Indications

1. Elective
   • Haematological disorders
   • Part of radical upper abdominal surgery
   • Splenic tumours
   • (Previously - staging of lymphoma)
2. Emergency
   • Trauma

Preparation

1. GA
2. NGT
3. Antibiotics
4. DVT prophylaxis
5. Supine position
6. Vaccination against streptococcus pneumoniae 6/52 before elective surgery and ASAP post-operatively in emergency splenectomy
7. + Long-term prophylaxis against pneumococcal sepsis (with PenV - 250mg bd)

Elective Procedure
(remove spleen and look for speniculi)

1. Incision
   • Left paramedian
   • Midline: for trauma
   • Transverse
   • Left subcostal
2. Divide lienorenal ligament - attaches spleen to kidney
   • (stand on right of patient)
   • Pass hand over spleen onto lienorenal ligament
   • Retract spleen and divide - start from lower end and move towards apex/upper pole using long scissors (obviously!)
   • Deliver spleen up into wound (sweep away peritoneum with swab on a stick)
3. Detach omentum from lower pole of spleen
   • Divide left gastroepiploic vessles between artey forceps + ligation with ties
4. Ligate main splenic vessels
   • Pass fingers around hilum and palpate branches of splenic artery as they pass into spleen; clip + divide branches
   • Remove artery before the vein (if you don't - blood can enter but not leave and you end up in a bloody mess from an exploded spleen) - removing artery "deflates" the spleen
   • (Protect tail of pancreas), left colic flexure and diaphragm
5. Detach gastrosplenic ligament
6. Remove spleen + place suction drain in subphrenic space
7. Close abdominal wall in layers

Emergency splenectomy
(Aim to preserve spleen if possible - prevents post op splenic sepsis)
IV access, resuscitate
Correct coagulopathy
Cross match lots of blood (4+ units)

1. Evacuate clots (manually + suction)
2. Pass hand down to hilum to control bleeding
3. Assess degree of splenic damage
   • Minor decapsulating injury - managed by application of topical haemostatic agents + wrapping spleen in absorbable mesh
   • Single laceration: suture (splenorrhapy)
   • Complete/partial avulsed fragment: partial splenectomy - divide splenic vessels supplying pole in question, resect the fragment and oversew edge with absorbable mattress sutures
   • Massive irreprable damage: splenectomy
4. Close abdomen

Complications of splenectomy

1. General
   • Bleeding
   • Atelectasis of lower lobe
   • Ischaemic perforation of greater curvature of stomach
   • Wound infection / subphrenic abscess
   • Damage to organs causing gastric fistula, pancreatitis, pancreatic fistula
2. Specific
   • Thromobcythaemia (strokes, clots) + leucocytosis - commence aspirin 300mg daily if platelets >750
   • Infection from encapsulated organisms