Fig. 12.7  Terminal branches of the splenic artery

Surgical Principles

 Anterior Approach. The procedure follows these key steps:

Division of the short gastric vessels and opening the lesser sac (Fig. 12.8).

Exposure of the tail of the pancreas.

Division of the splenocolic ligament.

Lateral and superior retraction of the inferior pole of the spleen and division of the inferior pole vessels.

Division of the hilar vessels.

Division of the phrenic attachments.

Extraction of the spleen in a bag.

 Technique

Division of the Short Gastric Vessels and Exposure of the Tail of the Pancreas

The first step is division of the short gastric vessels and entry into the lesser sac along the greater curvature of the stomach. This proceeds as for a Nissen fundoplication with the exception that the dissection is carried out much closer to the spleen than to the stomach (Chap. 5). The first assistant gently grasps the fatty tissue surrounding the short gastric vessels and retracts it superiorly, while the surgeon gently retracts the stomach to the right. This will expose the short gastric vessels, which are subsequently controlled with the harmonic shears. Clips can be added for larger vessels if needed. The division is then continued superiorly and then inferiorly until the tail of the pancreas is completely exposed (Fig. 12.9).

Fig. 12.8  Access to the hilar vessels through the lesser sac. Figure depicts ligaments of the  posterior mesogastrum

b

a

c

d

Fig. 12.9 Division of short gastric vessels: (a) exposure of short gastric vessels; (b) dissection 

with scissors; (c) clips;  (d) harmonic shears

Exposure of the Inferior Pole of the Spleen and Division of the Inferior Pole Vessels

The next step is exposure of the inferior pole of the spleen (Fig. 12.10). The first assistant retracts the spleen superiorly and laterally with a closed Babcock clamp to expose the splenic flexure of the colon. The surgeon’s left hand retracts the transverse colon inferiorly, exposing the splenocolic ligament. The ligament is divided using the harmonic shears to allow safe dissection of the inferior pole of the spleen. Once the splenocolic ligament has been divided, lateral and superior retraction will expose the inferior pole vessels that branch from the main splenic vessels. The inferior pole vessels are divided at this point, permitting full mobilization of the inferior pole of the spleen. These vessels are usually large in size and should be clipped or divided using an endo-GIA with a white load.We do not recommend the use of the harmonic shears on these vessels, as it will not achieve efficient hemostasis. Uncontrollable bleeding from these vessels can result in an early conversion to open surgery.

Division of the Hilar Vessels and Phrenic Attachments

In order to expose the hilar vessels, opposing retraction by the first assistant and the surgeon is required. The first assistant retracts the mobilized inferior pole of the spleen superiorly and laterally. The surgeon gently pushes the exposed tail of the pancreas down, creating access to the hilum and the main splenic vessels (Fig. 12.11). Division of the hilar artery and vein is a critical step that should be performed meticulously and carefully to avoid any bleeding. Use of a blunt right-angled dissector is safe.

The surgeon has two choices for ligation of the splenic vessels at the hilum of the spleen: transection of the vessels with one firing of a 30-mm Endolinear cutter using vascular staples (Fig. 12.12a), or a more formal division of the artery and vein separately between clips (Fig. 12.12b). Using a combination of clips and staplers should also be done very cautiously, as clips can result in misfiring of the stapler and subsequent bleeding from a partially divided vessel.

Finally, the attachments of the spleen to the diaphragm are divided, allowing full mobilization of the spleen.

Extraction of the Spleen in a Bag

The next step is introduction of the retrieval bag. A good trick is to push the bag to the diaphragm with the opening of the bag facing the surgeon. This will allow introduction of the spleen into the bag using a “surfing” technique. The spleen is grabbed by its attachments and rolled onto its back, using hilar and fatty attachments as a handle. Thus, the spleen is shoved in a gentle sliding motion into the bag (Fig. 12.13).

The bag is closed and the umbilical port removed. The fascia of the umbilical port can be slightly enlarged to allow extraction of the bag. The introduction of two fingers (or a Kelly clamp) to squeeze the spleen between the fingers and the anterior abdominal wall will enable morcellation of the spleen and extraction of both the bag and the splenic fragments. One should be careful not to drop any fragments in the abdomen, which can lead to splenosis and recurrent disease.