1. Abdomen is opened from the left subcostal inciosion extending to the right subcostal area upto the lateral border of rectus abdominis. A midline incision is equally effecive.
2. Abnormal bleeders in the skin and subcutaneous tissues aswell as bleeders between the abdominal wall and abdominal contents are encountered which should be suture ligated.
3. There are venous collaterals in the falciform ligament and around the umbilicus which should be effectively ligated.
4. Abdomen is explored and any suspicious nodule in the liver is biopsied. Gallbladded is palpated for stones.
5. Gentle retraction is used with adequate padding under the retractors as the tissues are congested and liable to bleed.
6. Devascularization is begun at the greater curvature of stomach, close to the gastric wall extending from the pylorus to the 1st short gastric vein.
7. Right and Left gastroepiploic veins are suture ligated and splenic flexure of colon taken down.
8. Transverse colon is pushed down and stomach is retracted up exposing the pancreas.
9. The peritoneum at the inferior border of pancreas is incised and splenic vein is identified.
There are two ways to identify the splenic vein, one is medially where it loops inferiorly around the
Superior mesenteric vein and the 2nd is to follow the inferior mesenteric vein .
10. The splenic vein is then mobilized first inferiorly, anteriorly , posteriorly and finally superiorly.
11.The pancreatic veins arising from the slenic vein are very friable and require careful handling and tying.
12. After mobilizing the splenic vein, the left renal vein is identifed. It can be identified either above or below the transverse colon.
13. All the tributaries of left renal vein are ligated
14 Splenic vein is ligated near the superior mesenteric vein and closed with 5-0 prolene
15. Splenic end is further mobilized and all the pancreatic veins are tied
16. Satinsky clamp is applied over the Left renal vein and a rim of tissue about 1-1.5 cm is cut
17. Splenic vein is then anastomosed to Left renal vein using continuous prolene 5-0
18. Haemostasis checked and abdomen is closed without drains.
