Splenectomy (elective and emergency / trauma)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• bleeding and blood transfusion
• injury to the tail of the pancreas, with pancreatic leak or fistula
• injury to the stomach or colon
• need for a drain
• missed accessory spleen with return of the blood disorder (elective cases)
• lifelong risk of severe infection with encapsulated organisms, needing vaccines
• splenic salvage may fail and the spleen may then be removed

Pre-operative details for this operation

1. IndicationTrauma: splenic injury with haemodynamic instabilityTrauma: failed non-operative managementHaematological (e.g. ITP, hereditary spherocytosis)Other (state)for trauma: mechanism, time of injury, BP and pulse, response to fluids, FAST or CT findings with injury grade if CT was done
2. Haemoglobin, platelet count, coagulation profilevalues and time, for low platelets, platelets arranged and when to give them
3. Blood grouped and cross-matchedgroup, units reserved, massive transfusion protocol activated or not
4. Vaccination against encapsulated organismsGiven before surgery (dates)Emergency: to be given before discharge
5. Consent coversSplenectomyLaparotomy and proceed, including splenectomy or splenic repairDistal pancreas resection if needed
6. Nasogastric tube and urinary cathetersizes, urine output before incision

Anaesthesia and position

1. AnaesthesiaGeneral with endotracheal intubation
2. PositionSupine, arms outSupine with folded sheet under left costal margin
3. Skin preparationtrauma: nipples to knees
4. Special equipmentself-retaining retractor, vascular clamps, vessel sealing device, absorbable mesh if salvage planned, cell saver if used

Operative findings

1. Haemoperitoneumvolume and clots, where most of it was
2. Spleensize, site and depth of each laceration, hilar injury, capsular avulsion, active bleeding, injury grade if you use one
3. Relation of pancreatic tail to hilumClear gapTail in the hilum
4. Accessory spleenNone foundFound and removed (site, size)
5. Other organsstomach, colon, pancreas, left kidney, diaphragm, liver, bowel: all examined, state findings

Procedure (steps)

1. IncisionUpper midline from xiphoidLeft subcostalLeft paramedianlength, midline for trauma and for a large spleen
2. Blood and clots evacuated, left upper quadrant packednumber of packs, temporary control by hand compression of the hilum or vascular clamp if used
3. Early splenic artery ligation in the lesser sacDoneNot donefor large spleens: gastrocolic window, artery tied at upper border of pancreas with heavy silk
4. Spleen mobilisedsplenorenal and splenophrenic peritoneum incised, spleen with pancreatic tail rotated medially, packs placed behind
5. Short gastric vessels dividedTiesVessel sealing devicenumber of vessels, divided close to the spleen, away from the gastric wall
6. Splenocolic attachments dividedclamped and tied
7. Hilar vessels ligatedArtery and vein ligated separatelyMass ligation (unstable patient)Stapler / vessel sealing deviceclose to the spleen, suture material, distance from pancreatic tail
8. Spleen removedintact or fragmented, weight
9. Splenic salvage (if done instead)Haemostatic agentMattress sutures, with or without pledgetsOmental buttressPartial splenectomyAbsorbable mesh wrapsuture used, which pole removed, residual spleen viable
10. Haemostasis checkedsplenic bed, pancreatic tail, greater curvature where short gastrics were tied
11. Stomach and pancreatic tail inspectedany gastric wall injury oversewn with Lembert sutures, pancreatic tail intact or resected
12. Search for accessory spleenshilum, gastrocolic omentum, around pancreatic tail, mesentery, pelvis
13. Rest of the abdomen exploredtrauma: whole bowel run, retroperitoneum checked

Closure, drains and dressing

1. DrainNoneClosed suction drain in splenic bedreason if placed: doubtful haemostasis or pancreatic tail injury
2. PacksAll removedLeft in (damage control): number
3. Sheathe.g. continuous looped monofilament absorbable (PDS) No. 1
4. SkinStaplesSubcuticular monofilamentLeft open (contaminated)

Specimens and implants

1. Spleen sent for HPEYesNoweight and size, fresh if lymphoma is suspected
2. Accessory spleen sentYesNot found
3. Absorbable mesh (salvage)type, size, batch number, sticker in file

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Pulse, BP, urine outputhourly, watch for fresh bleeding
2. Drain outputvolume and colour, inform if output rises (bleeding or pancreatic leak)
3. Hb and platelet counttime of the next check
4. Nasogastric tubeaspirate every 4 hours, removal plan
5. IV fluids and bloodtype and rate, units still to be given
6. Analgesiadrug, dose, frequency
7. Incentive spirometry and early mobilisationsit up and walk as early as condition allows
8. Vaccination against encapsulated organismsbefore discharge, record vaccine names and dates on the discharge card
9. Contrast CT after splenic salvagefor severe injuries treated by repair, to look for false aneurysm or AV fistula
10. Patient educationcarry a card saying no spleen, seek care early for fever

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery