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1
Stomach
Stomach
Lesser sac
B
A
Splenic artery
Pancreas
Kidney
Splenorenal
ligament
Splenic artery
Gastrosplenic
ligament
Splenic vein
Spleen
4
Spleen
Left
gastroepiploic
Pancreas
5
6
Point of
incision
artery
7
Splenorenal
ligament
Kidney
Spleen
303
Pancreas
PLATE
142
DETAILS OF PROCEDURE When the spleen is mobilized
outside the wound, the splenocolic ligament is divided between curved
clamps (figure 8). is procedure is carried out carefully in order to avoid
any possibility of damage to the colon. e contents of these clamps are
ligated with a trans xing suture of silk or absorbable suture. In the presence of portal hypertension, many large veins may be present in this area.
e spleen is then retracted medially by the surgeon’s le hand, while the
tail of the pancreas, if it extends up to the splenic hilus, is separated by blunt
dissection from the splenic vessels in order to avoid damage to it by the
subsequent ligation of the pedicle (figures 9 and 10). e surgeon should
keep in mind the possibility of accessory spleens in this location. e spleen
is held upward and laterally by an assistant, while the large vessels in the
pedicle are separated from the adjacent tissues to permit the application of
several curved clamps to the individual vessels (figure 11). ese vessels
should be ligated at the base of the pedicle proximal to the bifurcation of the
splenic vessels. Despite the fact that the splenic artery has been ligated previously, it is tied again proximally and trans xed distally (figure 12). e
same principle of double ligature for the splenic vein is also carried out. In
those instances where preoperative transfusions have been contraindicated,
they may be started as soon as the splenic artery has been divided. e
operative site is searched for evidence of persistent oozing. Warm, moist
packs or a coagulant matrix may be introduced to control the small bleeding points. Following this, a nal careful search is made for any existing
accessory spleens that must be resected.
S
ALTERNATIVE METHOD
When the spleen is quite mobile and the pedicle is long, which is apt to be
the case in the presence of splenomegaly of long standing, splenectomy may
be facilitated if the splenorenal ligament is incised rst without an attempt
to divide the gastrosplenic ligament (figure 13). e spleen is pulled gently
upward and medially, providing exposure of the vessels in the pedicle from
the lateral side (figure 14). It may be necessary to divide the splenocolic
ligament rst in order to better expose the contents of the splenic pedicle. In the presence of a ruptured spleen the urgency of the situation may
require mass clamping of the splenic pedicle; however, individual ligation
of the major vessels is safer and more desirable. is may be accomplished
by ascertaining the position of the splenic artery by palpation followed by
blunt dissection, in an e ort to isolate the splenic artery (figure 14). When
the splenic artery has been divided, the spleen should be compressed to
ensure an autotransfusion through the intact splenic vein. Since the gastrosplenic ligament has not been previously divided, it may be included in the
clamps applied to the splenic pedicle, thereby sealing o the lesser omental sac (figure 15). If the gastrosplenic ligament is to be included in these
clamps, great care is necessary to avoid including a portion of the greater
curvature of the stomach, especially when the gastrosplenic ligament
is very short. is is more likely to occur high in the region of the fundus
of the stomach. e inclusion of the gastrosplenic ligament in the clamps
applied to the splenic pedicle should not be attempted unless the pedicle
is long and all structures may be identi ed easily and clearly (figure 16).
e contents of the clamps applied to the splenic pedicle are doubly ligated.
e most super cial of these ligatures should be of the trans xing type.
Deep trans xing sutures should not be taken, since troublesome hemorrhage may result, especially from the splenic vein.
In good-risk patients cholecystectomy is performed if gallstones are
found, especially in association with congenital hemolytic anemia. A routine cholangiogram also is carried out. In the younger age groups with primary hypersplenism the appendix may be removed if the cecum is easily
mobilized.
