This post is for my own benefit I am afraid, purely so the next time I am faced with an emergency open splenectomy I can access this handy refresher article and bash on, unhindered by the need to locate a surgical textbook. In this article I am assuming there is no option for any fancy interventional radiology person coming to save the day (ruin my fun) this is old school, spleen out following major trauma.
The Spleen. You don’t really need it.
The first thing is to calm down, this is a stressful situation but one which if handled correctly (by you) will be life saving. In my hospital and in my experience the patient has suffered some sort of major trauma is usually young, very ill and and there are anxious and terrified relatives all milling about. Most of the time, A&E have whipped everybody involved (including themselves) into a sort of frenzy of hysterics and are not headless chickens as such, but there may be stress induced errors; they have forgotten to alert CT that we are en route to them for example or they send the bloods off incorrectly labelled in the rush. Lots of the time (such as in Bighospital) splenic injuries are manageable through interventional radiology and embolization; but that usually takes awhile to arrange and on a number of occasions I have had to reverse that plan and proceed to a laparotomy when the IR guy and his team are taking too long to get themselves in the hospital and ready to go.
You need to pour oil on these troubled waters and exude calm and confidence, even if you don’t feel it, which is easy to do if you are following the KBW plan…
1. Prep the theatre staff on the kit you want: omnitract, 2 suckers with guards, array of sternal and mayo retractors for the omnitract, lots of big abdo packs, a Ligasure, standard major laparotomy tray, cell saver.
2. Prep the assistant (ideally 2 assistants) on the plan, make sure they are clear on it.
The plan: GA on the table, omnitract ready to go, attached to side of table before they are asleep, prep the skin and drape awake, surgeon on patient’s right, assistant on left. As soon as they are asleep open the skin (midline laparotomy) and fascia,then open the peritoneum and the assistant presses down on the LUQ as you unzip the whole abdomen. A big pack in behind the spleen, another pack above the spleen, another pack in left paracolic gutter. Pack over the liver and on top of the liver and you and the assistant get sucking with both suctions.
4. Check the liver, mobilise falciform off abdominal wall if you need to retract left lobe to access spleen. Pack liver if further trauma there. Get the Omnitract set up, sternals and mayos right and left upper half, fish slice on the liver if required.
5. If haemostasis is ok and you have nicely packed the spleen now is the time to do a thorough laparotomy whilst you are waiting for the anaesthetists to get on top of things at their end.
6. The approach to the packed up spleen: Use the ligasure. Enter the lesser sac, you are going to leave the gastroepiploics behind on the stomach and come up the greater curve sticking close to stomach but not taking any of it using the ligasure. Munch, munch all the way up the short gastrics. See the pancreas, see the splenic artery on top of it, take the artery here if you want. Careful as can be with the pancreas, we do not want a fistula. Usually the bleeding is temporarily controlled by the pressure, if it is still hosing out use a pair of scissors and cut it out, deal with any bleeding afterwards.
7. Flip stomach up and out of the way, free the spleen above and medially, be careful up here at the diaphragm, little bites, stay close to the spleen.
8. Fully unpack the spleen if patient stable and have a look at the damage, leave unpacked if bleeding stopped. Come up to the spleen from left paracolic gutter now, it will be attached here, come round to the hilum, now reach round the back and divide the posterior attachments, deliver the spleen up out of the hole and it should now just be attached at the hilum.
9. Ligasure up the medial surface of the spleen, take the vessels and tie them off. Careful, careful, careful that you don’t munch any pancreas here.
10. Spleen out, wash, drain (for panreatic fistula rather than blood) close and go.
Don’t forget to give you may need an NG tube to decompress the stomach. You need to give prophylactic antibiotics, a urinary catheter, consider a post op epidural, check current guidelines on post splenectomy immunisation schedule and antibiotic prophylaxis.
Your anaesthetist is crucial in this operation, the fatal triad of hypothermia, acidosis and coagulopathy will be activated and unless your anaesthetist is on the case all your brilliant surgery will be wasted.
(Spleen 1,3,5,7,9,11: The spleen is 1″thick,3″deep, 5″long, it weighs 7oz and lies between ribs 9 and 11. Not that anyone nowadays measures in inches and weighs in oz. If the spleen is enlarged: )