Splenectomy Surgical Procedure Medical Transcription Example Report
PREOPERATIVE DIAGNOSES:
1. Focal hypersplenism.
2. Suspected primary lymphoma of the spleen.
3. Immunosuppressed.
4. Status post orthotopic liver transplant.
POSTOPERATIVE DIAGNOSES:
1. Focal hypersplenism.
2. Suspected primary lymphoma of the spleen.
3. Immunosuppressed.
4. Status post orthotopic liver transplant.
PROCEDURES PERFORMED:
1. Open abdominal exploration.
2. Lysis of adhesions.
3. Splenectomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal tube anesthesia.
COMPLICATIONS: None.
SPECIMENS: Spleen weighing 5.5 kg after exsanguination.
DRAINS: One JP drain to bulb suction.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a gentleman who had orthotopic liver transplantation in the past and was noted to not feel well over the last several months. He was diagnosed with primary splenic lymphoma versus PTLD. The patient was referred for splenectomy for diagnosis and therapy. After discussing the extreme risks to splenectomy of a giant spleen in an immunosuppressed patient, discussing the complications, benefits and risks of the surgery and not having surgery, the patient and his wife discussed the issue and consented for surgery.
SPECIAL CONSIDERATIONS: This patient is an immunosuppressed patient, status post liver transplantation with a tremendous amount of adhesions and a giant spleen, which has been compressing his left lung making it atelectatic causing GERD symptoms and reaching down into the pelvis and across the midline of the abdomen. With such an enormous spleen and the volume of blood within it, the risks to the patient were quite significant and the surgery itself was quite involved, much greater than a normal splenectomy. Lysis of adhesions took 45 minutes alone and the splenectomy required twice the amount of time to perform than a normal spleen.
DESCRIPTION OF PROCEDURE: The patient was placed supine on the operating table. After adequate IV access and IV sedation, the patient was intubated and anesthetized. Venous access and Foley catheter were gained by anesthesiology and nursing staff respectively. The abdomen was prepped with Betadine solution and draped with sterile linen and sterile drapes.
The patient’s previous transplant incision was inspected. It was opened from the right midclavicular line to the left lateral flank, extending it approximately 5 cm from its original stopping point. The midline extension was also opened. After 10-blade scalpel was used, electrocautery was used to take the incision all the way down to the peritoneum. The peritoneum was opened. The sutures were removed in the muscle layer, and multiple adhesions between the small bowel and the omentum, the liver and the anterior abdominal wall were encountered. All of these adhesions were taken down with electrocautery or between silk ties as needed. The left lobe of the liver had to be mobilized off the peritoneum in order to open the midline extension for access into the left upper quadrant. With all adhesions now taken down and the left lobe of the liver mobilized, the Thompson retractor system was set up for visualization retraction.
Dissection of the spleen began first, raising the right lateral edge of the spleen upwards and palpating the hilum. The hilum was extremely large. The vessels were between four and five times the normal diameter of splenic veins and arteries. The peritoneum overlying the hilum was taken down with blunt dissection and electrocautery. This was brought down to the lower pole. Lower pole and anterior upper pole accessory vessels were circumferentially dissected and ligated with 0 silk ligatures. Larger vessels were divided with the EndoGIA vascular stapler. Dissection down to the pedicle was performed. The spleen was now rotated upward out of the retroperitoneum attempting to mobilize its inferior edge from the retroperitoneal peritoneum. The peritoneum was taken down with electrocautery to the extent possible. This was an extremely difficult dissection; however, the left upper quadrant adhesions were unable to be visualized or mobilized. Spleen was placed back into the retroperitoneum. The hilum was again encountered. The peritoneum going up over the short gastrics was taken down and multiple short gastrics were taken in groups with the EndoGIA vascular stapler. The hilum was encircled with an umbilical tape. The splenic vein and splenic artery were unable to be separated. The artery was palpated and its location of coiling was noted. With serial loads of the endovascular stapler, the pedicle was now divided going through the area of the coiling so as to prevent AV fistulas down the line. The spleen retroperitoneal attachments were taken with the electrocautery and between clamps and removed. The spleen, after exsanguination, weighed just over 5.5 kg.
The defect within the abdomen now was evaluated and packed with lap pads. Lap pads were now serially removed. Multiple areas of short gastric vessels and peritoneal dilated vessels were encountered. They were clamped, ligated with 2-0 silk ligatures and oversewn as needed with 2-0 pop-off silk sutures. The staple line at the vein and the artery was not completely hemostatic. This was oversewn with a 2-0 Prolene whipstitch. The retroperitoneum was inspected. The adrenal gland and kidney were well away from the dissection plane. This area was fulgurated and FloSeal hemostatic gelatin was placed. This area was irrigated now copiously and then aspirated dry. The area was hemostatic. CoSeal fibrin glue was now placed on all of the vascular structures of the retroperitoneum and the tail of the pancreas that had to be dissected out from the splenic hilum at the time of pedicle dissection.
The abdominal wall was now closed in one layer fashion with #1 Prolene sutures. Subcutaneous tissues were irrigated with Kantrex solution, and the skin was reapproximated with sterile staples. The JP drain was placed to bulb suction. The patient tolerated the procedure well, was hemodynamically stable throughout the case. Estimated blood loss was 1 liter but most all of this was blood from within the spleen and was not active bleeding during the case. The patient was taken to the recovery room in awake and stable condition.