SPLENIC PRESERVATION
Recognition that splenectomy increases susceptibility to infection by encapsulated bacterial organisms necessitates a conservative approach to splenic
injuries. Special e ort should be made to conserve spleen tissue with its
attached blood supply, especially in the very young. Every e ort is made to
avoid splenectomy in children by following a conservative routine of close
observation, nasogastric suction, frequent recordings of pulse and blood
pressure, repeated blood counts and radionuclide or computed tomography
(CT) scans. If the scan shows only a single linear laceration, a conservative
regimen is followed. When the scan shows a fragmented spleen or evidence
of devascularization, surgical repair is required.
Tears of the splenic capsule during upper abdominal operations are minimized by avoiding undue traction on the greater omentum of the stomach
or the le transverse colon, or by dividing peritoneal strands attached to
the splenic capsule. Mobilization of the spleen with temporary control of
the major blood supply permits evaluation of the feasibility of repair of the
capsule or, alternatively, segmental resection with ligation of the segmental
vasculature in the hilum, as well as in the small intrahepatic vessels, combined with liberal use of a hemostatic agent and possible xation of the
omentum to the area of repair. Locally applied hemostatic agents, compression of splenic tissue by mattress sutures on atraumatic needles, or ligation
of one or more major vessels in the splenic hilus may control the bleeding
and avoid splenectomy.
CLOSURE e wound edges can be approximated more easily by return-
ing the table to its original horizontal position, thus facilitating return of the
abdominal contents to their anatomic location. A routine closure is done without drainage. On occasion, a closed-suction Silastic drain may be placed near
the tail of the pancreas if there has been extensive dissection in this region.
POSTOPERATIVE CARE is will vary, depending upon the requirement
for whole blood replacement. Within a short time a er splenectomy for
a blood dyscrasia involving a bleeding tendency, it is usually noted that
the platelet count rises rapidly; thus, transfusion may be unnecessary for
this purpose. It is good practice to monitor platelet counts postoperatively,
even in elective procedures, because of the marked thrombocytosis that
is occasionally seen. In patients with markedly elevated platelet counts or
abnormal platelet function, anticoagulants, such as acetylsalicylic acid and
dipyridamole, may be indicated. Anticoagulants are rarely necessary in
routine splenectomy. A marked leukocytosis commonly follows splenectomy and should not be interpreted as indicative of infection. Constant gastric suction for a day or so is o en advisable. e patient is permitted out
of bed on the rst postoperative day. Fluid balance is carefully maintained
according to the patient’s general condition. Any steroid therapy given preoperatively is continued during the postoperative period. Further steroid
therapy will be regulated by the hematologist, who will be guided by the
response of the patient’s blood picture to splenectomy. In patients with secondary hypersplenism, their primary disease will not be altered, although
the patient’s life has been saved or prolonged by removal of the overactive
spleen. e incidence of venous thrombosis is increased when the splenectomy is performed for myeloproliferative disorders or lymphomas. Anticoagulant prophylaxis should be considered in such patients. Atelectasis
of the le basal lobe is one of the common complications a er splenectomy. When complete splenectomy has been performed, patients should be
informed and urged to seek immediate medical attention at the rst sign
or symptom of infection. Daily oral penicillin for an inde nite period has
been suggested for patients of all ages. Polyvalent vaccines for pneumococcus, Haemophilus in uenzae, and Neisseria meningitidis are also suggested
except for pregnant women. ■
304
Original ligature on
splenic artery
8
Liver
9
Diaphragm
10
Spleen
Splenic
artery
11
Accessory spleen
Clamps on
splenocolic ligament
Splenic vein
12
Pancreas
Pancreas
Splenic artery
and vein
Pancreas
Perirenal fat
Alternate method
13
Lesser
sac
Stomach
14
Accessory spleen
Stomach
Splenocolic
ligament
15
Splenic artery
Gastrosplenic
ligament
16
Lesser sac
Splenic
vein
305
PLATE
143
INDICATIONS Laparoscopic splenectomy is most commonly performed
for immune (idiopathic) thrombocytopenic purpura (ITP) or other splenic
conditions causing anemia or neutropenia. Massive trauma to the spleen as
well as overly large spleens are still best approached with an open laparotomy. However, virtually all other indications for splenectomy listed in the
preceding Plate apply for laparoscopic splenectomy. A complete hematologic evaluation, including bone marrow studies, is essential. e patient
must be informed of the lifelong consequences of increased susceptibility to
bacterial infection. Ideally, the patient should receive polyvalent pneumococcal, H. in uenzae, and N. meningitidis vaccination prior to surgery.
