Exploratory Laparotomy and Splenectomy for Ruptured Spleen Following Blunt Force Trauma

CHAPTER 1

Hi, I'm Dr. Brian Williams.I'm an associate professor of trauma and acute care surgeryat the University of Chicago, and it is -I think it's about four o'clock in the morning on Saturday.We've just finished another trauma case.This one was a splenectomy, another classic trauma case -blunt trauma to the abdomen.Our patient was assaulted and sentto us from another hospital.She had a grade IV splenic lacerationon her CT scan and intermittently was hypotensive.We also found a lot of blood on her scan,so that combination of findings pretty much mandatedthat she get a laparotomy.So blunt trauma, hypotensive, a known splenic injury,as well as blood on her scan.So we brought her to the operating room,did an exploratory laparotomy, whichstarts with a midline incision, evacuated all the bloodthat was in the abdomen, packed off where her spleen was, and then did our exploration,found no other injuries,so then we went to work on the spleen.So, taking out the spleen involvestaking down three attachments.There's your lateral attachment,which is your splenorenal ligament.Inferiorly, your splenocolic ligament,and superiorly there's a splenophrenic ligament.Now your lateral and superior ligaments are avascular.Your inferior ligament has one or two vessels in those.So you take down those ligaments, and the big thing you want to dois mobilize the spleen from way upin the left upper quadrant to the midline.Once it's in the midline, then you can go to workand control the hilar vessels, control yourshort gastric vessels, and remove the spleen.Now why is that important?Hilar vessels, of course, you want to controlthe splenic artery and vein.And your short gastrics are the small vessels that attachthe stomach to the spleen, and if you don't control those,when you're done with your operation,you're going to have a lot more bleeding.So, key steps here -mobilize to the midline by taking downthe splenorenal, which is lateral;splenophrenic, which is superior;and splenocolic, which is inferior.Get to the midline, control the hilar vessels,control your short gastrics, spleen's in the bucket.Thank you.Dr. Brian Williams, University of Chicago.

