Chapter 17 Operative Exposure in Abdominal Trauma: Exposure of the Spleen and Splenic Injuries

This chapter will discuss exposure and mobilization of the spleen.

Learning Objectives

By the end of the ASSET course, participants should be able to do the following:

1. Demonstrate the steps to mobilize the spleen.
2. Demonstrate isolation of splenic hilar vessels and splenectomy.

Considerations

• While nonoperative management (NOM) of splenic injuries is common, splenic surgery remains an important technique in patients who are not candidates for or fail NOM.
• Guidelines for NOM of spleen injuries are available on the EAST website, www.east.org.
• Patients requiring splenic surgery are often actively bleeding and hemodynamically unstable, making it very important that the surgeon is capable of rapid, effective surgical exposure in order to control hemorrhage.
• In a resource-limited setting without (or with limited) access to blood products or interventional radiology, consideration should be given to early splenectomy in lieu of NOM. Additionally, if the patient requires lengthy transport to a higher level of care and if close observation and frequent reevaluation are not possible, early splenectomy may be warranted.
• Patients requiring operative intervention should undergo a trauma laparotomy, as described in chapter 15.

Technique: Emergent Exposure for Splenectomy

• Make a generous midline incision, with the operating surgeon on the right side of the patient.
• It is important to remember the anatomical relationship of the spleen to the kidney and the tail of the pancreas (Figure 1).

• The spleen is a posterolateral structure and must be mobilized to the midline for evaluation and management.
• Mobilization of the spleen requires division of the attachments (splenophrenic, splenorenal, splenocolic, and splenogastric) that connect it to surrounding structures (Figure 2).
• The spleen is grasped with the surgeon’s nondominant hand and pulled medially while carefully dividing the ligaments, using long scissors or electrocautery (Figure 3).
• In the setting of trauma, the ligaments may have already been partially or completely disrupted, and rapid blunt dissection may be possible.
• Placing laparotomy pads behind the spleen may assist in elevating it medially and anteriorly.
• Once the spleen is mobilized, the hilum can be controlled with digital occlusion.

• The short gastric vessels in the gastrosplenic ligament are divided and ligated, taking care to avoid injury to the stomach. This maneuver exposes the splenic hilum.
• The decision to salvage the spleen or perform a splenectomy requires consideration of the total complexity of the patient’s injuries and potential for future blood loss. In general, if a patient has other injuries or physiologic perturbations, splenectomy is the default.
• The vessels of the splenic hilum can be dissected out (individually or en bloc) and ligated (Figure 4).
• Alternatively, the hilar vessels can be divided with a stapling device (Figure 5).
• Care must be taken not to injure the tail of the pancreas when clamping or dividing the splenic hilum.
• In hypotensive patients, it is important to examine the splenic bed once blood pressure has been restored and prior to closing the abdomen. Uncontrolled short gastric vessels that were not initially bleeding can bleed profusely once perfusion is restored.
• Sponges placed in the left upper quadrant (LUQ) should be removed systematically by having the operating surgeon roll them anteromedially to evaluate the splenic bed. The assistant can then easily see and control any further bleeding.
• If splenectomy has been performed, remember to provide appropriate immunizations to prevent subsequent infection with encapsulated organisms.