PREOPERATIVE PREPARATION Patients for elective splenectomy are
usually referred to the surgeon by hematologists or oncologists, because
their treatment with blood products, corticosteroids, plasmaphoresis,
gamma globulins, or chemotherapy can no longer safely control the primary disease. Accordingly, the patient may require transfusion of blood
products to raise the hematocrit or platelet counts to safe levels for general
anesthesia and coagulation during surgery. Packed red cells may be given
in advance of planned surgery, whereas platelets, with their short life span,
may be infused just prior to and during the procedure. When platelet transfusions are contraindicated, endogenous platelet counts are o en temporarily boosted with a few days of increased corticosteroid therapy, immune
globulin or Rho D immune globulin (winrho) prior to surgery. If steroids
are used, then they must be continued during and immediately a er surgery. e patient should have a type and screening blood test, and blood
products must be available for infusion. e size of the spleen should be
determined by physical examination or imaging studies, as massive spleens
are more safely approached by open splenectomy.
ANESTHESIA General anesthesia with endotracheal intubation is required.
Two large, well-secured intravenous catheters are placed for easy access by
the anesthesiologist. e intravenous sites and any nger pulse oximeters
should not be positioned distal to an arm blood pressure cu . A Foley
catheter and an orogastric (OG) tube are passed and pneumatic sequential
compression stockings are applied to the lower legs. Care must be taken in
the placement of the endotracheal, OG, and Foley tubes in patients with
marked thrombocytopenia lest bleeding occur.
POSITION e patient is placed in a lateral position with the le arm cross-
ing the chest and lying on top of the right arm. Liberal padding is used
between and around both arms. e le hip and chest are elevated with pillows, leaving the ank area open and the le knee exed, with a padding of
blankets between the legs. e patient is secured across the chest and hips to
the table with wide adhesive tape, as the operating room table will be tilted.
OPERATIVE PREPARATION e skin is prepared from the lower chest to
the pubis in a routine manner.
S, L
INCISION AND EXPOSURE A -mm videoscope port is placed either
through the umbilicus or in the lateral midsubcostal position using the
open technique of Hasson as described in Plate . e videoscope is
introduced and all four quadrants of the abdomen are examined. e
size and location of the spleen and the presence of accessory spleens are
noted. A second -mm port is placed in the le lateral subcostal position and a -mm port is placed just to the le of the midline. ese ports
are in a line about two ngerbreadths or so below the edge of the costal
margin for a normal-sized spleen. Additional locations or ports may be
placed according to the preference of the surgeon, the size of the spleen,
and the shape of the patient’s body. In general, larger spleens require a
lower (more caudal) and more medial placement of ports. e patient is
positioned with the le side up and then placed in a reversed Trendelenburg
position.
DETAILS OF PROCEDURE e general anatomy of the spleen, stomach,
colon, and omentum is shown in figure 1, which complements the crosssectional anatomy of this region shown in Plate . e splenocolic ligament is visualized along with the greater omentum in its attachment to the
transverse colon is visualized. e splenic end of this ligament is elevated
with traction (figure 2) and a suitable zone just above the splenic exure of the colon is entered with the ultrasonic dissector. is elevation is
done with grasping and gentle traction using a dissecting instrument. e
dissection proceeds medially around the tip of the spleen, where the gastrosplenic ligament containing the short gastric vessels is identi ed. Using
blunt dissection, the lesser sac is entered and the short gastric vessels are
sequentially divided about cm away from the gastric wall (figure 3). is
cu minimizes potential thermal damage to the stomach. As the dissection
proceeds toward the gastroesophageal junction, care is taken to visualize
each short gastric vessel within the jaws of the ultrasonic dissector before
it is activated. Partial transection of the next short gastric vessel will result
in bleeding that is di cult to control. Exposure for this dissection within
the gastrosplenic ligament is improved by gentle retraction of the greater
curvature of the stomach, using the dissecting instrument to li the greater
curvature forward and medially. e pancreas, with the splenic artery and
vein running along its superior or cephalad border, is seen in the base of
the lesser sac. e short gastrics are divided almost to the gastroesophageal
junction (figure 4).
