Tricks of the Senior Surgeon

■ If bleeding is excessive and control of the splenic artery has not already been secured, or is not immediately feasible, the splenic artery and veins are easily controlled by gentle pressure applied between the second and third fingers of the surgeon's right hand.

■ Control of the splenic artery is most easily accomplished near its origin through the gastrohepatic ligament posterior to the lesser curvature of the stomach (see STEP 1), which is particularly useful during splenorrhaphy.

■ Another approach to the splenic hilum is anteriorly which carries increased risk as the splenic vein is immediately posterior to the splenic artery near the hilum and the tail of the pancreas is also intimately associated to the splenic hilum.

■ A linear stapler, as with laparoscopic splenectomy, is particularly useful when expeditious division of the hilum is necessary to control hemorrhage.

■ For patients in whom difficulty gaining vascular control is anticipated, for those with enormous splenomegaly or those with portal hypertension, splenic artery embolization done immediately prior to the operation can reduce splenic sequestration, congestion and bleeding.

■ Early ligation of the splenic artery diminishes blood loss, maximizes the amount of blood in the spleen returning to the patient, decreases the size of the spleen, improves ease of handling, facilitates removal and improves transfusion efficiency of blood products sooner rather than later during the procedure, if necessary.

■ Make a thorough search for accessory spleens before and after the spleen is removed, especially when operating for hematological indications. Accessory spleens are found in 15-35% of patients undergoing splenectomy and higher in those with hematological diseases. In order of decreasing frequency, accessory spleens are found in the splenic hilum, the splenorenal ligament, the greater omentum, the retroperitoneum near the tail of the pancreas, and the splenocolic ligament. Less commonly, accessory spleens are found in the mesentery of the small and large intestine, as well as the pelvis, in particular the left ureter and left adnexa, and left gonads.

■ Mobilize the splenic flexure and the rest of the colon whenever necessary. Be just as careful protecting the colon and the stomach to prevent injury to either hollow viscus.

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How to Stay Young

How to Stay Young

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