Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 52 • Splenectomy/Splenic Repair 605

Retropancreatic, prenephric plane

of dissection manually dissected

FIGURE 52 –3

Laparotomy pads packed

behind spleen to tamponade

bleeding

Short gastric

vessels ligated

Splenocolic ligament

divided

FIGURE 52 –4

606 Section VIII • Spleen

◆ After the spleen is mobilized to the midline, it can be rapidly determined whether the in-

jury has active hemorrhage that will require splenectomy or is a more modest injury ame-

nable to splenorrhaphy or mesh wrapping. If the patient is hypotensive, coagulopathic,

acidotic, or hypothermic or has multiple other injuries that contribute to or are worsened

by ongoing hemorrhage (closed head injury), the decision to control hemorrhage by sple-

nectomy is straightforward and should be made rapidly (Figure 52-5).

◆ In patients who respond to control of the bleeding and resuscitation, splenorrhaphy re-

mains an option. This can be accomplished with topical hemostatic agents, suture ligature

with or without pledgets, and in some cases, wrapping of the spleen in absorbable mesh

(Figure 52-6).

◆ The splenic fossa should be carefully examined for hemorrhage and possible injury to the

pancreas before closing. If there is evidence of or reasonable concern for possible injury to

the pancreas, a closed suction drain should be left in the splenic bed (Figure 52-7).

Splenic artery and

vein are ligated and

divided

FIGURE 52 –5

CHAPTER 52 • Splenectomy/Splenic Repair 607

FIGURE 52 –6

FIGURE 52 –7

608 Section VIII • Spleen

3. CLOSING

◆ Although nonoperative management is successful in more than 80% of patients with spleen

injuries, rapid emergent operative treatment may be required.

◆ It cannot be overemphasized that nonoperative treatment is applicable only when the patient

is hemodynamically stable. Patients who have evidence of signiﬁ cant hemoperitoneum, in-

cluding signiﬁ cant free ﬂ uid surrounding loops of small intestine; those with contrast blush

on the CT scan; those taking anticoagulants (warfarin [Coumadin], clopidogrel [Plavix]);

those with portal hypertension; those with multiple injuries that may increase the risk from

hemorrhage or intracranial injury; and the elderly are at increased risk of ongoing hemorrhage

and failure of nonoperative treatment.

◆ When operative intervention is indicated, exposure and full mobilization of the spleen are

essential to either splenorrhaphy or splenectomy.

STEP 4: POSTOPERATIVE CARE

◆ A nasogastric tube is continued in place until evidence of effective gastric emptying is

clearly present. Incentive spirometry and pulmonary toilet are important to limit postopera-

tive atelectasis and pneumonia. Prophylaxis for deep venous thrombosis (DVT) with frac-

tionated heparin may begin on postoperative day 1. In the patients who undergo splenec-

tomy, immunization against pneumococcus, meningococcus, and Haemophilus inﬂ uenzae

should be administered before discharge from the hospital.

STEP 5: PEARLS AND PITFALLS

◆ Pancreatic ﬁ stula may occur following splenectomy as a result of pancreatic trauma or iatro-

genic injury. Careful inspection of the tail of the pancreas and taking care to avoid pancre-

atic injury while ligating the vasculature of the spleen are the best preventative measures. If

there is concern that the tail of the pancreas might be damaged at the time of surgery, a

closed suction drain should be left and efﬂ uent assayed for amylase and lipase levels before

the drain is removed.

◆ Gastric ﬁ stula following splenectomy is a recognized complication that can be avoided by

careful ligation of the short gastric vessels without including any of the gastric serosa, or if

necessary imbricating the short gastric ligatures.

◆ Overwhelming postsplenectomy sepsis may occur.

◆ The spleen contributes to immune competence in a variety of ways, including opsonization

and phagocytosis. Asplenic patients are at increased risk of overwhelming postsplenectomy

infection from encapsulated bacteria, such as Streptococcus pneumoniae, Neisseria meningit-

idis, and H. inﬂ uenzae. Following splenectomy patients should be counseled regarding the

increased susceptibility to infections and vaccinated against these potential infections with

Prevnar, Menactra, and ActHIB before discharge from the hospital.

SELECTED REFERENCES

1. Starnes S, Klein P, Magagna L, Pomerantz R: Computed tomographic grading is useful in the selection of

patients for nonoperative management of blunt injury to the spleen. Am Surg 1998;64:743-648;748-749

[discussion].

2. Cocanour CS, Moore FA, Ware DN, et al: Delayed complications of nonoperative management of blunt

adult splenic trauma. Arch Surg 1998;133:619-624;624-625 [discussion].

3. Ochsner MG: Factors of failure for nonoperative management of blunt liver and splenic injuries. World

J Surg 2001;25:1393-1396.

CHAPTER 52 • Splenectomy/Splenic Repair 609

612

STEP 1: SURGICAL ANATOMY

◆ It is useful to review the anatomy of the abdominal musculature when planning a laparo-

scopic operation.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Laparoscopic colonic surgery is usually performed with the patient in the modiﬁ ed lithotomy

position. The lower extremities should not be ﬂ exed so much as to interfere with movement

of the long laparoscopic instruments (Figure 53-1). When tucking the upper extremities,

protect the hand from entrapment in the movement of the bed surfaces.