e splenorenal ligament is opened by gently elevating the spleen medially with the dissecting instrument (figure 5). is thin peritoneal layer is
easily seen in the le gutter behind the spleen. e ligament has few vessels,
but it must be transected with coagulation in a cephalad direction until
the top of the spleen is free. e splenic pedicle is inspected in all areas
by li ing the spleen from side to side to make certain that no ligamentous
attachments remain. e spleen should be completely mobile on its vascular pedicle (figure 6).
CONTINUES
306
307
PLATE
144
DETAILS OF PROCEDURE e area chosen should be distal
to the tail of the pancreas but proximal to the trifurcation of the splenic
vessels. Dissection is performed until the vessels can be safely encompassed within the jaws of an endoscopic vascular stapler. is instrument
currently requires a -mm port. It is common practice to use a vascular
stapling device to occlude and divide the entire splenic pedicle together.
In some cases it is preferable to individually ligate the splenic artery and
vein using the endovascular stapler. When this technique is employed the
artery should be divided rst. If either splenic vessel is entered during the
dissection, emergency control of the hemorrhage is obtained by crossclamping both the splenic artery and vein with the dissecting instrument
(figure 7). As all collateral vessels to the spleen have been transected,
only temporary back bleeding should occur. is maneuver allows the surgeon to place another operating port for further proximal dissection and
stapling of the splenic artery and vein or to control the hemorrhage during
conversion to an open procedure.
When the tail of the pancreatic tissue extends into the hilum of the
spleen, the zone for transection of the splenic vessels is quite short.
Dissection is more di cult, as the vessels may have divided into their
branches. In this case, the pedicle may be taken in serial transections,
as opposed to stapling of the vascular pedicle en bloc (figure 8). In
reality, the splenic artery and vein are rarely skeletonized as cleanly as
shown in these illustrations, but the general principle is that the tissue to
be stapled must be contained well within the span of the stapling instrument’s jaws. A useful maneuver is a -degree rotation of the stapler to
ensure that no tissue or vessels extend beyond the staple zone within the
instrument’s jaws.
A reinforced oversized plastic bag is placed through a large port site. is
special bag comes in an extra-large instrument that usually requires removal
of a -mm port and nger dilation of this site to approximately mm. e
videoscope is used for visualization as the collapsed bag and instrument are
passed through the abdominal wall. e bag is opened, noting the arrow
S, L
orientation on its rim. e spleen is placed into the bag (figure 9), which is
closed. is reinforced bag is then partially withdrawn through the abdominal wall until the open rim of the bag is under control outside of the abdomen. e bag is cut free from the carrier using the drawstring in the end of
the instrument handle. e spleen is morcellized with either nger fracture
within the bag or, most o en, with a ringed forceps, which then extracts the
spleen in pieces (figure 10). Care must be taken not to pinch or tear the bag
with the ringed forceps.
Following complete extraction of the spleen and bag, the right upper quadrant of the abdomen is lavaged with the suction irrigator and a careful inspection is made of all cut surfaces and vessels. e tail of the pancreas is examined
for possible injury that might necessitate placement of a closed-suction Silastic
catheter drain. A nal search for accessory spleens is made in the usual locations and they are simply excised using the ultrasonic dissector.
CLOSURE Each of the ports is removed under direct vision of the vid-
eoscope and the enlarged Hasson and -mm port sites are closed with
interrupted delayed absorbable sutures. e skin is approximated with
absorbable subcuticular sutures. Adhesive skin strips and dry sterile
dressings complete the procedure.
