■ 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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For centuries, ever since the legendary Ponce de Leon went searching for the elusive Fountain of Youth, people have been looking for ways to slow down the aging process. Medical science has made great strides in keeping people alive longer by preventing and curing disease, and helping people to live healthier lives. Average life expectancy keeps increasing, and most of us can look forward to the chance to live much longer lives than our ancestors.