Types of surgeries and indications
Splenorrhaphy is an organ-preserving intervention in which injuries are sutured using catgut sutures. Depending on the situation, the surgeon may use mattress, horizontal mattress, or continuous running sutures. This technique is indicated exclusively for solitary and superficial parenchymal injuries.
Splenectomy is the complete removal of the organ. The list of indications for it is significantly broader and includes:
- Traumatic injuries: multiple deep parenchymal ruptures or injuries to the vascular pedicle.
- Parasitic and neoplastic lesions (e.g., echinococcosis).
- Hematological diseases: Werlhof's disease (thrombocytopenic purpura) and hemolytic jaundice.
- Splenomegaly developed against the background of portal hypertension.
Preoperative preparation and approach
The intervention is performed under endotracheal anesthesia. The patient is placed on the operating table in the supine position. In some cases, the right lateral position is preferred with a mandatory roll placed under the lumbar region.
One of two main approaches is used to expose the organ:
- Oblique left subcostal incision, made parallel to the costal margin.
- Upper midline laparotomy.
Splenectomy technique: mobilization and luxation
For adequate exploration and exposure of the surgical field, the costal margin is retracted upward, while the stomach and transverse colon are displaced to the right and downward. The surgeon introduces the left hand into the left hypochondrium above the upper pole of the organ, pulls it downward, and locates the phrenicocolic ligament. After dissecting this ligament, the spleen is luxated into the surgical wound.
> Critical rule: if the surgery is performed for an organ rupture with the development of abdominal bleeding (hemoperitoneum), the sequence of actions changes. The primary objective is to apply a reliable hemostatic clamp to the vascular pedicle, and only then luxate the organ into the wound.
Management of ligaments and vascular pedicle
After successful exteriorization of the organ, the surgeon proceeds to dissect the ligamentous apparatus — the gastrosplenic and splenocolic ligaments. They are transected in stages, in small portions between clamps, followed by ligation. For convenience, the spleen is retracted to the left, and the stomach is displaced to the right.
Next, the surgeon proceeds to manage the vascular pedicle. The splenic artery and vein are isolated bluntly using the fingers.
Ligation rule: the artery is always ligated first. This is necessary to stop the inflow of blood and reduce organ congestion while venous outflow is still functioning. Only after this are two ligatures applied to the splenic vein (v. lienalis).
A crucial topographical and anatomical nuance: ligatures are applied not to the main trunk of the splenic artery (a. lienalis), but to its branches, as close to the splenic hilum as possible. This serves two purposes:
- Elimination of the risk of accidentally incorporating and damaging the tail of the pancreas in the ligature.
- Preservation of blood flow through the short gastric arteries (aa. gastricae breves), which branch off from the splenic artery within the gastrosplenic ligament and supply blood to the gastric fundus.
Organ removal and completion of the surgery
Tissues clamped between instruments (vessels and adhesions) are transected, ligated, and the spleen is finally removed. Afterwards, a thorough hemostasis check is performed.
The surgery is completed with drainage: the drainage tube is usually brought out through a separate stab incision in the left hypochondrium. The main laparotomy wound is closed tightly.
Briefly: answers to topical questions
Which ligaments are dissected during spleen mobilization in a splenectomy?
During spleen mobilization, the phrenicocolic, gastrosplenic, and pancreatosplenic ligaments are sequentially dissected.
Which branches arise from the splenic artery in the area of the organ's hilum?
In the splenic hilum, the splenic artery typically divides into two branches — superior and inferior; less commonly, it divides into three to four branches.
What early and late complications may develop after a splenectomy?
Subphrenic abscess, portal vein thrombosis, postoperative pneumonia, infections, and thromboembolism may develop after a splenectomy.
The “A–V” rule in splenectomy: first ligate the Artery (to devascularize the organ), then the Vein (to prevent trapping blood inside).
Class and exam questions
Why are ligatures applied very close to the splenic hilum during a splenectomy?
This is done to avoid damaging the tail of the pancreas, which lies close to the hilum, and to avoid ligating the short gastric arteries supplying the gastric fundus.
In what sequence are the vessels of the splenic pedicle managed?
The splenic artery is always ligated first to reduce organ blood volume, and only then is the splenic vein ligated.
How does surgical tactics change in splenic rupture?
In case of hemoperitoneum, the organ must not be immediately luxated into the wound. The surgeon's primary task is to apply a hemostatic clamp to the vascular pedicle.
What else to study on this topic
- Topographical anatomy of the spleen's ligamentous apparatus
- Syntopy of the spleen: relationships with the stomach and pancreas
- Features of the blood supply to the gastric fundus (aa. gastricae breves)
- Types of surgical sutures used in splenorrhaphy
- Pathophysiology of portal hypertension and splenomegaly
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