CHAPTER 2

So guys we're going to review the FAST examfrom this patient with a splenic rupture.And initially looking, right, our depth is a little bit too deep, right?Because we're imaging way past the organ of interest,which is our kidney and our liver, right?And it's a little bright, right? So the gain's a little high.And then we're going to obviously adjust our depth down,as you can tell here, right? Which brings that kidneyand liver more into focus.And then in the next view what we do is, we kind ofadjust the gain down so now everything's a little bit darkerand not over-gained or super bright and white.And you'll see the kidney, you'll see the liver,and in the area that, you know, is known as Morison's pouch,which is the potential space between the twoas the kidney is retroperitoneal, and rememberthat the liver is intraperitoneal.And that, by the way, is like one of those mythsyou're told in med school, right? That there's a pouch,when really, if you think about it, if thisis your peritoneum, the kidney is retroperitoneal,and the liver is intraperitoneal, and it's justthe reflection, when the patient's supine,of the kidney that the liver lays on, right?And so when you feel fluid in the belly,in the peritoneum, all you're doing is lifting thatand separating your liver from your kidney.You're not really like filling up any space,the space is the peritoneum.But, you know, oftentimes if you just get this view,it's hard to identify that fluid, right?Because I mean it's pretty subtle, right?But if you think about it gravitationally,this is the patient's head, this is the patient's foot, right?This is patient's right side, and this isdown and towards the left side.The way that we hold the probe with the indicatortowards the head on the patient's right side,then if you take your probe and you rock it downtowards the inferior liver tip, which is what we do here,you can see the most gravitationally-dependent areaand you'll find the free fluid, right?Because it'll fill up here and then track backin that direction because this is his foot and that his head, right?So, nice picture there.And then you can tell that free fluid reallydoes cause like sharp angles, right?Like that's a pretty acute angle, whereas nothing in your bodyreally has that, everything's kind of rounded.If it's in a vascular structure, it'll be linear,but it won't be triangular or sharp.And if it's in the bladder or if it's in the heart,all those have rounded edges, right?Like none of those chambers come to super acute angles, right?But that's the hallmark of free fluidis it's black, anechoic, and it basicallyis giving you an acute angle somewhere, right?And then we go over to the pelvis viewand immediately we find a ton of anechoic fluid, right?So it should never have this much free fluidin the pelvis, and these sharp corners here -this can't be the bladder, right?The bladder is trigonal, it's got soft rounded edges,it's not that sharp.And as we fan through, that appears to be her uterusand that's her bladder coming back into view.And then if we do a sagittal/longitudinal,where we put the indicator towards the patient's head,we get a great line up.So head, feet, superior, and deep and inferior,and basically we see that there's fluidall the way around the uterus, right?So you got bladder, free fluid, and then uterus.And then there's fluid basically behind the uterusin the rectouterine pouch of Douglas, whichis where you would expect it on a female, whereasin the male, you expect it directly behind the bladder.You're not going to see it directly between the bladderand the uterus, you're going to see it around the uterusand mostly posterior.And again, some sharp angles, right?We can talk ourselves into the fact that thatkind of becomes a triangle, right?So again, right? Like triangular, right?All free fluid is usually pointy.Black and pointy is free fluid.And this is the left upper quadrant, and we don't geta great view of the spleen.We get a good view of the kidney, right?But the spleen kind of comes in and out, which is not shocking, right?Because if this is her spleen, right about here, right?Then we know that that spleen was ruptured, right?So we knew there was damage to the spleen and it wasn'tgoing to have normal anatomy, right? But you can see right hereat the edge between the inferior tip of the spleenand the kidney that you have free black fluid.It's not a lot, which you'd think would be surprisingbecause it's the left upper quadrant,so you think there'd be more.But if you look along the splenic edge here,there are some small amounts of fluid,and you can see, right? Free fluid, sharp angle, black, right?That's the way it goes. And then -I didn't do her subxiphoid view just because shewas so peritonitic and tender, so I went ahead and didthe parasternal long to evaluate the pericardial space,and there was no fluid, as we should have -a pericardial effusion should layer out back here,right along the posterior inferior edge there,above the descending thoracic aorta.Then we did her lung spaces - we kept the same probejust to keep it fast, decreased the depth, right?To allow us to see that pleural sliding better.And then aided that with an M-mode, right?To get our seashore sign, which is linear on top,grainy on the bottom, so seashore is always good.And if you get the barcode sign, that's bad.But you have to remember if it's barcodeon the left and they're intubated, they could be mainstemed,so it doesn't mean they have a pneumothorax.What you really want is a lung point, which we don't seethat often, or catch that often here sometimesbecause we're already putting chest tubes in that quicklywhen we know that the patient has penetrating trauma,and you know they have a pneumothorax because they'realready like leaking blood out of that side.But if you have, basically, a barcode all the waydown and then you get strips of each,that means you got the probe right where the lungis inflating like to be in the M-mode and then out of the M-mode,and in the M-mode and out of the M-mode, and that's the mostsensitive and specific and has a positive predictive valueof 100%, so that's a great sign to find, left or right,because it tells you there's a pneumothorax.And this is the left side - also had lung sliding.

