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352 Atlas of Gastrointestinal Surgery: Spleen
Vasa
brevia
Spleen
Posterior
stomach
Pancreas
At this stage, the vasa brevia along
the gastroepiploic arcade are divided
using an appropriate energy source.
This is begun just below the inferior
pole of the spleen, and opens up
the lesser sac (3).
As this dissection progresses up
towards the superior pole of the
spleen and the angle of His, the
pancreas and splenic artery come nice-
ly into view. When this phase of dissec-
tion is completed, the superior pole of the
spleen will retract away from the midline.
Additional dissection around the superior pole of
3
completely divided, the only remaining blood supply to the spleen is
that traversing the splenic hilum itself.
Before approaching the hilar vessels, much of the remaining
spleen can be mobilized by dividing the filmy attachments
that secure the spleen to the retroperitoneum (4).
The spleen should not be completely freed, as
some fixation is helpful during the hilar dissection. If the majority of this dissection is
the spleen to divide filmy attachments to the
diaphragm and retroperitoneum can be undertaken at this
time to begin to mobilize the spleen. Once the vasa brevia are
Retroperitoneal attachments
divided
accomplished at this time, then when the
splenic vessels are completely divided,
the spleen can easily be removed.
4
Division of the hilar vessels is the most challenging
and potentially dangerous portion of the operation. Prior to this undertaking, blunt instruments should be used to ensure there is an
adequate plane behind the splenic hilum.
Then, sequential vascular load firings of a
laparoscopic stapler are used to progressively divide the hilum adjacent to the
spleen (5). Obviously, if untoward
bleeding is encountered, rapid conversion to laparotomy may be necessary. If,
Laparoscopic Splenectomy 353
5
however, less dramatic bleeding is
encountered, a quick attempt can be
made to control the bleeding by grasping a
vessel with the laparoscopic instrument followed by control with either another stapler load
or with another energy source. Care must be taken
not to apply excessive heat or electrical energy to regions
that already have clips. Doing so can affect those clips and precipitate post-operative bleeding.
6
Spleen
Hilar vessels
divided
Organ
removal
sac
Once the splenic hilum is completely
divided, it remains only for the surgeon to
fully mobilize the spleen from the
retroperitoneum and from the diaphragm.
Once this is done, the spleen can be
placed in an organ removal sac (6). The
12 mm auxiliary port is generally used for
this purpose.
354 Atlas of Gastrointestinal Surgery: Spleen
This incision is then enlarged to approximately
one inch to allow removal of the spleen piecemeal with a ring forceps or other device
(7). This wound is then closed, and the
patient again undergoes laparoscopy.
The surgical field is carefully examined for bleeding and for any sign
of accessory spleens. If an accessory spleen is found, it should
also be removed laparoscopically.
7
Spleen removed piecemeal from sac
1 inch
incision
Splenectomy for a Massive Spleen
Operative Indications:
There are a variety of situations when a splenectomy is required for a massively enlarged spleen. Myeloid metaplasia is perhaps the most notable. The potential for massive bleeding is much greater with a markedly enlarged spleen, but splenectomy may actually be easier than with a normal-sized spleen in a deep-chested or obese individual. Because of the massive enlargement, the spleen generally is no longer attached firmly to the retroperitoneum. It has become peritonealized. It
can often be easily delivered out of the wound after opening the abdomen.
Operative Technique:
When performing a splenectomy in an individual with a normal-sized spleen, either an
upper midline or left subcostal incision is appropriate. When performing a splenectomy
for a massive spleen, a long midline incision should be used. It may be difficult to deliver the spleen through a shorter subcostal incision.
356 Atlas of Gastrointestinal Surgery: Spleen
When the abdomen is entered, the spleen maybe mobile enough that it can be delivered up into the
wound without the usual division of the retroperitoneum in the left upper quadrant (1).
Enlarged spleen
1
Splenectomy for a Massive Spleen 357
2
Omentum
Transverse colon
The lesser sac is entered by removing the omentum from the entire length of the left transverse colon.
This is often an avascular plane, and can be easily divided with the electrocautery (2).
358 Atlas of Gastrointestinal Surgery: Spleen
Once the splenic flexure of the colon is reached,
the attachments between the splenic flexure of
the colon and the spleen (the lienocolic
ligament/attachments) are divided and
the splenic flexure is retracted in an
inferior direction. The omentum is
divided anterior to the splenic
3
Omentum divided
hilum between Kelly clamps, and
ligated with 2-0 silks (3).
Stomach
Massive spleen
Vasa brevis divided
Splenectomy for a Massive Spleen 359
The vasa brevia are divided between
Reinhoff clamps, and ligated with
2-0 silks (4). As the superior
aspect of the spleen and the
superior aspect of the greater
curvature of the stomach are
approached, long Reinhoff
clamps are often of benefit in
clamping, dividing and ligating the vasa brevia. At this
4
The splenic artery, which may
be markedly enlarged, is dissected
out along the superior aspect of
the junction of the body and the
tail of the pancreas. At this
point, the body and the tail
of the pancreas are widely
exposed in the lesser sac.
Splenic a. clamped
point, it is often desirable to
clamp the artery with a bulldog
clamp before splenic mobilization is attempted (5). The
blood flow to a massively
enlarged spleen is substantial,
and the potential for massive
blood loss is significant.
Therefore the enlarged splenic
artery should be clamped early in
the procedure, before mobilization
of the spleen is attempted.
5
360 Atlas of Gastrointestinal Surgery: Spleen
At this point, the spleen is mobilized. As mentioned earlier, often the spleen is already fairly mobile and has assumed an
intraperitoneal position. It often does not have the retroperitoneal fixation of a normal-sized spleen. Nevertheless, the peritoneal attachments lateral to the spleen in the retroperitoneum need to be divided. The surgeon should place the left hand on
the spleen, and rotate and retract it medially toward the spine. An assistant can pick up the retroperitoneal serosa adjacent to
the left lateral aspect of the spleen with a long Reinhoff clamp, and the surgeon, using an electrocautery with an extension, can
divide the retroperitoneal attachments (6). This will allow the spleen to be further mobilized up into the wound.
6
Lateral peritoneal
attachments
divided
Splenic a. divided
at hilum
Splenectomy for a Massive Spleen 361
At this point, the splenic artery along the
superior border of the tail of the pancreas, just
before it enters the splenic hilum, should be
dissected free. The splenic artery should
be triply clamped, divided, and triply lig-
ated (7). Occasionally, it will have
bifurcated or trifurcated before entering
the splenic hilum, and the various
branches will need to be controlled.
7
The splenic vein is best approached posteriorly. In con-
trast to the splenic artery, which courses along the superior aspect of the body and the tail of the pancreas, the
splenic vein generally courses along a groove in the
midportion of the posterior aspect of the pancreas. In
the face of a massively enlarged spleen, the splenic
vein will be huge. It has to be dissected free very
carefully, triply clamped, divided, and triply ligated
with 2-0 silk ties (8). Again, it is often possible to
work with the main trunk, but occasionally, one will
Splenic v.
divided on
posterior aspect
of pancreas
have to divide its various branches. Prior to ligating
the splenic vein, the spleen should be compressed,
giving the patient an autotransfusion. Once the
splenic artery and vein have been controlled, the various areolar and soft tissue attachments between the tail
of the pancreas and the spleen should be doubly clamped,
divided, and ligated with 2-0 silks.
8