What is the open approach to surgery for splenic infarct?

Updated: Jul 27, 2020
  • Author: Manish Parikh, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Answer

Open approach

For the open approach, a standard midline incision or left subcostal incision (with possible Kehr extension up to the xiphocostal junction) may be used. Placing a large roll under the left flank often aids in exposure.

Usually, the gastrocolic ligament is opened outside the gastroepiploic arcade and the splenic artery is identified along the superior border of the pancreas and then ligated. Next, the spleen is completely mobilized by dividing the avascular splenophrenic and splenorenal ligaments. The splenocolic ligament is divided, and the spleen is mobilized into the wound. The tail of the pancreas is separated from the splenic artery and vein, the splenic vessels are ligated, and the spleen is extracted.

There are several techniques described for splenic repair. [23] The critical intraoperative maneuver regarding intraoperative splenic salvage entails fully mobilizing the spleen into the wound; this requires the division of one or two of the short gastric vessels combined with gentle dissection posteriorly, so that the capsule is not torn in the mobilization process. [17]

The use of postoperative drainage depends on the operative findings, including the presence of a frank abscess, and the proximity of the dissection to the pancreatic tail. The authors' preference is for closed suction drainage to be placed in the splenic bed, with early removal (ie, within 24 hours). There is some evidence that the routine use of drainage of the splenic bed in the absence of extrasplenic abscess or pancreatic injury is associated with an increased risk of local infection.

If concern exists regarding possible impingement upon the gastric wall during short gastric vessel division, a nasogastric tube may be left in place.


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