operative treatment mode. Some centers have reported success in controlling hemorrhage from both liver and spleen injuries with angioembolization, but this requires prompt availability of the interventional radiologists, which may not be applicable in many situations. There is no clear definition of what transfusion requirement merits abandonment of nonoperative treatment or how far to allow the hemoglobin to fall in these cases before transfusion and/or operative intervention. In most instances, however, persistent hemorrhage is manifest in the first 24 hours, with progressive reduction in hemoglobin levels at 6, 12, and 18 hours after injury or episodes of hypotension. The development of peritonitis is another clear indication for operative intervention.

Because most patients with spleen injuries who undergo surgery are those who present hemodynamically unstable with severe hemorrhage or have failed attempts at nonoperative management, the approach to surgery is generally of an emergent nature and requires direct and rapid control of hemorrhage. The torso should be widely prepped and draped, and a generous midline incision carried from the xiphisternum to just above the pubis. The use of fixed self-retaining retractors (e.g., Upper Hand, Omni-Tract, Thompson, or Buchwalter) can aid in retraction of the costal margin and exposure.

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In some patients, opening of the peritoneum may result in decompression of a degree of tamponade and result in severe hypotension; temporary compression of the aorta at the diaphragmatic hiatus, either manually with an aortic compression device or with the end of a small Richardson retractor, can provide temporization while the anesthesiologists restore intravascular volume. Upon evacuation of the hemoperitoneum, the right upper and left upper quadrants of the abdomen can be initially packed with laparotomy pads and the source of hemorrhage determined.

STEP 3: OPERATIVE STEPS

1.INCISION AND MOBILIZATION OF THE SPLEEN

Through a midline incision the spleen is retracted caudally and medially by the surgeon’s left hand, and the assistant retracts the abdominal wall laterally (see Figure 52-2).

2.DISSECTION

The lateral, posterior, and superior retroperitoneal attachments are rapidly released by sharp dissection with a long Metzenbaum scissor (see Figure 52-2).

A retropancreatic/prenephric plane can then be manually dissected, allowing the spleen to be retracted anteriorly and medially into the midline incision (Figure 52-3).

Active bleeding can be easily controlled with manual compression of the splenic hilum or application of vascular clamps to the hilum. If clamps are used, it is important to exercise care to avoid injury to the tail of the pancreas, which may be close by.

Several laparotomy pads should be packed behind the spleen to tamponade bleeding and support the spleen while the lesser sac is opened on the proximal aspect of the greater curve of the stomach, and the short gastric vessels are ligated. While ligating the short gastric vessels, care should be taken to avoid incorporating the gastric wall in the ligatures, which can later lead to necrosis and a gastric fistula. At this point the spleen can be freely mobilized along with the tail of the pancreas to the midline (Figure 52-4).

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After the spleen is mobilized to the midline, it can be rapidly determined whether the injury has active hemorrhage that will require splenectomy or is a more modest injury amenable to splenorrhaphy or mesh wrapping. If the patient is hypotensive, coagulopathic, acidotic, or hypothermic or has multiple other injuries that contribute to or are worsened by ongoing hemorrhage (closed head injury), the decision to control hemorrhage by splenectomy is straightforward and should be made rapidly (Figure 52-5).

In patients who respond to control of the bleeding and resuscitation, splenorrhaphy remains an option. This can be accomplished with topical hemostatic agents, suture ligature with or without pledgets, and in some cases, wrapping of the spleen in absorbable mesh

(Figure 52-6).

The splenic fossa should be carefully examined for hemorrhage and possible injury to the pancreas before closing. If there is evidence of or reasonable concern for possible injury to the pancreas, a closed suction drain should be left in the splenic bed (Figure 52-7).

Splenic artery and vein are ligated and divided

FIGURE 52–5

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3. CLOSING

Although nonoperative management is successful in more than 80% of patients with spleen injuries, rapid emergent operative treatment may be required.

It cannot be overemphasized that nonoperative treatment is applicable only when the patient is hemodynamically stable. Patients who have evidence of significant hemoperitoneum, including significant free fluid surrounding loops of small intestine; those with contrast blush on the CT scan; those taking anticoagulants (warfarin [Coumadin], clopidogrel [Plavix]); those with portal hypertension; those with multiple injuries that may increase the risk from hemorrhage or intracranial injury; and the elderly are at increased risk of ongoing hemorrhage and failure of nonoperative treatment.

When operative intervention is indicated, exposure and full mobilization of the spleen are essential to either splenorrhaphy or splenectomy.

STEP 4: POSTOPERATIVE CARE

A nasogastric tube is continued in place until evidence of effective gastric emptying is clearly present. Incentive spirometry and pulmonary toilet are important to limit postoperative atelectasis and pneumonia. Prophylaxis for deep venous thrombosis (DVT) with fractionated heparin may begin on postoperative day 1. In the patients who undergo splenectomy, immunization against pneumococcus, meningococcus, and Haemophilus influenzae should be administered before discharge from the hospital.

STEP 5: PEARLS AND PITFALLS

Pancreatic fistula may occur following splenectomy as a result of pancreatic trauma or iatrogenic injury. Careful inspection of the tail of the pancreas and taking care to avoid pancreatic injury while ligating the vasculature of the spleen are the best preventative measures. If there is concern that the tail of the pancreas might be damaged at the time of surgery, a closed suction drain should be left and effluent assayed for amylase and lipase levels before the drain is removed.

Gastric fistula following splenectomy is a recognized complication that can be avoided by careful ligation of the short gastric vessels without including any of the gastric serosa, or if necessary imbricating the short gastric ligatures.

Overwhelming postsplenectomy sepsis may occur.