POSTOPERATIVE CARE e OG tube is removed before the patient
awakens and the Foley catheter is discontinued when the patient is alert
enough to void. Intake of clear liquid is begun within a day and the diet
is advanced as tolerated. Corticosteroid coverage is tapered to the preoperative basal levels and serial blood counts are performed. Additional
medical consultation may be needed with the hematologist or oncologist to regulate medications in complex cases. Recurrence of le -upperquadrant and shoulder pain along with the appearance of a le pleural
e usion may signal either a pancreatic leak or an abscess if signs of infection are present. Either may require placement of a subdiaphragmatic
closed drain using imaging study guidance. Prolonged follow-up by the
hematologist or oncologist is necessary. ■
308
309
PLATE
145
INDICATIONS Injury to the spleen is one of the more serious problems
associated with trauma. Emergently there is the possibility of exsanguination.
However, for the remainder of the patient’s life a er splenectomy, there is the
possibility of catastrophic bacterial infection with encapsulated organisms,
such as pneumococci, especially in the very young. is has stimulated clinicians to conserve the spleen with or without operation. Nonoperative treatment
in children is o en successful if careful monitoring is provided in-hospital and
therea er at home until full healing is documented. Additionally, in adults as
well as in children, splenorrhaphy is o en possible, as it is desirable to salvage as
much of the traumatized spleen as possible. It is uncertain how much retained
spleen is essential to provide normal protection for the patient, but many recommend preservation of half or more if possible. e surgeon must appreciate
that it is essential to control exsanguination and that total splenectomy should
be performed for splenic fractures that are massive or that cannot be easily
controlled in the presence of continued major hemorrhage.
Rib fractures (especially those in the le lower and posterior region) and an
elevated le diaphragm on roentgenograms of the chest are suggestive of splenic
injury. Abdominal CT scans are invaluable in demonstrating splenic injury
and their ndings may support a decision for or against immediate splenectomy. Early operation should be considered when the scan shows a fracture that
extends into the hilum of the spleen. e patient with splenic injury who is managed with observation must be evaluated frequently as occult hemorrhage may
result in sudden hypotension and shock. e decision for or against nonsurgical
treatment of a splenic injury should be based upon clinical judgment rather than
solely on radiographic ndings. If the diagnosis is not clear, a peritoneal tap or
lavage yielding an obviously bloody return can be helpful in supporting surgical
intervention as this indicates a free or noncontained rupture of the spleen.
Familiarity with the major blood supply of the spleen is required if salvage
of the portion of the spleen is to be successful (
artery and vein run just under the peritoneum along the top of the pancreas.
e easiest accessibility to the vessels occurs through an opening in the gastrocolic omentum (Plate ). A bulldog clamp can be applied temporarily to the
splenic artery and this will lessen the massive bleeding as the surgeon mobilizes up the extensively damaged spleen. e clamp is applied proximally as
the splenic artery within the hilum divides into three terminal vessels, each
supplying approximately one-third of the spleen. It is important to remember
that the spleen has a dual blood supply—namely, the short gastric vessels from
the greater curve of the stomach in the gastrosplenic ligament as well as the
retroperitoneal splenic artery and vein.
PREOPERATIVE PREPARATION Evidence of shock associated with a falling
hematocrit or hemoglobin should be viewed with alarm and result in early surgical intervention. e patient with a potential splenic injury should be typed
and cross-matched while reserving several units of packed red cells or blood at
all times. e importance of sustained observation day and night in a patient
treated nonsurgically cannot be overemphasized, since the decision for surgical
intervention can come at any time!
Hypotension and shock must be treated with adequate volumes of uid
and blood. A tendency to recurrent hypotension a er resuscitation should be
viewed with alarm and early surgical intervention undertaken. CT scans of the
spleen in a stable patient can provide signi cant help in establishing the location, extent, and progress of the injury.
ANESTHESIA A general anesthesia is required. Large-bore venous access catheters
are placed in both arms for rapid administration of blood, uids, and medications.
POSITION Because of associated injury, the supine position may need to be
altered. e patient is usually placed at upon the table, thus preserving the
option to accomplish a Trendelenburg position if shock develops.
OPERATIVE PREPARATION Nasogastric intubation is useful in improving
exposure by lessening gastric dilatation. Antibiotics are given, and a routine
preparation of the skin of the upper abdomen and le side of the lower chest is
rapidly performed.
INCISION AND EXPOSURE A midline or le subcostal incision is made.
e latter may provide a better exposure when the splenic trauma is severe,
whereas the midline incision may be useful if other associated intra-abdominal
injuries are suspect.
