Splenectomy

Historical background

• “An organ of mystery” (Galen)• “Unnecessary” (Aristotle)• “An organ that hinders the speed of runners”

(Pliny)• “An organ that produce laughter and mirth”

(Babylonian Talmud)

Open splenic surgery

• 1st splenectomy: 1549, Adrian Zacarelli• 1st partial splenectomy: 1590, Franciscus

Rosetti• 1st splenectomy in the USA: 1816, O’Brien• 1st repair of lacerated spleen: 1895, Zikoff

(Russian)

Laparoscopic splenectomy

• In 1992, several reports of laparoscopic splenectomies started emerging in small series.

• Laparoscopic splenectomy has become a useful alternative to open splenectomy.

Spleen Anatomy

• Most common relationship of artery and vein is artery anterior

• Other positions occur• Main artery divides

into hilar branches over the pancreatic tail

Spleen Anatomy

• Major Ligaments– Gastrosplenic

• Short gastrics

– Splenorenal (lienorenal)

– Splenocoloic

• Minor Ligament– Splenophrenic

– Pancreaticosplenic

Anatomy

Blood SupplyBlood Supply• Splenic arterySplenic artery (pattern of terminal branches)

– Distributed type: (70%)– Short trunk w/ many long branches over ¾ of the

medial surface of the spleen.

– Magistral type: (30%)– Long main trunk dividing near the hilum into short

terminal branches.

• Short gastric arteryShort gastric artery

Anatomy

• The most common anomaly of splenic embryology is the accessory spleen..

• 80% in the splenic hilum and vascular pedicle

Spleen Anatomy

Locations of Accessory SpleensA Splenic hilum

B Along splenic vessels

C Splenocolic ligament

D Perirenal omentum

E Small bowel mesentery

F Presacral area

G Uterine adnexa

H Peritesticular region

Splenic Function

• Immune function– Filtering function– Opsonin production– Clearance of

encapsulated organisms– Clearance of metastatic

cells

• Erythrocyte maintenance

• Platelet reservoir• Storage organ for factor

VIII

Indications for Splenectomy

• Most common indication is trauma totrauma to spleenspleen, whether iatrogenic or otherwise

• Most common elective splenectomy is ITP– followed by • hereditary spherocytosis• autoimmune hemolytic anemia• thrombotic thrombocytopenic purpura.

Indications for splenectomy

• Hematologic disorder– Hereditary spherocytosis– Autoimmune anemia– Thalassemia– Hereditary Hemolytic anemia– Sickle cell disease– ITP– TTP– Sickle cell

• Malignancy– Lymphoma (Hodgkin’s and non

Hodgkin’s disease)– Lymphoproliferative disorders– Hairy cell leukemia

• Splenic Mass– Cysts and tumors– Abscesses

• Ruptured spleen– Trauma– Incidental

• Other– Felty’s syndrome– Gaucher’s disease– Splenic vein thrombosis– AIDS

Change of Indications

Decrease Increase

• Decline of staging laparotomy for Hodgkin’s disease

• Increase of splenectomies for hereditary spherocytosis and myeloproliferative disorders

• Significant Increase indication for ITP

• New indication: Hairy cell leukemia, Felty’s syndrome, AIDS

Preoperative Considerations

• Splenic artery embolization:– Recommended for:• Massive splenomegaly• Previous pancreatitis, gastric or pancreatic surgery• Portal hypertension, varices • Uncorrectable thrombocytopenia

Preoperative Considerations• Splenic artery embolizations:– Advantages:• Reduced operative blood loss from devascularized

spleen• Reduces spleen size for easier dissection and removal.

– Disadvantages:• Acute left sided pain (limited duration)

– This is mitigated by general anesthesia ---> OR

• pancreatitis

• Currently no consensus

Preoperative Considerations

• Pneumovax, haemophilus, meningococcus vaccinations 2 weeks pre-op

• Corticosteroids• Availability of blood and platelet products• Preoperative IgG administration to patients

with ITP and critically low platelet counts• Perioperative antibiotics• Pre-operative embolization- controversial

Preoperative Considerations

• Vaccination::– Splenectomy imparts <1 to 5% fulminant infection

(overwhelming post-splenectomy infections)

– Vaccination against encapsulated bacteria 2 wks before surgery.

Preoperative Considerations• Vaccination:– Common bacteria:• Streptococcus pneumoniaeStreptococcus pneumoniae• Hemophilus influenzae type BHemophilus influenzae type B• MeningococcusMeningococcus• Grp A streptococcus• Capnocytophaga canimorsus (related to dog bites)• Grp B streptococcus• Enterococcus sp.• Bacteroides sp.• Salmonella sp.• Bartonella sp.

