- Email: [email protected]
Extreme emergency splenectomy
Journal of Visceral Surgery (2014) 151, 41—44
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL TECHNIQUE
Extreme emergency splenectomy G. Martin ∗, K. Slim Service de chirurgie digestive, CHU Estaing, place Lucie-Aubrac, 63003 Clermont-Ferrand, France Available online 24 January 2014
Introduction Surgical management of a patient with severe splenic injury, in deep shock with a massive hemoperitoneum, is critically important and must be conducted according to a standardized protocol with a high probability of damage-control laparotomy (risk of sudden cardiac decompensation upon opening the abdomen and associated coagulopathy in the emergency setting). The indication for total splenectomy is urgent and constitutes a surgical salvage procedure [1—3].
∗
Corresponding author. E-mail address: [email protected] (G. Martin).
1878-7886/$ — see front matter © 2014 Published by Elsevier Masson SAS. http://dx.doi.org/10.1016/j.jviscsurg.2013.12.010
42
G. Martin, K. Slim
1
Patient position and surgical approach
2
Temporary hemostasis and exposure
The patient is positioned supine, both arms abducted (to permit optimal vascular filling). A cushion can be placed at the level of the lower scapula to open the costo-iliac angle. A nasogastric tube is placed to empty the stomach and facilitate access to the spleen. The operator stands on the patient’s right side. In the emergency setting, a rapid supra-umbilical midline incision, extended infra-umbilically, to the right or left if necessary to treat other associated injuries.
The most efficient manner to obtain hemostasis in an unstable patient with a massively bleeding spleen is to palm the spleen with the left hand (for right-handers) and to push the organ against the spine. Insertion of several abdominal pads with a grasper held in the operator’s right hand usually obtains temporary hemostasis until a more definitive approach can be pursued. As soon as temporary hemostasis is obtained, the left costal margin is retracted with a costal margin retractor and the operation table is rolled slightly to the right, especially when the patient is obese.
Mobilization of the spleen: freeing 3 the splenic convexity and lower pole
The left hand palms the convexity of the spleen and delicately draws the organ toward the midline in order to incise the posterior parietal peritoneum (or lienorenal ligament). It is important to remain close to the spleen to limit deperitonealization. The lower pole of the spleen is freed by exercising gentle cephalad traction. The splenic flexure of the colon is maintained at distance by an abdominal pad folded under a broad Deaver (or Leriche) retractor held by the assistant. The left hand of the operator cups the lower pole of the spleen in order to divide the suspensory ligament and any eventual adhesions between the colonic angle and the spleen. The spleen is held in the left hand during the mobilization and ligament divisions.
Extreme emergency splenectomy
4
Liberation of the upper pole and the posterior aspect of the pancreas
5
Division of the gastro-splenic ligament
6
Ligation of the splenic pedicle
To free the upper pole of the spleen, pads can be placed in the splenic bed to bring the spleen forward. The peritoneum is incised close to the spleen, caution being exercised not to injure the short gastric vessels between the spleen and the greater curvature of the stomach. While still compressing the spleen, the posterior mesogastrium (or posterior aspect of the pancreas) is entered with cupped fingers of the left hand in the retropancreatic space pulling upwards, while the posterior attachments are divided. The anterior aspect of the kidney and adrenal gland are exposed while the spleen and the tail of the pancreas can now be exteriorized.
Once the spleen has been mobilized and retracted to the right, the splenic vessels can be doubly clamped in the pedicle, divided, and doubly ligated. Total splenectomy is pursued by dividing the gastro-splenic (gastrolienal) ligament and the short gastric vessels. At the lower margin of the ligament, the gastroepiploic (left gastro-omental) pedicle is divided, opening the lesser sac and exposing the splenic pedicle.
During this step, the tail of the pancreas must be completely identified, and care must be taken to avoid including it in the ligatures. The elements of the splenic pedicle are isolated by retracting the spleen, clamping and then dividing the vessels. The pedicle is ligated at the level of the hilum of the spleen, with non-absorbable suture ligatures, starting either from in front or from behind. During ligation, caution must be exercised to avoid ligation of the pancreatic tail. Thermofusion instruments can also be used to seal off and divide the splenic vessels: hemostasis is obtained more quickly, this approach should not be used for the major vessels of the splenic pedicle but for the smaller vessels close to the spleen.
43
44
7
G. Martin, K. Slim
Hemostasis and closure
After removal of the spleen, hemostasis is carefully checked from deep to superficial as the same time that the pads packed into the splenic bed are removed. Omentum is laid into the splenic bed, along with the splenic flexure of the colon and the remaining stump of the gastro-splenic ligament. Drainage is not routine but can be indicated when there is a risk of pancreatic fistula.
Disclosure of interest
References
The authors declare that they have no conflicts of interest concerning this article.
[1] Harbrecht BG. Is anything new in adult blunt splenic trauma? Am J Surg 2005;190:273—8. [2] Letoublon C, Reche F, Abba J, Arvieux C. Damage control laparotomy. J Visc Surg 2011;148:e366—70. [3] Arvieux C, Reche F, Breil P, Létoublon C. Traumatismes de la rate. Principes de techniques et de tactique chirurgicales. EMC - Tech Chir - Appar Dig 2009;4:1—18.