CHAPTER 3

Okay, so our patient here was a womantransferred from an outside Hospital,reportedly was assaulted - stomped on her abdomen.The report from the hospital - that she washypotensive, CT scan showed a splenic lacerationwith some blood in her belly - transferred her here,she had systolics over 120, en route and sinceshe arrived here, and her images were suboptimal.So we repeated her CT scan, which confirms a grade IVsplenic laceration, as well as grade I/II liver lacerationwith a belly full of blood.So we are going to do an exploratory laparotomywith a plan to take out her spleen.And we'll see what else we find.Incision.Right by the umbo.All right, so that bleeding from the sub-q is a good sign.Can you get that bleeding controlled first?Bovie and a Poole.We have time, so get all that controlledbefore we start going down through the sub-q.All right, so her - since she's not crashing,we're looking at the belly full of blood.We're going to get the entire incision opened all alongits length first, before we get in, release the tamponade.Before we do that we make sure we notify anesthesia thatthat is about to happen so they are prepared.You want it all opendown to the fascia all the way?Yes.Well you know, she got TXA also,I'm not sure if you knew that.Yeah, she did.Bovie scratch, please.Down here as well.Let's see here - extra.Not too bad, so just go ahead and clean it offthat way, with that blunt dissection.Find your midline.All right, see - find your midline by the umbo.I think you've got it deep enough there.All right - we're releasing the tamponadehere in a minute.All right, since we know the patienthas a belly full of blood, we are methodicallygetting down to the midline fascia.Before we open up the fascia and release the tamponade,we let anesthesia know so they can be preparedif she dumps her pressure and they need to intervene.Want to do a finger?Are we all the way in or is this fascia?It's in.Okay.You know, sometimes it's okay to gopreperitoneal in such cases like this,if they're hypotensive, but she's been okayfor a couple of hours.Abdomen is open.So we've just been informed by anesthesiathat her pressure's doing okay, her gases okay,So it's important that we maintain ongoing communicationon both sides of the curtain during the case.Oh, we got lots of room.Man, look at all that!Get the knife and open that bad boy up.Knife back.Because we're going to be up in here, we definitely need as much roomup top as we can. I got your knife for you.Knife is on your tray. Thank you.So we released the tamponade, and her pressure did fine.MAP of 97, systolic's in the 130s.Okay, open up - open down here.All right, we need a bucket here, please.And a Poole sucker.Protecting the bladderdown there, Dr. Suah?Yep. Okay.Okay, may we have a bunch of packs, please?Open this up some more for me.Poole sucker.Okay, we're packing the right upper quadrant.Oh, I was going to do the left, is that okay?The left - that's what I meant. Okay.My right, patient's left.One pack in.Two packs - so right now we're packing the left upper quadrantwhere the busted spleen is to provide some tamponade -three packs in -tamponade to slow down the bleeding.All right, now let's get these clots out.Hold this here, David.Let's just put our hands in here and get all this out.Do you have another large Rich?What's that?Another large Rich?Need to put some down here. Two more packs, please.Don't worry about down there.Okay.On your oral boards - yeah, do all that.Uterus, ovaries - see all that, David?Yep.Uterus, fallopian tube, ovaries?Yep.All right.Laps, please.Before you do that, run your handover the liver, see if you can feel any cracks in the liver.Do you want to take down falci? Yep.Maybe like a small, posterior... All right, so-don't worry about packing that.Okay.May I have two curved...You're caught on something here.Come out, Ashley.Yeah, she's kind of stuck there. Can we have the Bovie, please?So take those down.So...All right, give us some traction here, Dr. Suah,so we can take that down.Then you guys can get your falciform down,put the retractor in, then we have exposure.So, yes, she had blunt trauma, hypotensive,again a belly full of blood - pack all four quadrants.Then slow down, talk to anesthesia,make your plan of attack.We know it's her spleen.We get in, it's her spleen.We've packed that off, evacuated the rest of the blood,and take down this adhesion.You can give yourself a little bit more.So we want to cut, spread, cut, spread.Just give me one second, please.All right, take down the falciform, put your retractor in.Yes?Metz, please?I got it. Okay.And those 2-0 ties.You usually just pass this behind,and it gives you more length.Okay. Right? As opposed to trying toreach behind there to get that.Pass it behind yourself and then you go through,save yourself some time.Throw your knot and then tie.Yes.Suture scissors, please.Cut on the knot.And another 0 tie, please?That's fine.Back to the Yankauer, please.This has to go into our Bovie binso we don't burn our patient.Okay, we have the abdomen open, we have our falciformtaken down, we're putting in our retractorso we can get some exposure.There you go.We have our spleen packed off.I'll take a folded up blue towel, please.Keep it folded up.Put this up top to pad your pressure points.All right, let's see if we can get some more room here.Bovie, please?Okay, so let's take a pause here, all right?Her vitals have been fine.Her spleen is packed off.She has blunt trauma, so let's go aheadand check for RP hematomas really quick. Okay.Because she's doing all right.So we're digging at zone one, which again,is your periaortic and peri-IVC.So...Pull down the stomach, pull up the liver.Liver up, stomach down.It's a little hard with this retractor.Get a little suction.I don't see anything obvious.Yep, don't see anything there.Okay, let's go inframesocolic.That was...Ooh, this is beautiful anatomy here.Look at this, this is nice.Nothing there, keep moving - big Rich.Wow, her kidney is like...Floating. Right there.Yep, keep moving - big Rich.So zone two.Nothing, right? Negative.All right, just go around clockwise.Zone three - left zone three.This will be your iliacs.So zone two would be your left kidney.Zone three would be your left iliacs.Nothing?Nope.All right, Dr. Suah, you take this.Keep going all the way around.Right zone three - nothing?All right, so that's just a quick look forretroperitoneal hematomas, okay?Don't see any.No.We're going to run the bowel real quick,to make sure we're not missing any holes.Again, we'll do this multiple timesbefore we close, but just a quick pass throughnow looking for anything obvious.So start at the ligament of Treitz,the suspensory ligament of the duodenum.So colon - transverse colon goes up and ontothe chest, all the way down to the base of the mesocolon.Then start running the bowel.Two person procedure, we fan out the bowel,milking the lumen all along the way,and examining both sides of the mesenteryall the way down to its base, looking for holes,vascular injury, hematomas, contusions, anything not normal.That's a good job working together, keepingit fanned out the entire way, flipping both sides, yep.And they're flipping, flipping - yep.It should be like, a 10-cm segment - flip.So it's flip, move - flip, move - flip, move.Now if she were dumping her pressure or hemorrhaging,we'd get that spleen out right away, butwe clearly have time to do this first.You just go with what's handed to you.But you would not be faulted forjust getting the spleen out and then doing this.Right, right, right.All right, now at the terminal ileum -so what are we going to find here, David?The appendix.The appendix is there.The fold of...?Treves, fold of Treves.Fat pad of Treves, or the fold of Treves.Fold of trees?Treves: T-R-E-V-E-S.All right, now we're working our wayup the ascending colon.It's nice and glossy for us.She's got very pretty anatomy.Yes, she does.How lucky are we?Okay. Big Rich, please?Uterus.Do we want a malleable...?That's okay, if we pull this up,and push this back…