Preoperative Considerations

• Vaccination::– in emergency splenectomy, trauma, give vaccine

3rd day– booster injections every 5 – 6 yrs regardless of the

reason for splenectomy for pneumococcal– annual influenza immunization

Preoperative Considerations• Deep venous Thrombosis Prophylaxis:– Specially in splenectomy for myeloproliferative

disorders (MPD).– 40% risk for PVT (portal vein thrombosis)

– Anorexia– Abdominal pain– Leukocytosis & thrombocytosis

● Early diagnosis w/ contrast-enhanced CT scan● Anticoagulation Prophylaxis

SPLENECTOMY• Open Splenectomy:– Indication:• traumatic rupture of the spleen (most

common)• massive splenomegaly• ascites• portal hypertension• multiple prior operations• extensive splenic radiations• possible splenic abscess

Partial Splenectomy• Indicated:– children (risk of splenectomy sepsis)– Lipid storage disorders (Gaucher’s disease)– Some blunt & penetrating splenic injuries

• Open or laparoscopic• Bleeding from cut surface of the spleen is

controlled by:– cauterization– argon coagulation– application of hemostatic agents (cellulose gauze /

fibrin glue)

Relative Contraindications to Laparoscopic Approach

• Active hemorrhage with hemodynamic instability

• Non-platelet coagulopathy• Contraindications to pneumoperitoneum• Splenomegaly• Pregnancy• Extensive previous upper abdominal surgery

Laparoscopic versus open splenectomy

• Earlier discharge• Less pain• Earlier resumption of oral intake• Fewer blood transfusions• Similar operative time with increased

experience

Three Areas of Controversy

• Massive splenomegaly • Splenic rupture• Higher recurrence?

Massive splenomegaly

• Technical challenge– Difficulty to manipulate the spleen– Difficulty in the extraction of the spleen

• Options– Totally laparoscopic splenectomy– Hand port assisted

Laparoscopic Splenectomy for Ruptured Spleen

• Indications– Incidental splenectomy– Trauma

Laparoscopic Splenectomy for Ruptured Spleen

• The patient has to be hemodynamically stable (on going bleeding requiring large blood transfusion)

• Use of 10mm suction/irrigation device• Early control of splenic hilum• Hand port could be helpful

Prevention of Residual Function

• Extreme care to avoid parenchymal rupture and cell spillage

• Systematic and careful exploration of the abdominal cavity for accessory spleens

SPLENECTOMY

• Open Splenectomy:–Position:

• Supine:–midline incision for rupture or massive

splenomegaly or for staging Hodgkin’s.–Left subcostal incision

• for elective splenectomies

Date of download: 9/18/2014 Copyright © 2014 McGraw-Hill Education. All rights reserved.

Splenocolic ligament is divided at the beginning of open splenectomy.

Legend:

From: Part II. Specific ConsiderationsSchwartz's Principles of Surgery, 9e, 2010

From: Part II. Specific ConsiderationsSchwartz's Principles of Surgery, 9e, 2010

Technique

• Patient Positioning– supine– lithotomy– right lateral decubitus

• Trocar placement– 3 vs. 4

• Angled scope

1) Splenic mobilization

2) Splenic hilum

3) Extraction after finger morcellation

Technique

(depends on the anatomy)

Technique

• Division of the lowermost short gastric vessels

Technique

• Inferior and lateral mobilization of the spleen– previously performed

last– now performed early

to gain better access to the hilum

Technique

• Division of the hilar vessels with the vascular stapler

Technique

• Division of the uppermost short gastric vessels

• Can be approached from the medial or lateral aspect

Technique

• Placement in a retrieval bag

• Extraction in piecemeal fashion

Post-op Considerations

• Removal of NGT and foley prior to extubation• Up in chair for a few hours the night of

surgery• Liquid diet begun on the first post-op day• Ambulate in the hall on the first post-op day• Discharge on the first or second post-op day

Accessory spleens (AS)

• Long term follow up is essential because a small accessory spleen can hypertrophy after splenectomy and be detected via CT scan or scintigraphy

Changes in blood after splenectomies

1. Appearance of Howell-Jolly bodies & siderocytes

2. Leukocytosis

3. Increased platelet counts

Complications of Splenectomies

• Pulmonary complications:– Left lower lobe atelectasis (most common) – Pleural effusion– Pneumonia

• Hemorrhage– subphrenic hematoma

• Infectious complication:– Subphrenic abscess

Complications of Splenectomies

• Pancreatic complications: due to intra-op trauma to tail of pancreas– Pancreatitis– Pseudocyts– Pancreatic fistula

• Thromboembolic phenomena (5-10%)– For pt. w/ hemolytic anemia / myeloproliferative

disorders and splenomegaly• Subcutaneous heparin & low-dose anticoagulantion

therapy postop

Complications of Splenectomies• Overwhelming Postsplenectomy Infection

(OPS):− lifetime risk of severe infection (1-5%)− incidence similar among children & adult but

mortality is higher in children.− mortality is highest in hematologic conditions:• Thalassemia major• Sickle cell

− lowered due to pneumococcal vaccine

Complications of Splenectomies• Overwhelming Postsplenectomy Infection

(OPS):− Loss the ability to filter and phagocytize bacteria

and parasitized blood cells− infection to encapsulated bacteria or parasites

− Loss a significant source of antibody production:• Streptococcus pneumoniae (most common infection

50-90%)• Haemophilus influenzae type B• Meningococcus• Grp A streptococcus

Complications of Splenectomies• Overwhelming Postsplenectomy Infection

(OPS):– Risk Factors:• Splenectomies for hematologic indications• Compromised immune system:

− Hodgkin’s.− taking chemotherapy / radiation therapy

• Children usually develops w/in 2 yrs postsplenectomy

Complications of Splenectomies

• Overwhelming Postsplenectomy Infection (OPS):− Immunoprophylaxis:• Pneumococcal vaccine – booster injection every 5-6yrs• Annual influenza immunization

− Antibiotic prophylaxis usually single daily dose of penicillin or amoxillin for children for 1st − asplenic children receive daily prophylaxis with oral

penicillin VK or amoxicillin until at least age five and for at least one year following splenectomy

• http://youtu.be/y6YtmRgvHrU