One of the more common minor injuries to the spleen may occur during an
upper abdominal procedure when traction is placed upon adjacent structures
which have attachments to the surface of the spleen. e resultant tear in the
capsule of the spleen can lead to a slow loss of blood (
injuries should be recognized early. Compression with a gauze sponge is applied
to the denuded area for several minutes, remembering that clotting times are
usually in the range of to minutes. If the bleeding persists, micro brillar collagen is applied directly to the spleen and further gauze compression is given.
S C
figure 1). e major splenic
figure 2). Such super cial
In the presence of major fracture of the spleen, a large gauze pad or towel
is placed over the spleen to enable medial traction by the surgeon’s le hand
(figure 3). is le hand also compresses the spleen so as to provide some
control over the bleeding. Blood in the le lumbar gutter is aspirated by suction and an incision is made in the splenorenal ligament several centimeters
away from the capsule of the spleen (
upward to free the spleen from the base of the diaphragm. e spleen and tail
of the pancreas are mobilized and li ed anteriorly and medially, as shown on
Plates and . If splenic preservation rather than splenectomy is to be
attempted, temporary control of the splenic artery is obtained with a bulldog
or vascular clamp. Finger compression of the splenic pedicle may be utilized
until the clamp is applied through either an anterior (Plate ) or posterior
(Plate ) approach. Salvage of the spleen that appears to be badly injured may
become feasible a er control of the arterial in ow slows the bleeding such that a
more thorough evaluation of the spleen and its vascular pedicle can be made.
e success of saving the spleen depends rst upon the extent of damage from
the trauma and second upon the e ective compression of the lacerated splenic
tissue with interrupted sutures. e splenic tissue is quite friable and some prefer
to ll the crevice of the injury with hemostatic material such as micro brillar collagen and then hold the cavity material in place with a series of carefully placed
interrupted sutures which gently compress the spleen (
the adjacent omentum may be mobilized on a viable vascular pedicle so as to ll
the cavity created by the laceration. Again mattress sutures are used to hold the
omentum in place so as to approximate the margins of the laceration and minimize further bleeding.
Laceration of the midportion of the spleen with extension into the hilum is
usually considered an indication against splenic conservation. However, laceration
involving either pole of the spleen may be controlled by isolating the appropriate
artery and vein within the hilus that supplies the polar region of the organ. A er
dividing the gastrosplenic ligament and securely ligating the short gastric blood vessels, control of bleeding is enhanced by freeing up a segment of the splenic artery for
the application of a bulldog clamp. e major arterial and venous vessels heading to
the lower pole of the spleen are dissected free, ligated, and divided (
e devascularized section of the lower pole of the spleen is demarcated by
its change in color and this ischemic damaged section is excised using cautery
(
figure 7). e bulldog clamp on the splenic artery can be released a er the
polar splenic artery and vein branches of the major splenic vessels are divided
and ligated. Active bleeding points are ligated by ne absorbable or silk sutures.
Mattress sutures tied over Gelfoam pledgets may be required to control the
bleeding (
beam electrocoagulation system. It is desirable to have the raw splenic surface
as dry as possible before micro brillar collagen is applied.
occurs a er to minutes, the spleen is returned to the le upper quadrant
a er inspecting the cut edge of the splenorenal ligament for hemostasis.
CLOSURE Closure is delayed if there is any uncertainty about continued
slow bleeding. Accessory spleens need not be excised, but all free splenic tissue should be removed to avoid subsequent splenosis. e tail of the pancreas
is inspected to determine if pancreatic tissue has been injured. If disruption of
the pancreatic tail is found, the pancreatic duct should be ligated if it is visible.
Mattress sutures may be placed through the anterior and posterior capsules of
the pancreas so as to compress the cut end. Alternatively, the pancreas may be
divided with a stapling instrument. A Silastic closed-suction catheter may be
placed in this region although, in general, catheter drainage in a splenectomy
site is to be avoided as it may increase the hazard of subphrenic abscess.
also may have been injured. A er a nal look at the spleen to verify viability and
hemostasis, the abdominal incision is closed. is is done in a routine manner
a er all bleeding points have been ligated. Skin staples or subcuticular closure
may be used for skin approximation.
