Adequate exposure for a normal size spleen is obtained with an upper midline or generous subcostal incision. Occasionally a massive spleen may require a thoracoabdominal incision.
Fixed mechanical retractors aid exposure of the deep left upper quadrant. Only the lower pole of the spleen is visible at the greater curve of the stomach.
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The splenic artery may be exposed and ligated above the tail of the pancreas by opening the gastrocolic ligament outside the gastroepiploic arcade and opening the posterior peritoneum of the lesser sac over the vessel. Proximal ligation should be avoided to prevent ischemic pancreatic injury. Preliminary ligation reduces the risk of hemorrhage and allows a large spleen to decompress and shrink, making surgery easier and safer.
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