Complex spleen refers to a giant spleen, or a spleen that is not large but has severe vascular infiltration, extensive expansion of collateral vessels making intraoperative bleeding extremely easy, extensive peripleural fibrosis, vascular dense adhesions causing splenic fixation, or even firm dense adhesions into plates, and some hematologic spleens, with high surgical risk and difficulty. Now this paper retrospectively summarizes the clinical data of 126 cases of complex splenectomy admitted from January 2005 to December 2011, and summarizes how to perform the freeing of the whole spleen, complete hemostasis of the splenic bed and avoid damage to the surrounding organs. DATA AND METHODS 1.1 General data 126 patients with complex splenectomy, 86 males and 40 females, were collected retrospectively from January 2005 to December 2011. The mean age was 42.8±7.6 years (14-72 years). The criteria for giant spleen in this group were defined as the lower edge of the spleen exceeding the level of the umbilicus or the right edge of the spleen exceeding the anterior positive line during deep inspiration in a flat supine position or the weight of the spleen >3.0 Kg [2]. 98 cases of giant spleen had the following primary diseases: 84 cases of post-hepatitis B cirrhotic portal hypertension, 12 cases of schistosomiasis cirrhotic portal hypertension giant spleen, and 2 cases of hematological disease giant spleen. There were 84 cases of extensively adherent spleen, which consisted of schistosomal splenomegaly, splenomegaly due to portal hypertension and infectious splenomegaly, including 50 cases of extensively vascular adherent giant spleen. The other 28 cases had only mild to moderate enlargement but formed extensive, dense vascular adhesions around the spleen. The liver function was Child A grade in 52 cases and B grade in 74 cases. 1.2 Surgical situation: The patient was placed in a flat position and under general anesthesia. A median upper abdominal incision was made to the left around the lower umbilicus to fully expose the trauma margin. All patients underwent total splenectomy. Splenic artery ligation was performed in all patients. The average intraoperative bleeding volume was 227±60 ml, with a maximum of 650 ml; the average operating time for splenectomy was 75±16 min. Results 1. Perioperative conditions All patients in this group were discharged with no surgical death or serious complications such as pancreatic leakage, gastric and colonic injury. 14 patients (11.1%) had postoperative complications. The main complications included: (1) intra-abdominal hemorrhage: 5 cases, accounting for 4.0%. All five patients had hepatitis B cirrhosis and preoperative liver function was Child B grade. The splenic bed drainage tube drained fresh blood >1000 ml within 24 h after surgery, and it was difficult to maintain normal range of BP in vital signs. The bleeding site of re-operation: 1 case of splenictibial vessels, 1 case of gastric vessels; the remaining 3 cases had no obvious bleeding points, all of them were diaphragmatic surface and splenic bed oozing blood, these 3 patients when it was rechecked coagulation function were found that prothrombin time (PT) was significantly prolonged are greater than 20 seconds, while preoperative platelets were lower than 20´109/L. After complete hemostasis again, they were cured and discharged, the abnormal coagulation function and platelets were too low Patients with abnormal coagulation and low platelets were given drugs to promote blood clotting and platelet transfusions after which the traumatic bleeding improved significantly. (2) Massive ascites: 10 cases (7.9%), all of them were Child B patients with intraoperative bleeding >400 ml, which were cured after conservative treatment with diuretic, liver protection and albumin supplementation. (3) Pulmonary complications: 7 cases, accounting for 5.6%, including 4 cases of postoperative pulmonary infection and 6 cases of left pleural effusion, which were cured after anti-inflammatory or thoracentesis aspiration. (4) Left subphrenic abscess: 2 cases, accounting for 1.6%, were cured by ultrasound or CT localization of puncture or tube drainage. The common postoperative complications of portal vein system are (1) splenic vein embolic phlebitis: there are 11 cases, accounting for 8.7%, confirmed by ultrasound or/and CT, and the symptoms disappeared after anti-inflammation, anticoagulation and thrombolysis; (2) splenic vein embolism and portal vein trunk embolism in 12 cases, among which there are 9 cases of splenic vein embolism (6 cases of hepatitis B cirrhosis; 3 cases of schistosome cirrhosis) and 3 cases of splenic vein embolism The embolism rate was 50.0% after splenectomy for schistosomal cirrhosis and 7.1% (6/84) after splenectomy for hepatitis B cirrhosis, with a significant difference (t=13.4, P<0.01). Discussion For complex splenectomy, the most critical question is: ? When the spleen is very large and has extensive adhesions to the surrounding area, especially in schistosomiasis cirrhosis, such adhesions are severe and extensive vascular adhesions, which can tear the spleen and cause uncontrollable hemorrhage if revealed with difficulty at the slightest inadvertence; ? When pancreatic disease causes contracture of the peripleural ligament and there is abundant vascular collateral circulation due to regional portal hypertension, the operation must be delicate to avoid damage to the gastric wall and the tail of the pancreas;? Due to the large surgical trauma, as well as the fact that most patients have cirrhotic portal hypertension and poor coagulation, there is often widespread recalcitrant bleeding, for which we must carefully evaluate and handle from three aspects: preoperative, intraoperative and postoperative [3]. 