POSTOPERATIVE CARE Frequent monitoring is required for several days
and additional transfusions may be needed. Many surgeons maintain nasogastric decompression for a few days until gastrointestinal function resumes. is
lessens the chance of gastric dilation, which may dislodge ligatures on the short
gastric vessels along the greater curvature of the stomach. Vigorous pulmonary
toilet may be necessary to avoid atelectasis and pneumonia, especially if rib
fractures are present. e patient should be observed for signs and symptoms of
a subphrenic abscess or an unrecognized pancreatic leak. If the injured spleen is
removed, polyvalent vaccines for pneumococcus, Haemophilus in uenzae, and
Neisseria meningitidis are given except to pregnant patients and children below
years of age. Antibiotics may be given prophylactically to the very young
patient a er splenectomy. Both children and adults should be advised to seek
medical attention without delay if signs of infection develop at any time for the
remainder of their lives.
figure 8). Additional hemostasis can be obtained using the argon-
e surface is compressed with a dry gauze sponge. If no active bleeding
It is important to evaluate the liver and other intra-abdominal organs that
■
figure 4). is incision is extended
figure 5). Alternatively,
figure 6).
310
Short
12
gastrics
Splenic
artery
Stomach
Spleen
Colon
Torn capsule
Omental adhesion
3
Gauze pad
4
Splenorenal
ligament
5
Powered
microbrillar
collagen
Splenic
artery
Stomach
6
7
8
Pancreas
311
PLATE
146
INDICATIONS e presence of cortical or medullary tumors of either a
malignant or benign adenomatous nature is a well-established indication for
unilateral adrenalectomy. In recent years, however, the number of indications for bilateral adrenalectomy has gradually increased. It is occasionally
performed to control complex endocrine states a er partial or unilateral
adrenalectomy has failed to alleviate hyperaldosteronism or hypercortisolism, as in Cushing’s syndrome.
PREOPERATIVE PREPARATION e most important preoperative proce-
dure is to establish a rm diagnosis. Clinical ndings o en indicate the
altered pathophysiology, but extensive endocrine studies are usually necessary, not only to establish the disorder within the adrenals but also to
rule out associated disorders in other endocrine glands. Unless they are
malignant, tumors are seldom large enough to be identi ed by pyelography, tomography, retroperitoneal gas injection, or aortography. Computed
tomography scans may be helpful. Accordingly, the reader should refer to
current texts on diagnostic endocrinology for the required procedures.
When adrenalectomy is decided upon, the surgeon should investigate and,
if possible, correct many of the secondary systemic and metabolic e ects
that are the direct result of the altered functional activity of the adrenal. e
management of the hypertension and its cardiovascular sequelae is a major
problem with pheochromocytomas. Problems associated with hypercorticolism include hypokalemia with alkalosis, hypertension, polycythemia,
musculoskeletal depletion with osteoporosis and hypercalcemia, abnormal glucose tolerance, multiple areas of skin furunculosis, and, nally,
poor wound healing. us, the surgeon must be aware that many organ
systems and their responses to surgery are profoundly a ected by adrenal
malfunction.
ANESTHESIA Preoperative consultation and communication among endo-
crinologist, surgeon, and anesthesiologist are necessary. e anesthesiologist must be prepared for adequate blood and endocrine replacement and
occasionally for a prolonged procedure that may be extended into the chest.
Electrolytes should be in optimum condition and the patient prepared with
parenteral cortisone the evening before and on the morning of surgery for
hypercorticolism or bilateral adrenalectomy. Adequate blood must be available, as hypertension plus increased vascularity and fragile veins about the
adrenals all tend to increase blood losses.