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL TECHNIQUE
Extreme emergency splenectomy G. Martin ∗, K. Slim Service de chirurgie digestive, CHU Estaing, place Lucie-Aubrac, 63003 Clermont-Ferrand, France Available online 24 January 2014
Introduction Surgical management of a patient with severe splenic injury, in deep shock with a massive hemoperitoneum, is critically important and must be conducted according to a standardized protocol with a high probability of damage-control laparotomy (risk of sudden cardiac decompensation upon opening the abdomen and associated coagulopathy in the emergency setting). The indication for total splenectomy is urgent and constitutes a surgical salvage procedure [1—3].
∗
Corresponding author. E-mail address: [email protected] (G. Martin).
1878-7886/$ — see front matter © 2014 Published by Elsevier Masson SAS. http://dx.doi.org/10.1016/j.jviscsurg.2013.12.010
42
G. Martin, K. Slim
1
Patient position and surgical approach
2
Temporary hemostasis and exposure
The patient is positioned supine, both arms abducted (to permit optimal vascular filling). A cushion can be placed at the level of the lower scapula to open the costo-iliac angle. A nasogastric tube is placed to empty the stomach and facilitate access to the spleen. The operator stands on the patient’s right side. In the emergency setting, a rapid supra-umbilical midline incision, extended infra-umbilically, to the right or left if necessary to treat other associated injuries.
The most efficient manner to obtain hemostasis in an unstable patient with a massively bleeding spleen is to palm the spleen with the left hand (for right-handers) and to push the organ against the spine. Insertion of several abdominal pads with a grasper held in the operator’s right hand usually obtains temporary hemostasis until a more definitive approach can be pursued. As soon as temporary hemostasis is obtained, the left costal margin is retracted with a costal margin retractor and the operation table is rolled slightly to the right, especially when the patient is obese.
Mobilization of the spleen: freeing 3 the splenic convexity and lower pole
The left hand palms the convexity of the spleen and delicately draws the organ toward the midline in order to incise the posterior parietal peritoneum (or lienorenal ligament). It is important to remain close to the spleen to limit deperitonealization. The lower pole of the spleen is freed by exercising gentle cephalad traction. The splenic flexure of the colon is maintained at distance by an abdominal pad folded under a broad Deaver (or Leriche) retractor held by the assistant. The left hand of the operator cups the lower pole of the spleen in order to divide the suspensory ligament and any eventual adhesions between the colonic angle and the spleen. The spleen is held in the left hand during the mobilization and ligament divisions.
Extreme emergency splenectomy
4
Liberation of the upper pole and the posterior aspect of the pancreas
5
Division of the gastro-splenic ligament
6
Ligation of the splenic pedicle
To free the upper pole of the spleen, pads can be placed in the splenic bed to bring the spleen forward. The peritoneum is incised close to the spleen, caution being exercised not to injure the short gastric vessels between the spleen and the greater curvature of the stomach. While still compressing the spleen, the posterior mesogastrium (or posterior aspect of the pancreas) is entered with cupped fingers of the left hand in the retropancreatic space pulling upwards, while the posterior attachments are divided. The anterior aspect of the kidney and adrenal gland are exposed while the spleen and the tail of the pancreas can now be exteriorized.
Once the spleen has been mobilized and retracted to the right, the splenic vessels can be doubly clamped in the pedicle, divided, and doubly ligated. Total splenectomy is pursued by dividing the gastro-splenic (gastrolienal) ligament and the short gastric vessels. At the lower margin of the ligament, the gastroepiploic (left gastro-omental) pedicle is divided, opening the lesser sac and exposing the splenic pedicle.
During this step, the tail of the pancreas must be completely identified, and care must be taken to avoid including it in the ligatures. The elements of the splenic pedicle are isolated by retracting the spleen, clamping and then dividing the vessels. The pedicle is ligated at the level of the hilum of the spleen, with non-absorbable suture ligatures, starting either from in front or from behind. During ligation, caution must be exercised to avoid ligation of the pancreatic tail. Thermofusion instruments can also be used to seal off and divide the splenic vessels: hemostasis is obtained more quickly, this approach should not be used for the major vessels of the splenic pedicle but for the smaller vessels close to the spleen.
43
44
7
G. Martin, K. Slim
Hemostasis and closure
After removal of the spleen, hemostasis is carefully checked from deep to superficial as the same time that the pads packed into the splenic bed are removed. Omentum is laid into the splenic bed, along with the splenic flexure of the colon and the remaining stump of the gastro-splenic ligament. Drainage is not routine but can be indicated when there is a risk of pancreatic fistula.
Disclosure of interest
References
The authors declare that they have no conflicts of interest concerning this article.
[1] Harbrecht BG. Is anything new in adult blunt splenic trauma? Am J Surg 2005;190:273—8. [2] Letoublon C, Reche F, Abba J, Arvieux C. Damage control laparotomy. J Visc Surg 2011;148:e366—70. [3] Arvieux C, Reche F, Breil P, Létoublon C. Traumatismes de la rate. Principes de techniques et de tactique chirurgicales. EMC - Tech Chir - Appar Dig 2009;4:1—18.