CHAPTER 4

All right, so we've doneour initial exploration, know the spleen's busted.On CT scan, there's some liver lacerations, which we don'tfeel so they're not really clinically significant.We checked for RP hematomas, nothing there.We've run the bowel, nothing there.So now our plan of attack is to get this spleen out.So, the spleen has three attachments.Laterally you have your splenorenal - spleen to kidney,those are avascular.Inferiorly you have your splenocolic - you may haveone or two small vessels in there.And superiorly you have you're - So, splenocolic is spleen to colon.And superiorly you have your splenophrenic,which is to your diaphragm.That's avascular.So you can pretty much take a paw laterallywith impunity, superiorly -inferiorly you have to make sure to control the vessels.And when we get to the hilum, we also have to worry aboutthe gastrosplenic, which is where your short gastrics is.But for now we need to mobilize those three attachments.Superiorly, laterally, and inferiorly,that way we can mobilize the spleen to the midline,get to the hilum, control the hilum - that comes out,short gastrics, spleen's in the bucket.All right, so your goal is to get this spleensitting right there because right now it's way back therewhere it's not doing you any good.So, David, you know what your job is going to be?Tell me.Come around on this side.Grab a big Rich.Go up on top of Harry here,and give him some exposure.Can I have that bucket? Yep.Dr. Suah, how many of these have you done?None, this is my first.Okay, Harry - this is going to be a...This is just all clot coming from the spleen here.So here- you're going to be pulling up here.If you ever need to take a rest, let me know, okay?Because this part that you're doing does get tiring.Okay, up there?If you want switch with him, let me know, Harry.I can see better here.Okay.Okay, we've got, so far, out about,I don't know, 500 cc of clot?She's doing good, she's doing good up here.Okay.Don't, don't, don't let that...Let me get a feel here and see what you got. Okay.Yeah, that's going to fall apart in your hand, seriously.So you can feel where it's attached, right? Mm hmm.So when you get those mobilized -so your left hand is going to be over the spleen, holding -pulling it towards your midline.Your right hand's going to be doing the work, okay?Okay.All right, so get your left hand.Okay. With the Bovie or do you want...?Get a Metz.Okay, Metz please.