General anesthesia with endotracheal intubation is preferred. Patients
with pheochromocytomas should have adequate preoperative preparation with a long-acting adrenergic (alpha receptor) blocking agent, such
as phenoxybenzamine hydrochloride (Dibenzyline). To minimize wide
uctuations of blood pressure, an intra-arterial line should be placed and
hypertension controlled with an intravenous infusion of sodium nitroprusside (Nipride). A er assuring that adequate uid and blood replacement
has been accomplished, an infusion of norepinephrine (Levophed) may be
necessary to treat hypotension. Propranolol hydrochloride (Inderal) and
lidocaine hydrochloride (Xylocaine) may be needed to control tachycardia
and cardiac arrhythmias. Once the tumor is out, norepinephrine may be
needed for several days with gradual tapering as tolerated.
POSITION e patient is placed supine with the foot of the table slightly
down, so that moderate hyperextension can be obtained if necessary. A
posterior approach to the adrenals can be used but is not described here.
is approach may be used for the ablation of normal-size adrenal glands.
OPERATIVE PREPARATION e patient’s hair should be completely
removed with minimal trauma to the skin. In the anterior approach, the
B A
skin of the lower chest and abdomen well into the anks should be included
in the preparation, since, in making a transverse incision, it may be necessary to go far into the anks in obese patients.
INCISION AND EXPOSURE e surgeon stands on the patient’s right side
and outlines an incision about two to three ngerbreadths below the costal
margin with its apex about two ngers below the tip of the xiphoid process
(figure 1). A thoracoabdominal approach through the ninth interspace
may be used for large adrenal tumors occurring on the right side. When
the posterior approach is used, the incision extends from the level between
the th and th ribs cm from the midline and curved downward to the
midportion of the ileum. Increased vascularity in the subcutaneous tissue is common in these cases, particularly in Cushing’s syndrome. us
meticulous ligation of all bleeding points or control with electrocoagulation
should be carried out before the peritoneal cavity is opened. Both rectus
muscles are divided, and then the transversus muscle and peritoneum are
incised through a liberal incision. is is necessary since many of these
patients tend to be obese. Additional exposure may be obtained by dividing the internal oblique muscles in the direction of their bers out into
the anks. e falciform ligament to the liver is divided between curved
hemostats and then ligated. In some patients it may be prudent to mobilize
the right lobe of the liver by dividing the falciform and right triangular ligaments (Plate ).
DETAILS OF PROCEDURE e surgeon must rst be aware of the ana-
tomic di erences of the two adrenal glands (figure 2). e right adrenal
is close to the superior pole of the kidney, the vena cava medially, and the
right lobe of the liver superiorly. Its main arterial supply comes directly to
its medial edge from the aorta (figures 2, 11), and the main right adrenal
vein () comes directly from the inferior vena cava in a parallel manner. In
contrast, the le adrenal is in proximity to the aorta medially, the renal vein
inferiorly, and the superior pole of the le kidney. Its main arterial supply
comes directly from the aorta (), but the main le adrenal vein () usually comes from the le renal vein (). Both adrenal glands, however, have
many arterial twigs from both the inferior phrenic arteries ( and ) and
both renal arteries.
e operative exposure of the right adrenal is shown rst (figure 3);
it is begun with a classic Kocher maneuver, a er the transverse colon and
omentum have been carefully packed away and the right lobe of the liver has
been retracted gently. e right lobe of the liver should be fully mobilized
to gain a better exposure of the right adrenal. A er the peritoneum lateral
to the duodenum has been incised, it is mobilized in the usual manner by
blunt dissection with the surgeon’s index nger under the head of the pancreas. e inferior vena cava is exposed in its position directly posterior to
the second portion of the duodenum (figure 4) and then cleared to show
the right renal vein. e superior pole of the right kidney is located and
exposed with further blunt nger dissection. e adrenal is identi ed by its
characteristic yellowish color, lobulated appearance, and clearly de nable
blunt lateral edge. is generally avascular area is then incised (figure 5),
and additional exposure and mobility of the adrenal gland may be obtained
by gentle blunt nger dissection directly posterior to the gland. e surgeon
should bear in mind that the vascular attachments are usually on or near
the medial and superior edges of the gland rather than on its broad surfaces.
If preoperative studies show a large adrenal tumor, especially on the right
side, a thoracoabdominal incision should be considered in order to provide
exposure for mobilizing the right lobe of the liver. It may be necessary to
remove the kidney along with the invading adrenal neoplasm.
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