Splenectomy (Open and MIS Approach)
This chapter describes the surgical procedure for splenectomy, as performed by the following approaches: open and MIS (minimally invasive surgical). Elective splenectomy in a child is often required for management of splenomegaly or splenic sequestration secondary to hematologic pathologies (i.e., hereditary spherocytosis, immune thrombotic purpura, sickle cell anemia, and Felty Syndrome). Splenectomy for traumatic injury in a child is uncommon but occasionally required for a child who has failed nonoperative management. In the latter case, this should always be performed as an open procedure. Risks of surgery include bleeding, pancreatic and bowel injury, and future risk of overwhelming postsplenectomy infection. If splenectomy is being considered for management of hematologic pathology, cross-sectional imaging should be pursued before surgery to rule out accessory splenic tissue that would require additional resection. Alternatives to splenectomy include medical management of underlying hematologic pathologies and nonoperative management of blunt splenic injury as outlined by Advance Trauma Life Support (ATLS). Essential steps include mobilizing the splenic flexure, entering the lesser sac, ligation of the short gastric vessels, exposure of the hilar vessels, ligation of the hilar vessels, division of the splenodiaphragmatic, splenocolic, and splenorenal attachments, and extraction of the spleen. In the acute trauma setting, serially clamping the short gastric vessels along the greater curvature of the stomach, ligation of the splenic hilum with a vascular clamp, and mobilization of the spleen occurs rapidly utilizing the clamp-cut-ligate technique. Utilization of a self-retaining retractor such as a Bookwalter enhances visualization. For elective MIS approaches, a 5-mm Ligasure device and a vascular load EndoGIA facilitate exposure and hemostasis. Often, extraction of the spleen via an MIS approach requires upsizing the umbilical trocar to 15 mm, deployment of a 15-mm Endocatch bag, and morcellation of the spleen within the bag until the surgeon is able to extract the remaining specimen through the 15-mm trocar site.