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When the spleen is mobilized outside the wound, the splenocolic ligament is divided between curved clamps (Figure 8). This procedure is carried out carefully in order to avoid any possibility of damage to the colon. The contents of these clamps are ligated with a transfixing suture of 00 silk or absorbable suture. In the presence of portal hypertension, many large veins may be present in this area. The spleen is then retracted medially by the surgeon's left hand, while the tail of the pancreas, if it extends up to the splenic hilus, is separated by blunt dissection from the splenic vessels in order to avoid damage to it by the subsequent ligation of the pedicle (Figures 9 and 10). The surgeon should keep in mind the possibility of accessory spleens in this location. The spleen is held upward and laterally by an assistant, while the large vessels in the pedicle are separated from the adjacent tissues to permit the application of several curved clamps to the individual vessels (Figure 11). These vessels should be ligated at the base of the pedicle proximal to the bifurcation of the splenic vessels. Despite the fact that the splenic artery has been ligated previously, it is tied again proximally and transfixed distally (Figure 12). The same principle of double ligature for the splenic vein is also carried out. In those instances where preoperative transfusions have been contraindicated, they may be started as soon as the splenic artery has been divided. The operative site is searched for evidence of persistent oozing. Warm, moist packs or a coagulant matrix may be introduced to control the small bleeding points. Following this, a final careful search is made for any existing accessory spleens that must be resected.

When the spleen is quite mobile and the pedicle is long, which is apt to be the case in the presence of splenomegaly of long standing, splenectomy may be facilitated if the splenorenal ligament is incised first without an attempt to divide the gastrosplenic ligament (Figure 13). The spleen is pulled gently upward and medially, providing exposure of the vessels ...

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