1. The importance of preoperative evaluation We usually pay more attention to giant spleen, but preoperatively we must not take moderately enlarged spleen lightly, because the ease of splenectomy depends on the ease of management of peripleural adhesions and splenic tissues. In patients with portal hypertension, especially regional portal hypertension, the lateral circulation in the peripleural ligament is often widely expanded, and the splenic parenchyma forms dense adhesions with the peripleural ligament, the abdominal wall, and the diaphragm, with thick and tough tissue and rich blood flow. Therefore, we should fully estimate the difficulty and complexity of splenectomy for patients with pancreatic-derived portal hypertension. If the spleen is supinated on physical examination, it often indicates that there may be extensive adhesions [4], and if there are images of tortuous and thickened varicose veins around the spleen on CT and ultrasound, it indicates that splenectomy is very difficult. 2. Intraoperative points and precautions Our surgical operation routine is to open the gastrocolic ligament first, and the pulsation of the splenic artery can be palpated at the superior margin of the pancreas, and double ligate the splenic artery at the site where it is most easily revealed, but not cut it off. In general, the splenic artery is often sclerotic in patients with portal hypertension, so it should be ligated loosely and tightly to avoid cutting the vessel too tightly with the ligature and intrathecal rupture. In the 126 patients we performed, all splenic arteries were ligated successfully. We emphasize that in complex splenectomy, even with severe local inflammatory adhesions and extensive collateral circulation expansion, it is important to emphasize ligation of the splenic artery first to avoid intraoperative hemorrhage. While ligating the splenic artery, sometimes there are significant adhesions between the splenic artery and the splenic vein, which must be carefully protected to avoid tearing the splenic vein when freeing the splenic artery [5]. Freeing the spleen is a critical point in complex splenectomy. In most cases, as long as the peripleural ligament is carefully separated after splenic artery ligation, the 1 to 2 short gastric vessels at the uppermost pole of the splenogastric ligament are first preserved and the spleen is held up. The technique to hold up the spleen is to extend the right hand to the deepest part of the splenic fossa and rotate it upward to the right to hold up the spleen and place it on the right forearm while placing the large cotton pad in the splenic fossa, treating the splenic hilum first according to the secondary splenic hilum dissection [6] and finally treating the previously temporarily retained 1 to 2 branches of the short gastric vessels. When the peripleural ligament, lateral retroperitoneum and diaphragm are rich in collateral circulation, or when the spleen is fixed due to recurrent peripleural inflammation, the procedure should be performed gradually, following the "superficial to deep, first easy and then difficult" procedure, to avoid the embarrassing situation of deep bleeding and helplessness. Due to the complexity of the giant spleen, which is often accompanied by more severe varicose veins and abundant collateral vessels in the fibrous cord, it is important to ligate the ligaments and not to tear and separate them in large pieces and treat them all together [7]. Separation of the peripleural ligament should be performed as close to the spleen as possible to free it and operate precisely to prevent accidental bleeding caused by improper operations such as pulling the hook and injuring the spleen. In patients with portal hypertension, the splenogastric ligament is often accompanied by abnormally thickened vessels, and in order to prevent early postoperative gastric distension resulting in dislodgement of the ligament, we should avoid large ligaments and suture ligation when necessary. The splenic colonic ligament should be treated to avoid damage to the colon and its tethered vessels. In case of severe stenosis of the splenorenal space, it is appropriate to give priority to the treatment of the dorsal splenorenal ligament by ligation, while the splenic side is left to be fully exposed and treated under direct vision. Finally, the splenic diaphragmatic ligament should be treated with direct visual clamping, cutting and ligation as much as possible because of its deep location and difficulty of exposure. For the treatment of the splenic hilum, our experience is to avoid ligating large pieces or damaging the tail of the pancreas, and to use the ligation of the splenic pole vessels method as much as possible, that is, to follow the splenic pole vessels near the parenchyma of the spleen to reach one or more lax gaps, to cut the branches of the splenic vessels through the gaps, to remove the spleen after dissection, and to ligate and suture the severed ends. The advantages are reliable ligation, less ischemic and necrotic tissue at the stump, and reduced postoperative pancreatic leakage and splenic fever. If the splenic hilum is adherent to the retroperitoneum in a plate-like fashion, our experience is that the posterior peritoneum is cut away from the mural peritoneal margin of the splenorenal ligament, and after separating the extraperitoneal nodal tissue, the spleen is turned forward and inward and the small varicose vein of the retroperitoneum is ligated to reveal the dorsal surface of the tail of the pancreas and the splenic vessels, but this treatment of the splenic hilum is safer and avoids the possibility of hemorrhage [8]. It is also important to know how to treat the trauma when the spleen is removed, and our experience is to peritonealize the trauma, with extra care when entering the needle because the retroperitoneum has the Retzins vein plexus that has formed lateral branches, and the use of a non-invasive Prolene 4-0 wire is recommended. In conclusion, the most important things for complex splenectomy are careful preoperative assessment of the anatomical relationship between the spleen and the surrounding organs, delicate intraoperative manipulation to avoid intraoperative hemorrhage, avoiding large dissection and ligation of the splenic hilum, and paying attention to the tail of the pancreas, which should be handled as close to the spleen as possible. If we pay attention to the above points then complex splenectomy is safe and feasible.