clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Complications

■Bleeding

■Pancreatitis

■Pancreatic fistula

■Colonic or gastric perforation

■Subphrenic abscess

■Wound infection

■Atelectasis

■Left pleural effusion

■Postsplenectomy sepsis

■Thrombocytosis

Tricks of the Senior Surgeon

■If bleeding is excessive and control of the splenic artery has not already been secured, or is not immediately feasible, the splenic artery and veins are easily controlled by gentle pressure applied between the second and third fingers of the surgeon’s right hand.

■Control of the splenic artery is most easily accomplished near its origin through the gastrohepatic ligament posterior to the lesser curvature of the stomach

(see STEP 1), which is particularly useful during splenorrhaphy.

■Another approach to the splenic hilum is anteriorly which carries increased risk as the splenic vein is immediately posterior to the splenic artery near the hilum and the tail of the pancreas is also intimately associated to the splenic hilum.

■A linear stapler, as with laparoscopic splenectomy, is particularly useful when expeditious division of the hilum is necessary to control hemorrhage.

■For patients in whom difficulty gaining vascular control is anticipated, for those with enormous splenomegaly or those with portal hypertension, splenic artery embolization done immediately prior to the operation can reduce splenic sequestration, congestion and bleeding.

■Early ligation of the splenic artery diminishes blood loss, maximizes the amount of blood in the spleen returning to the patient, decreases the size of the spleen, improves ease of handling, facilitates removal and improves transfusion efficiency of blood products sooner rather than later during the procedure,

if necessary.

■Make a thorough search for accessory spleens before and after the spleen is removed, especially when operating for hematological indications. Accessory spleens are found in 15–35% of patients undergoing splenectomy and higher in those with hematological diseases. In order of decreasing frequency, accessory spleens are found in the splenic hilum, the splenorenal ligament, the greater omentum, the retroperitoneum near the tail of the pancreas, and the splenocolic ligament. Less commonly, accessory spleens are found in the mesentery of the small and large intestine, as well as the pelvis, in particular the left ureter and left adnexa, and left gonads.

■Mobilize the splenic flexure and the rest of the colon whenever necessary. Be just as careful protecting the colon and the stomach to prevent injury to either hollow viscus.

No retractors are required. In the lateral position gravity enhances exposure of the posterior splenic attachments. A blunt ended 5-mm-diameter grasping instrument is placed through the most medial port is used to manipulate the spleen, lifting it upwards to expose the hilum, or rotating it towards the midline to expose the posterior attachments. A search for accessory spleens (see “Open Splenectomy,”“Tricks of the Senior Surgeon”) should be made before commencing dissection of the spleen, as accessory spleens are more easily identified at this stage, and they should be removed as soon as they have been found. Removal later in the procedure can be more difficult.

With the spleen rotated towards the midline, the posterior peritoneal attachments are divided 5–10mm away from the splenic capsule using a diathermy hook or ultrasonic shears. The spleen is progressively mobilized towards the midline, exposing the “splenic mesentery,” which contains the main splenic vessels inferiorly, the short gastric vessels superiorly, and the tail of the pancreas. For adequate mobilization it is necessary to divide the posterior splenic attachments up to the left side of the oesophageal diaphragmatic hiatus superiorly (see “Open Splenectomy,” STEP 3). A combination

of gravity and rotation of the spleen displays an avascular fascial plane behind the splenic mesentery.

It is important to avoid damage to the tail of the pancreas during this dissection. If bleeding occurs during this step, then dissection is in an incorrect tissue plane.

An AutoSuture Endocatch II retrieval bag (U.S. Surgical, Norwalk, CT, USA) is positioned underneath the spleen, and then opened so that the spleen drops directly into the bag as the bag is opened. Other specimen bags require additional manipulation to get the spleen into the retrieval bag and are more difficult to use. The neck of the bag is then pulled out through the lateral 12-mm port wound.

■This procedure is most suitable for spleens which are normal in size or only mildly enlarged. The size of the spleen is best assessed before surgery with patients in the lateral position. If the spleen is easily palpable then it may be too big for laparoscopic dissection of the hilum in the lateral position.

Partial Splenectomy, Open and Laparoscopic

Eric C. Poulin, Christopher M. Schlachta, Joseph Mamazza

Indications and Contraindications

Elective

■Resection of non-parasitic cysts

■Hamartomas and other benign splenic tumors

■Inflammatory pseudotumor of the spleen, Type J Gaucher’s disease

■Cholesteryl ester storage disease, chronic myelogenous leukemia

■Thalassemia major, spherocytosis, staging of Hodgkin’s disease in children

Preoperative Investigation and Preparation for the Procedure

See chapter “Open Splenectomy.”

The spleen in the majority of cases can be divided into independent lobes or segments, each with its own terminal blood supply (A, B). The superior pole is supplied by the short gastric vessels and the lower pole by branches of the gastroepiploic artery (up to five) known to anastomose with the inferior polar artery. In addition, most patients, despite possible variations, have two or three major vessels entering the hilum. Therefore there are usually four or five regions or lobes available for partial splenectomy. It is also important to understand that these vessels lie in different supportive ligaments. Vessels to the superior pole (short gastrics) and inferior pole (gastroepiploic branches) rest in the gastrosplenic ligament, whereas the splenic branches proper lie in the splenorenal ligament with the tail of the pancreas.