RUPTURED SPLEEN

For earlier steps in the operation see Section 66.3. Make sure the patient has a nasogastric tube in his stomach, and a free flowing drip in a big vein.

ANAESTHESIA Good relaxation is necessary. (1) A ketamine drip with a relaxant. (2) Ketamine induction followed by ether with a relaxant. In a grave emergency, when a patient is desperately ill, you may have to remove his spleen under local anaesthesia.

POSITION Lie the patient on his back with his left arm drawn over to his right and his forearm supported on a pad or arm rest. It is sometimes helpful to rotate his thorax to the right with a sandbag under his left chest and pelvis.

INCISION If you are sure that a patient’s spleen has ruptured, make a left paramedian, rectus split, or upper midline incision. Otherwise, make a right paramedian or a midline incision.

CONFIRM THAT THE SPLEEN HAS BEEN INJURED

Fresh blood or clots in a patient’s left hypochondrium nearly always mean that his spleen has ruptured. Confirm this by feeling its surface. It should have a smooth surface facing his diaphragm, and a notch on its anterior border. The injury may have torn any of its surfaces, or pulled it off its pedicle. If it is damaged in any way, remove it. If you are not sure if it has been injured or not, extend the incision.

Control bleeding temporarily by compressing his splenic pedicle between the thumb and fingers of your left hand. Save as much blood as you can for autotransfusion (16.11). Keep holding the pedicle until the anaesthetist confirms that the patient is in a satisfactory condition to proceed.

First get at his injured spleen: (1) Tilt him on to his right side. (2) Pack his stomach and his transerve colon out of the way. Ask a strong assistant with a large left hand to draw the patient’s stomach and colon downwards, and retract his left costal margin upwards. (3) If necessary, and especially if there are dense adhesions between the spleen and the diaphragm or abdominal wall, extend the incision. Extend a midline incision laterally, by cutting his left rectus through one of its tendinous insertions. If necessary, cut beyond its outer borders.

If you cannot find a tear, look elsewhere in the patient’s abdomen. If you still cannot find a tear, return to his spleen, and examine it with more care.

TIE THE SPLENIC PEDICLE

If you are inexperienced and bleeding is severe, deliver the patient’s spleen, rotate it forwards, and to the right. Put a thick ligature right round the entire splenic pedicle. This is safer than trying to grasp it with a large clamp. As you do so, try not to damage his stomach, and to cause the least possible damage to his pancreas. When you have controlled bleeding, proceed to tie the vessels individually.

If you are more experienced, use blunt scissors to open up a window in his gastrosplenic ligament, as in B, Fig. 66-11. This will let you into his lesser sac. Feel for his splenic artery along the upper border of his pancreas. Incise the peritoneum over it, pass a haemostat underneath it, and tie it.

Don’t divide his splenic artery yet; his splenic vein lies under it—avoid injuring this. Clamp, cut, and tie his short gastric vessels passing from his spleen to the greater curvatureof his stomach. Tie them individually using small artery forceps. If you tear them, oversew the wall of his stomach with atraumatic sutures.

CAUTION! Don’t include an area of stomach wall with your ligatures, especially at the upper margin of the spleen.

FREE THE PATIENT’S SPLEEN Feel for his spleen by putting your hand under his diaphragm, and breaking down any light adhesions.

If adhesions are dense, cut them with long curved Metzenbaum scissors, or incise the peritoneum and separate his spleen from his diaphragm extraperitoneally.

Rotate his spleen gently downwards and medially (C). Incise his splenorenal ligament (D). Put your finger into the peritoneal opening and gently free its margin. You can now bring his spleen well outside his abdomen (E).

Divide his splenocoiic ligament between curved clamps, taking care to avoid clamping his colon (F).

Reflect his spleen medially and use blunt dissection to separate the tail of his pancreas from his splenic vessels (G). Tie them at the splenic pedicle just before they divide.

Clamp the vessels in his splenic pedicle (H). Pass ligatures of No. 1 linen thread or silk under the vessels of the pedicle, and tie them securely.

For extra security apply a second set of ligatures at the same point.

CAUTION! Make sure your assistant releases the haemostats gently and steadily, as you tighten the ligature, without a sudden click. If the cut vessel drops off and is lost in a pool of blood, you may never find it again.

Bleeding vessels on the diaphragm are small, very persistent, and almost impossible to tie. If possible, use diathermy. Absolute haemostasis is essential.

Put a big dry pack over the patient’s splenic bed. Leave it there for a few minutes. Remove it and look for any bleeding vessels, and tie them off.

Look for other abdominal injuries before you close his abdomen.

AUTOTRANSPLANTATION Use a large scalpel to cut two large thin 2 mm slices from the patient’s spleen. Incise his parietal peritoneum under his left costal margin, slip the slices in, tie them flat against his intercostal muscles, and sew up the peritoneum over them.

If, 4 weeks later, he has no Howell Jolly bodies, and no target cells in his peripheral blood film, and his platelet count is normal, transplantation has probably succeeded.

DRAINS If: (1) the operative site is absolutely dry, and (2) you are sure you have not injured the tail of the pancreas, there is no need for a drain. Otherwise, place a large corrugated or tube drain down to the tail of the pancreas, and close the wound.

DIFFICULTIES WITH EMERGENCY SPLENECTOMY

If OOZING IS UNCONTROLLABLE, i nsert a large pack and remove it 48 hours later.

If a PATIENT SUDDENLY DETERIORATES postoperatively, a ligature has probably slipped. Operate immediately.

If a SEROUS EFFUSION DEVELOPS in his splenic bed it may resemble a subphrenic abscess; but it usually resolves slowly and spontaneously. If X–rays show that his stomach continues to be displaced, the effusion may need draining.

If VENOUS THROMBOSES OCCUR, they may involve any vein, but they won’t be disastrous unless they involve his portal vein. The platelet count always rises after splenectomy and then usually falls without reaching dangerous levels. If possible, check his platelet count at 4 and 8 days. If there are more than 750,000 platelets/mm  give him heparin (5,000 units every 4 hours intravenously depending on his size and his associated injuries).

If his WOUND SLOUGHS and there is a fluid discharge, the tail of his pancreas may have been injured. Reopen the wound and do a suture ligation of his damaged pancreas. Insert a suction drain (9.7).