Editing Splenic trauma (section)

=== '''Standard splenectomy:''' ===

* First, need to mobilise spleen towards midline: (spleen usually auto-dissects itself away from the wall)
** Me on patient's right, assistant on other wide with a body wall retractor under the costal margin
** Put left hand over spleen, pull towards midline, and divide adhesions to the abdominal wall
** Start laterally on spleen - divide splenophrenic, splenocolic, splenorenal ligaments with ligasure/diathermy/scissors
** Blunt dissection of plane between spleen and kidney/pancreatic tail. Pancreas most easily seen from behind.
** Medialise spleen, then divide gastrosplenic ligament with ligasure (watch out for short gastric vessels - will need to be clamped and tied off if no Ligasure ready)
* Clamp splenic hilum with a Roberts
* Avoid tail of pancreas (if you think you've injured it, leave a drain)
* Divide between clamps, remove spleen and pass off to nurse
* 0 vicryl to suture ligate splenic hilum vessels - double ligate

'''If spleen is too damaged/large to attack in the normal way:'''

* Could try accessing lesser sac through gastrocolic omentum, then identify splenic artery and clamp it early
* Could try going directly at hilum and then taking spleen from the front

'''Splenorrhaphy'''

* 'Reasonable to try one thing in a local injury with a stable patient'
* Main options are monofilament suture + bolster, APC, stapling
** Small capsular and parenchymal injuries: electrocautery/APC, with topical agents on top
** Deeper lacerations: haemostatic mattress sutures using 2-0 polypropylene or 0 chromic catgut, perhaps incorporating a tongue of omentum, can use Dacron strips to buttress
** Splenic lacerations that can't be repaired in other ways MAY be amenable to wrap mesh repair
* Don't try a second time if it doesn’t stop the bleeding
* Kate Martin says she has never done it in 12 years as a consultant

'''Partial splenectomy'''

* Appropriate option if at least half the splenic parenchyma is viable, and ligating a splenic artery branch results in a major reduction in haemorrhage rate
* Ligate relevant branches of artery and vein
* Divide parenchyma either with linear stapler of electrocautery, and oversew margin

'''Completion'''

* Further inspection of all four quadrants
* 19Fr Blakes drain in LUQ
* 1 loop PDS to fascia
* LA - 0.75% ropivicaine
* Skin with staples