Trauma laparotomy & splenectomy

Why are we operating?

The bleeding abdomen, answered in a fixed sequence: pack everything, find the bleeder, and for the shattered spleen, take it out and vaccinate the patient later.

Indication: Haemodynamic instability with abdominal bleeding; splenic injury failing non-operative management.

The operation in 4 steps

1. 01Rapid entry and four-quadrant packing

   Fast midline entry, evisceration of small bowel, and packs into all four quadrants before any bleeding is chased.

   Why: Packing first converts one uncontrolled haemorrhage into four temporarily controlled spaces, and buys anaesthesia time to catch up with volume. The quadrant that soaks its pack first is the answer to where the bleeding is.

2. 02Mobilising the spleen

   The splenic attachments are divided and the spleen delivered medially into the wound on its pedicle.

   Why: A spleen bleeding in the depths of the left upper quadrant cannot be controlled where it lies; delivered into the midline it becomes an organ on a stalk with a vascular pedicle you can hold between fingers.

3. 03Controlling the hilum

   The splenic artery and vein are clamped, ligated and divided close to the spleen, protecting the pancreatic tail.

   Why: Clamping the pedicle is the moment the operation wins; dividing close to the spleen keeps the ties off the pancreas, whose tail touches the hilum in most patients.

4. 04Haemostasis, drains, closure

   The bed is checked dry, packs are removed quadrant by quadrant with a final inspection of each, and the abdomen is closed or left as a laparostomy by physiology.

   Why: Every pack that went in is counted out against the record; a retained pack is both a septic focus and a never event. Post-splenectomy care starts now: vaccination against encapsulated organisms is part of the operation's aftermath, not an optional extra.

Anatomy you need

All four quadrants, the way the operation packs them; know what lives where before the blood obscures it.

What can go wrong

• Postoperative bleeding

  Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.

• Intra-abdominal abscess

  Swinging fevers, malaise, and localized pain from day 5 onward, classically after perforated appendicitis.

• Atelectasis & pulmonary complications

  Low-grade fever and mild desaturation in the first 48 hours, especially after upper-abdominal incisions.

• Venous thromboembolism

  Unilateral leg swelling, or sudden dyspnoea, pleuritic pain, tachycardia, sometimes the only sign is unexplained hypoxia.