Thank you.What you don't want to dois bring up the kidney, okay? Okay.And - yep.Does she, do you want her to...?She may go to the floor.Yep, see the white line there?Yes.Careful with my glove. Okay.All right, so that's - the kidney's down - you feel -I'm going to hold this here while youfeel that the kidney's down.Okay.Okay, so you don't want to bring up the kidney, so -we have mobilized the lateral attachment,that's your splenorenal, avascular,make sure we're leaving the kidney down.

Now we can do these inferior attachments, splenocolic.See that?Do you have her TA ready?TA or GIA?Actually, GIA, sorry.Can you open that GIA?Do you want a 60 or 80?Let's uh, 60.GIA 60, please.A little bit, little bit...Can we have a...? DeBakey, please.Do you want me to put a right angle on it?I'll get it.Can we have a right angle, please? Okay.2-0 tie on a pass.That's too much.Yep.Tie that.I'll hold that.Okay, get your spleen again, left hand.

Okay, so now it's your superior attachmentsthat are holding you up here. Okay.Just let me feel here before westart going blindly back there.Let me feel here.So you're going to take your left hand.You're going to have to pull up to your right hand,snipping away with your Metz,every now and then make sure you're feelingfor the hilum because you can feel the vessels in there.You don't want to get to the vessels, okay?And once those superior attachments come down,we can work our way towards the hilumand get that controlled.Yeah, the vessels are right there - right there, okay?Here?So you want to get...You are tethered up here - where there's this bandright here that you need to get.Hang on one second,make sure those aren't the short gastrics that we're getting into,which are right there. Might as well go ahead and getthose taken care of right now.Okay, do you want me to use the -a LigaSure or just tie them off?Tie them off, so right angle, right angle.Can I have a right angle, please?Ashley, pull that out. Okay.Just get me a hemostat.Times two.Okay, don't get the gastric wall. Okay.Cheat towards the spleen.Okay?Metz, please. Metz.Tie on a pass.Get this off the shadow there,so I'm not caught in your knot.So very important to control the short gastrics.If these are missed, they bleed.A lot.That's a re-operation.Cut yourself.There's usually two or three, so we got tofind the other one in there.Okay, let's try to get this...Do you want me to tie this one?It's the specimen side, it's coming out, so...All right, so we still...Pull up there, David.This is stomach right here, right?Yep, so cheat towards the spleen, yep.Take down that attachment.Bovie that.DeBakey, please.Right angle.Good, got it.Tie on a pass to Dr. Suah.Cut yourself.So we're just controlling the superior vasculature here.Right here.This looks pretty good, almost got it.Can we have a dry lap?Thanks Danny.Don't worry about that.Right angle.Really can't be too safe.Another right angle.Metz.And 2-0 ties on a pass, please.Do my right hand first, that's the important one.Scissors.Two knots here is fine, it's coming out.Okay.DeBakey.Suction.DeBakey.Can we have another right angle, please?I'm not worried about the spleen side, I just want to make we got the...Staying side? Staying side.Metz.2-0 tie, please.So we're just making sure we're gettingall the vessels controlledthat lead to the spleen.The spleen is a very vascular organ,lots of blood.Okay, trash, instruments, lap pads - back towards the feet.So take your left hand.See what you got there?Oh, yeah.Okay, don't pull, don't tug too hard.

So let's get a right angle, please.Because there's not much left here.Do you want me to 0 tie it, or...Go ahead and take the specimen off first.I'll take a 2-0 stick tie.A 2-0 stick?Yep.Can I have a 2-0 on a V-20?A 2-0 silk on a V-20.Specimen's coming.And I have a specimen coming.Do you want to go take a look at that, David?A look at the spleen? Yep.Yeah.Before it gets passed off?Y'all may want to get a picture of the spleen,over there.So, some people say you should divideout the two vessels separately because if you take themtogether it's a chance of AV fistula,it's not been borne out by data.I just take them and get them controlledand we're done. Okay.So...Here's your tie.You want to do it here?DeBakey, please.And I want to go around, right? Yeah.All right, I'm going to cut the needle and thenI want to do another tie below that one.Needle coming back - it's free.Needle back.Spleen is out.All right, let's suck up the rest of this blood.Big Rich, please.Got our bucket?All right, toss a couple packsup in there now, just for now.All right, two packs in the splenic fossa.We'll see the spleen before it goes -is it already gone?No, it's here.So yeah, see? This definitely would havebeen a problem in a couple days.The splenic capsule is torn.It's like ruptured.

