Operative help, which is the only measure when other treatment fails, should come either through a splenopexy or splenectomy, preferably the former, save in the presence of serious disease which may call for its extirpation. Nevertheless splenopexy, which seems so simple and so promising, is often unsatisfactory because of the friability of the spleen itself and the weakness of its capsule. Here, as in hepatopexy, the intent is to produce adhesions, by scarification of the external peritoneal surroundings, which is made through a suitable incision, directed usually along the left costal border; after thus intentionally provoking adhesions, sutures may be used if there be any prospect of their being serviceable.
PLATE LVI
Upper Abdominal Viscera, showing their Normal Relations. (Sobotta.)
NEOPLASMS OF THE SPLEEN.
Splenic cysts of the serous or blood type are seldom seen. Even hydatids here are uncommon. Sarcoma of the spleen may be primary; carcinoma is due to extension or metastasis. In proportion as splenic tumors develop they may be recognized as involving this particular organ. While a careful blood examination may permit the exclusion of certain conditions, exact early diagnosis will scarcely be made without exploration, which is justifiable whenever the blood count would indicate it. After exposing the lesion the surgeon is for the first time in a position to judge whether to drain or extirpate a cyst, or remove part or the whole of the spleen itself.
OPERATIONS UPON THE SPLEEN.
Besides those operations addressed toward fixation of a more or less enlarged or wandering spleen a splenotomy can be made—i. e., incision and drainage at any suitable point, anterior or posterior, which can be satisfactorily exposed; and evacuation of fluid may be followed, with or without suture of the deep to the external wound, by gauze packing or tubage, combined, if necessary, with counteropening or posterior drainage.
Splenectomy.
—Total removal of the spleen is performed through an incision which should be made ample for the purpose, either along the costal border or the left semilunar line or by combination of both. A median incision may be also utilized if it will permit better access. Splenectomy, under ordinary circumstances, would not be a difficult operation, but with the organ enormously enlarged and the vessels dilated, as they may be, it becomes usually a formidable procedure. The most serious difficulty and danger arise from the numerous adventitious vessels which may connect the spleen with the diaphragm or with some of its other surroundings, and whose location is to be made out before an attempt is made to remove it. Thus, in one instance, I have seen an adventitious vein, the size of the little finger, between the upper splenic surface and the diaphragm. Through such large vessels torrents of blood will pour unless they be first secured. All such connections then with the stomach and the diaphragm have to be ligated and separated with great care, while gentleness of manipulation is requisite throughout the operation. The spleen may be reached and adhesions be located with great speed of manipulation, but in the depths of such a wound valuable time may be consumed and much blood lost, all at a time when the patient can least tolerate them. Oozing from vessels which cannot be secured should be checked by gauze packing.