Sample Report: Exploratory Laparotomy & Splenectomy
PREOPERATIVE DIAGNOSIS: Blunt abdominal trauma.
POSTOPERATIVE DIAGNOSIS: Splenic laceration and hemoperitoneum.
PROCEDURE PERFORMED: Exploratory laparotomy and splenectomy.
FINDINGS
1. Hemoperitoneum, about 1000 cc.
2. Splenic laceration, grade 3.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where a Foley bladder catheter was placed using a sterile technique. The patient had two large-bore IVs and was given high-rate boluses of IV fluids and blood. The abdomen and upper thighs were prepped from the nipples to the knees. The patient was sterilely draped. The anesthetist then put the patient to sleep, and the incision was made nearly simultaneously. The blood pressure did remain stable with the administration of blood.
The subcutaneous tissues were opened sharply to the fascia, which was also opened sharply. The peritoneum was grasped and carefully opened. The incision was opened along its length, which extended from the xiphoid to the infraumbilical region. A large amount of hemoperitoneum, mainly in the left hemiabdomen, was evacuated. Packs were placed in all four quadrants, starting with left upper quadrant and then the right upper quadrant. There was a large gush of blood in the right upper quadrant, somewhat concerning for a liver injury. Once all four quadrants were packed and the patient remained stable, the packs were removed initially from the lower quadrants, revealing no injuries but adhesions and scarring around the cecum. Then packs were removed from around the liver, and careful inspection of the right and left lobes of the liver revealed no injury to the liver. The packs were gradually removed from the left upper quadrant, and it was found that the spleen was indeed lacerated in the lower half, fairly significantly. This was definitely the source of the bleeding. The peritoneal attachments were quickly divided bluntly. The hilum was isolated. The splenic vessels were divided between straight clamps, and the spleen was removed. Packs were held over the area until hemodynamic stability could again be confirmed. The blood vessels were then controlled with suture ligatures of 0 Vicryl. Short gastric vessels were also ligated. A pack was placed, and again the rest of the abdomen was explored. The adhesions in the right lower quadrant were divided so that the omentum could be freed up. Once this was done, the small bowel was run from the ligament of Treitz to the cecum, and no injury was noted. The entire colon was inspected, and again no injury was noted. The left upper quadrant was again inspected, and another 3-0 silk suture ligature was used to complete the hemostasis. Hemostasis was good. An NG tube was positioned in good location. All of the packs were removed.
The fascia was closed with running 0 Vicryl suture. Given the large amount of laps used, abdominal films were taken, which revealed no evidence of retained lap sponges. Subcutaneous tissues were irrigated, and the skin was closed with staples. The patient tolerated the procedure and was transported to the ICU postoperatively in good condition.