So Dr. Suah, we're going to make sure we got everythingcontrolled in the splenic fossa.So you're going to take the burrito.Burrito, please?Going to be way out laterally, you're going toroll this back towards yourself, you're going to havethe Bovie tip in your right hand.Long Bovie tip.Now as you're rolling it back,you see something, you zap it. Okay.Don't zap the bowel, though, okay? Okay.And just kind of roll it back -zap, zap, zap - roll.We're going to have to come up all the wayover the remnant of the splenic hilum,down the greater curvature of the stomach,make sure we've got the short gastrics.We're going to do this several times, okay?A couple times.So now we're just confirming we have hemostasiswhere we took out our spleen.These look pretty dry.Famous last words. I know.Famous last words,you're just jinxing us.Be careful, make sure we're not...That's not bowel there, so - or stomach.Is it pancreas?That's pancreas.So you're checking the fossa, you're checking the hilum,you're checking where you took down all your ligaments,so splenocolic, phrenic, and splenorenal ligament.Taking a good look at the greater curvatureof the stomach, make sure you got yourshort gastrics controlled.You miss those, they start bleeding - mmh.Back to the OR.All right, so what we've done so far -we'll talk about that in a minute, here. Let's make surewe got the bleeding under...Looks pretty dry.All right.Here's what you're going to do, okay?Harry, you're going to come over here.You're all going to do your exploration,irrigate, then I'm going to take a look, okay?

CHAPTER 5

All right, start from the very beginning.Just opened the belly.So for trauma laparotomies, you can neverrun the bowel too many times.And I say that with some facetiousness.Of course, if they're acidotic, hypothermic,coagulopathic, we don't want to spendtoo much time in the OR.They should to get to the ICU to get resuscitated.But the point I'm trying to make isyou want to be sure that you run everythingenough times that you're convincedyou have no missed injuries.I'll take one more lap.Do we need to do an x-ray, or did we count beforehand?We did count.We did count?So we're good?We're about to count. I mean, so -we don't need an x-ray then?If the counts are okay? Okay.If the count's okay.Hopefully - I mean - I think we'll be all right.We don't have to do a mandatoryx-ray, I mean.No.Yeah.Okay.Yeah, two, just like last time.Yeah.All right, my turn?Yep.All right, one last time.Okay.Okay, let's run the bowel - you and I.Let me get on your side, so I can showyou how you can run somebody through this quickly.So you have your trainee find the ligament of Treitz.So they're going to be proximal to you already, right?So you have them stay there and you're going toguide this along - that's what...Let's run the bowel.And they need to just keep up with you, right?So, my left hand will be handing itto your left hand, as I move along.Wow, look at this. This is nice.This is nice.All right, terminal ileum, appendix, cecum.Big Rich, please.I don't think we need it on this side.Or actually, don't worry about that. I know, it's likealready mobilized.All right, that's all good.Liver one more time. The diaphragm is fine.Man. I know.Man, too bad we can't do a sigmoid colon, this...I know, she's so floppy.She must be terrible with her colonoscopies...I know, she'd be like...It's so long, and redundant, all floppy.When she's an old lady, it'llbe really hard.All right, big Rich, please.And a couple burritos to me.Whoop, is it down? You got it.This is pancreas.Put your finger there, David.That rubbery thing is the pancreas. Uh huh.And the tail of the pancreaskisses the spleen.So we took the spleen out, that's what we have left.Another burrito, please.Short gastric tied off there.There are usually two or three - we've got two.I don't see any other vessels out there hanging.I'm going to get that in a second,I want to make sure the greater curvature's okay,before I let that go.Yeah, there's something here, see it?We can maybe put another tie around it.Yeah, let's switch sides so we can do that.Okay, can we have a right angle, please?Get this guy.So what we're going to do is take...I see it.Let's do those separately.Okay, because it's right here, yeah. Yeah.It's coming out of this...Yeah. Yep.Okay, can I have the 2-0 tie, please?2-0 tie? Mm hmm.Scissors.I got that tie to her.So just stop, see what you're doing now?You should pass your instrument to the tipnot your finger, especially when you're deepin a hole like that. Okay.Oh, like this?Yep, and then pull the tip down.Yes, exactly. How'd that feel?Good.Can I have a dry lap, please?Is this pancreas here?I think so.That's pancreas.That was still - that was a little oozy earlier. We'll get some of that slurry, that...Yeah, Surgicel or something?The Surgiflo stuff...Oh, Surgicel. Floseal?Whatever you guys call it here. Do we have Floseal, Allely?Long DeBakey.Just make sure we got it.Bovie? This, or...?No, I was just taking a look here.Take this off or...?Nope.Just leave it?Going to leave that exactly where it is.Okay.Put the lap pad on there.You can relax, David.Harry, you want to do it?I can show you.So it's right here.Yep.All of it?I guess, should I just push it in, or...?Just leave it there and then just letit fall back into his fossa. Okay.Do you have that thing? Yeah, I'm looking at bowel.All right, let it drop. Do you have the thing?Nice. All right.I have one more drop.Don't worry about it.Put everything into anatomical position.Okay.Make sure the bowel's not twisted up.This is cecum.Omentum down.