CHAPTER

Port Placement for Colon

Operations

Michael D. Trahan

FIGURE 53 –1

CHAPTER 53 • Port Placement for Colon Operations 613

◆ The principle of triangulation of the operative target should be kept in mind as the plan for

port placement is developed. In general, the surgeon should position the operative target

between himself or herself and the monitor screen. For a sigmoid colectomy, the surgeon

stands at the patient’s right and the monitor is at the foot (Figure 53-2). The surgeon

should move from the patient’s right to the left or between the legs as needed to comfort-

ably reach the target.

◆ An optically guided bladeless trocar is the best selection for the initial port to be inserted.

The optical guidance is provided by an end-viewing laparoscope. This port is usually placed

at or near the umbilicus but may be placed elsewhere in patients who are expected to have

midline adhesions.

◆ The size, selection, and number of the remaining ports are subject to much variability depend-

ing on the planned procedure, size and type of anticipated instruments, patient’s body habitus,

and surgeon’s preference.

Monitor

Light source

Camera

Insufflator

Monitor

Video recorder

Irrigation

Electrosurgical

unit

Anesthetist

Second assistant

First assistant Surgical technician

Surgeon

FIGURE 53 –2

614 Section IX • Colon

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The site of each incision should be preemptively anesthetized with a local anesthetic injec-

tion to include the skin and peritoneum.

◆ The incisions should be just large enough to accommodate the trocar without tension on

the skin as the trocar is inserted.

2. DISSECTION

◆ Five 10- to 12-mm ports are used. One port is near the umbilicus. One port is in each of

the abdominal quadrants lateral to the rectus muscles (Figure 53-3).

◆ A 10- to 12-mm port is near the umbilicus. A 5- or 10-mm port is in the left lower quad-

rant. A 10- to 12-mm port is in right lower quadrant. A 5- or 10-mm port is in the left

upper quadrant (Figure 53-4).

◆ A 10- to 12-mm port is near the umbilicus. A 10- to 12-mm port is in the right lower

quadrant. A 5- or 10-mm port is in the right upper quadrant. A 5- or 10-mm port is in the

left lower quadrant (Figure 53-5).

◆ Four 10- to 12-mm ports are used. One port is near the umbilicus. One port is in each of

the mid-clavicular lines at the level of the umbilicus. One port is in the right mid-clavicular

line, 10 to 15 cm inferior to the other (Figure 53-6).

3. CLOSING

◆ Bladeless trocar port sites up to and including 12 mm do not typically need to be closed at

the fascial level.

◆ Transabdominal laparoscopic suture passers provide a quick and relatively simple way to

close small abdominal fascial incisions, especially through a deep abdominal pannus.

◆ If no suture passer is available, larger port site fascial defects should be closed with transab-

dominal suture externally after appropriate retraction of the skin and subcutaneous tissue.

CHAPTER 53 • Port Placement for Colon Operations 615

FIGURE 53 –3

FIGURE 53 –4

FIGURE 53 –5

FIGURE 53 –6

616 Section IX • Colon

STEP 4: POSTOPERATIVE CONSIDERATIONS

◆ Postoperative care is provided consistent with the primary disease process and extent of the

operation.

STEP 5: PEARLS AND PITFALLS

◆ The initial optical entry should be made away from sites expected to have adhesions. In a

patient with extensive prior surgical history, the open insertion technique may be preferred.

◆ Each subsequent trocar entry should be made with direct internal visualization, avoiding

the epigastric vessels and the large subcutaneous vessels identiﬁ ed by transillumination.

◆ One should not hesitate to use additional trocars if needed to improve exposure and the

safety of the operation.

◆ Hand-assisted laparoscopic surgery (HALS) is the approach favored by many. The hand port

should be located at the proposed site of specimen extraction.

SELECTED REFERENCES

1. Ludwig KA, Lee WY: Laparoscopic partial colectomy. In Soper NJ, Swanstrom LL, Eubanks WS (eds):

Mastery of Endoscopic and Laparoscopic Surgery, 2nd ed. Philadelphia, Lippincott Williams & Wilkins,

2005, pp 436-448.

2. Baig MK, Wexner SD: Laparoscopic-assisted abdominoperineal resection. In Soper NJ, Swanstrom LL,

Eubanks WS (eds): Mastery of Endoscopic and Laparoscopic Surgery, 2nd ed. Philadelphia, Lippincott

Williams & Wilkins, 2005, pp 449-458.

3. Fowler DL, Sonoda TS, McGinty J: Laparoscopic subtotal and total colectomy. In Soper NJ, Swanstrom LL

and Eubanks WS (eds): Mastery of Endoscopic and Laparoscopic Surgery, 2nd ed. Philadelphia, Lippincott

Williams & Wilkins, 2005, pp 459-469.