Open splenectomy

Preop
Vaccinations: meningococcal, haemophilus, pneumovax
steroids in ITP
Antibiotics

1.Position patient supine with the left side raised in a bean bag.
2.Make a left subcostal incision.
3.Start by mobilizing the splenic flexure.
4.With the left hand retract the spleen medially and divide the lieno-renal ligament until the spleen is free from Gerota’s fascia and the diaphragm. This manouvre will deliver the spleen into the wound.
5.An alternative approach is to begin anteriorly and encounter the left gastro-epiploic vessels outside the arcade along the greater curvature and ligate them. Within the posterior wall of the lesser sac, you should be able to visualize the splenic artery which can be controlled with a silastic sling. Continue division of the gastro-splenic ligament and divide any short gastric vessels you encounter.
6.Ligate the main trunk of the splenic artery at the hilus. (spleen will shrink 15-20%)
7.Search the posterior aspect of the splenic hilus for the tail of the pancreas and dissect it away, ligating any vessels to the gland. This will give the spleen an opportunity to decrease in size.
8.Ligate the splenic vein at the hilus.
9.Examine the greater curve and if there is any suspicion of damage, invert the stomach with Lembert sutures.
10.Lavage and close.

Operations for splenic trauma
1.Preservation techniques
oSuperficial injuries – APC
oTransverse fractures – splenorrhaphy or hemisplenectomy
oLongitudinal fracture – pedicled omental patch
oStellate fractures – suture/tisseel duo or vicryl mesh wrap
2.Splenorrhaphy following complete mobilization by debriding edges and suturing lacerations between Teflon felt or a vicryl mesh wrap.
3.Partial splenectomy – complete the division of the remaining spleen ensuring that it will be viable, ligating vessels on the cut surface and then repair cut end of organ between Teflon felt.