No retractors are required. In the lateral position gravity enhances exposure of the posterior splenic attachments. A blunt ended 5-mm-diameter grasping instrument is placed through the most medial port is used to manipulate the spleen, lifting it upwards to expose the hilum, or rotating it towards the midline to expose the posterior attachments. A search for accessory spleens (see "Open Splenectomy,""Tricks of the Senior Surgeon") should be made before commencing dissection of the spleen, as accessory spleens are more easily identified at this stage, and they should be removed as soon as they have been found. Removal later in the procedure can be more difficult.
With the spleen rotated towards the midline, the posterior peritoneal attachments are divided 5-10mm away from the splenic capsule using a diathermy hook or ultrasonic shears. The spleen is progressively mobilized towards the midline, exposing the "splenic mesentery," which contains the main splenic vessels inferiorly, the short gastric vessels superiorly, and the tail of the pancreas. For adequate mobilization it is necessary to divide the posterior splenic attachments up to the left side of the oesophageal diaphragmatic hiatus superiorly (see "Open Splenectomy," STEP 3). A combination of gravity and rotation of the spleen displays an avascular fascial plane behind the splenic mesentery.
It is important to avoid damage to the tail of the pancreas during this dissection. If bleeding occurs during this step, then dissection is in an incorrect tissue plane.
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