CHAPTER 6

All right, so we had blunt trauma to the abdomen,due to assault, transferred from an outside hospital,reportedly hypotensive at the outside hospitalwith a splenic injury.She arrived here normotensive.We confirmed the splenic injury on a repeat CT scanbecause her images from the outside hospitalwere not adequate for us to make a clinical decisionabout what to do with her.Brought her up to the OR, midline incision,evacuated about a liter of blood and clot,did a splenectomy, found no other injuries,and now we're about to close.Some clinical pearls about doing a splenectomy -There are three attachments.You have your lateral attachment, which isthe splenorenal ligament, that is avascular.Your inferior attachment is your splenocolic,you may have one or two vessels there.And your superior is the splenophrenic,which is avascular.So those are the three attachments you needto mobilize to get the spleen to the midline.That is imperative to do because the spleen sitsway up in the left upper quadrant.You cannot operate deep in that hole.So mobilize it to the midline.Once you've done that, you do two things:that is control the hilum, which is your vasculatureto the spleen and then control your short gastrics,which are the gastrosplenic ligament.There's two to three vessels there.Once you've done that, spleen comes out.Confirm hemostasis, put everything backinto anatomical position, and close.Thank you for joining us for this splenectomy.

CHAPTER 7

All right, good time for a debrief,we all ready?Actual procedure performed: exploratory laparotomyand a splenectomy.Need for OR full x-ray: no.Wound classification: II.Incision closure: deep and superficial layers.Specimen: spleen - has it been labeled?Yes?It's labeled Dr., it's over there.EBL is 1.2 - let's say 1.8 L.1.2 in the bucket and 500-600 of blood and clot additional.1.8?1.8 L.1.8 L. Okay.And received two units of blood, two more coming.Yes.250 of the abdomen and 1.5 of crystalloid.And urine is?About 100.About 100, okay, I'll take that.Antibiotics, Doctor?Antibiotics post-op - no,but she will need splenectomy vaccines at some point.Post-op Foley - Foley's coming out.VTE: doesn't need any.Oh, okay. No VTE?Yeah, get her up walking. Okay.I continued the other guy's peri-op...That's fine.VTE prophylaxis - keep it going.Foley comes out, OG tube comes out.Wound care: going to have a dressing.Recovery: PACU.Anything else, recovery? No.ID band present?Anticipated date of discharge?Let's say - four days.Four days, okay.Surgeon: Williams.Okay, any issues?No issues. No issues, okay.