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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_738_Библиотеки_им_академика_М_И_Перельмана.pdf
THE SPLEEN
Splenectomy
Operative Indications:
Splenectomy is indicated for a wide spectrum of diseases. Perhaps the most common indication is trauma, either external
or operative. A variety of hematologic disorders also require splenectomy. It may be a part of staging for a lymphoma.
Finally, splenectomy may be performed as part of a cancer operation, either on the stomach, pancreas, or another left upper
quadrant or retroperitoneal structure. A splenic abscess may also rarely be treated best by splenectomy.
Operative
Technique:
Splenectomy can be performed through either an
upper midline or left subcostal incision. When the
spleen is normal size, a left
subcostal incision has some
advantage over an upper mid-
line incision. When the spleen is
massive, a long midline incision should be used. Retraction of the left
subcostal margin by a retractor fixed to a frame attached to the operating table is of great help. Initially, the areolar attachments to the
1
Spleen
Omental
attachments
divided
spleen from the omentum are divided to avoid capsular tears and
bleeding during the procedure (1).
346 Atlas of Gastrointestinal Surgery: Spleen
The lesser sac can be entered by going through the midportion of the omentum, but I prefer to take the omentum off of
the transverse colon over towards the spleen, beginning in the mid-transverse colon (2). The junction of the omentum with
the fat along the transverse colon is usually a relatively bloodless plane and can be divided with the electrocautery. This is
carried out all the way over to the splenic flexure.
The splenic flexure of the colon is then mobilized by dividing the splenocolic ligament/attachments and retracting the
splenic flexure inferiorly (3). Next the omentum anterior to the splenic hilum is divided between Kelly clamps and ligated
with 2-0 silks (4). As one continues in a cephalad direction, the vasa brevia are encountered and can be divided along
the greater curvature of the stomach (5). These vessels are clamped between Reinhoff clamps, divided, and ligated with
2-0 silks. As one divides the vasa brevia high on the stomach, long Reinhoff clamps can be helpful in a particularly deepchested individual. The stomach can then be retracted medially either by using a thin Deaver retractor or by grasping the
stomach with a Babcock clamp.
2
Omentum
Transverse colon
Splenectomy 347
3
4
5
At this point, the body and tail of the pancreas are widely
exposed in the lesser sac. It is often desirable to loop the
splenic artery along the superior border of the mid-body of the
pancreas. Generally, it is easily palpable and can be quickly
mobilized and looped with a vessel loop (6). Subsequently, if
one should get into troublesome bleeding during mobilization of
the spleen, one can quickly clamp the splenic artery at this point
with a DeBakey bulldog clamp.
6
348 Atlas of Gastrointestinal Surgery: Spleen
Retroperitoneal
serosa divided
Next, the spleen can be mobilized out of the retroperi-
toneum. If the patient is obese or has an acute costal
angle, and particularly if the patient has a deep tho-
racic cavity, this important part of the procedure can
be very difficult. It is best accomplished by the
surgeon placing the left hand on the spleen and
retracting it medially, as if one is trying to com-
press it up against the spinal column. It is impor-
tant not to retract anteriorly, as this can easily
result in avulsing part of the splenic capsule. As the
surgeon compresses the spleen medially, the assistant
can lift up the retroperitoneal serosa with forceps, or
with a long Reinhoff clamp, and the surgeon can incise the
peritoneum close to the spleen with the electrocautery (7). An
7
extension on the electrocautery often is helpful. This is obviously an
important part of the procedure. If it is carried out along the entire length of the
spleen, from the inferior border up to where the posterior aspect of the stomach is
retroperitoneal, it will then allow free mobility of the entire spleen during the remainder of the procedure. At this point,
the spleen and the tail of the pancreas can be elevated out of the retroperitoneum. This is a relatively bloodless plane.
One has to be careful, however, not to injure the left adrenal gland, which is in close approximation to the superior aspect
of the tail of the pancreas.
Spleen
8
Once the spleen has been completely mobilized, the splenic vessels can then be divided. The splenic artery usually traverses along
the superior aspect of the pancreas (8). One can either divide the
main splenic artery at the splenic hilum, or separately ligate each of
its branches. These are usually triply ligated with 2-0 silks and then
divided. Occasionally, there is ample room between the tail
of the pancreas and the splenic hilum so that vessel lig-
Splenic a.
ation can be easily carried out. Often, however,
the tail of the pancreas seems to extend right into
the splenic hilum, and one has to be very careful that the tail of the pancreas is not injured
during this vessel ligation.
Vasa
brevia
Pancreas
Splenic v.
L. gastroepiploic
a. and v.
Once the splenic artery has been divided, the spleen can be reflected medially and the posterior aspect of the tail of the pancreas visualized. In contrast
Splenectomy 349
to the splenic artery, the splenic vein is best approached posteriorly. The
splenic vein, as it enters the splenic hilum, closely adheres, often in a
groove, to the posterior middle aspect of the tail of the pancreas. Its
main trunk is dissected out, triply clamped, divided, and triply ligated
(9). Before this is carried out, it is often desirable to compress the
spleen, thus giving the patient an autotransfusion from the spleen
before dividing the splenic vein. Once the splenic artery and splenic
vein have been divided, the remaining areolar tissue between the tail
of the pancreas and the spleen is divided and the spleen is removed
from the operative field. My preference is to drain the tail of the pancreas with a closed suction Silastic drain (10). Inadvertent and often
unrecognized injury may occur to the tail of the pancreas during splenectomy. If one leaves a closed suction drain behind, an intra-abdominal collection
of pancreatic juice and/or abscess formation can be avoided. Patients who undergo
Spleen
reflected
medially
Splenic a.
Splenic v.
divided
Tail of pancreas
9
splenectomy should be vaccinated for the various encapsulated organisms.
Liver
10
Stomach
Splenic
a. and v.
Tail of
pancreas
Colon
Laparoscopic Splenectomy
Operative Indications:
The most common indication for laparoscopic splenectomy is idiopathic thrombocytopenic purpura, in which the spleen is
of normal size. Other diseases that cause varying degrees of splenomegaly may or may not be appropriate for a laparoscopic approach based upon the particular situation. This description is that of a splenectomy for a normal size or mildly
enlarged spleen in the elective setting.
Operative Technique:
5 mm
5 mm
5 mm
12 mm
(stapler)
Port-site placement for a laparoscopic splenectomy is shown. The patient is placed
in a modified right lateral decubitus position and is secured to the table. This allows
for a steep Trendelenburg and reverse Trendelenburg position as well as for rolling
the table far enough to bring the patient nearly into a prone position when necessary. The telescope is placed in a supraumbilical port position. Auxiliary 5 mm trocars are placed high in the midline and just right of midline midway between the
xiphoid and the camera port. A 5 mm port is placed in the anterior axillary line just
below the costal margin, and a 12 mm port capable of passing a laparoscopic stapler is placed in the mid-clavicular line below or at the level of the telescope port.
Laparoscopic Splenectomy 351
The first step in the dissection is to divide attachments between the inferior pole of the spleen and the splenic flexure of
the colon (2). With the patient positioned appropriately, the spleen appears to be up on the ceiling of the surgical workspace (1, 2) with the colon being retracted downward due to gravity. The patient is in a steep reverse Trendelenburg position. Once these attachments are divided, the splenic flexure of the colon retracts nicely away from the field.
Stomach
1
Liver
Spleen
Tail of pancreas
L. kidney
Inferior pole
of spleen
Colon
Splenocolic
attachments
divided
2