Open Splenectomy

Author: Ruben Peralta, MD, FACS; Chief Editor: Kurt E Roberts, MD more...
http://emedicine.medscape.com/article/1829892-overview#showall
Overview
Background
Open splenectomy is performed in 2 major clinical scenarios: trauma and
hematologic disease. The spleen is one of the most frequently injured
intraperitoneal organs, and management of splenic injuries may require
splenectomy or, rarely, splenorrhaphy. The current trends are toward
nonoperative management of the spleen after trauma
[21]
and toward
laparoscopic splenectomy for hematologic disorders.
[20]
Today, most
elective splenectomies are done laparoscopically, except in the case of
severe splenomegaly.
[1]

The spleen's key function is the removal of old red blood cells (RBCs),
defective circulating cells, and circulating bacteria. In addition, the spleen
helps maintain normal erythrocyte morphology by processing immature
erythrocytes, removing their nuclei, and changing the shape of the cellular
membrane. Other functions of the spleen include the removal of nuclear
remnants of RBCs, denatured hemoglobin, and iron granules and the
manufacture of opsonins (properdin and tuftsin).
Indications
The most common indications for open splenectomy in an adult are
traumatic splenic rupture and blood dyscrasias.
Splenic rupture is usually caused by blunt or penetrating trauma (see the
first, second, and third images below); delayed rupture of the spleen
[2,
3]
(see the fourth image below) and spontaneous splenic rupture
[4, 5]
occur
rarely. An analysis by the National Trauma Data Bank (NTDB) found high
failure rates and prolonged hospital stays when high-grade splenic injuries
were managed conservatively (ie, with nonoperative management).
[6]

CT scan of abdomen showing grade IV splenic injury.
CT scan of abdomen demonstrating grade IV injury of spleen.
Resected traumatized spleen with multiple lacerations.
CT scan of abdomen demonstrating large delayed rupture of
subcapsular hematoma of spleen in symptomatic polytrauma patient previously managed with
percutaneous angioembolization.
Surgical management of splenic rupture is indicated for patients who have
hemodynamic instability or shock on admission, those who have
associated injuries necessitating operative intervention, and those in whom
nonoperative management has failed.
[7]

Patients with various hematologic disorders may benefit from splenectomy.
Splenomegaly (see the image below) is observed in conditions such as
idiopathic (immune) thrombocytopenic purpura (ITP), thrombotic
thrombocytopenic purpura (TTP), and hereditary spherocytosis. Of these,
ITP is the most common indication for elective splenectomy. In hereditary
spherocytosis, the RBCs have a tendency to be trapped and destroyed in
the spleen. The main features of this disease include anemia,
reticulocytosis, jaundice, and splenomegaly.
Severe (massive) splenomegaly occupying most of left
abdominal cavity in patient with symptomatic hematologic disorder after failure to respond to
medical therapy.
Generally, the operation should be delayed until the patient is at least 6
years old to minimize the risk of overwhelming postsplenectomy sepsis
(OPSI).
[8, 9, 10, 11]
After removal of the spleen, the erythrocytes achieve a
normal life span, and the jaundice, if present, disappears in a timely
manner. Other, less common hematologic indications for splenectomy
include thalassemia and sickle cell anemia.
Other disorders for which splenectomy may be indicated include the
following:
Hodgkin disease - In patients who are refractory to medical therapy,
splenectomy is indicated to decrease pain, fullness, and hypersplenism
Felty syndrome (rheumatoid arthritis, splenomegaly, and neutropenia) -
Symptomatic splenomegaly and neutropenia can be corrected by
splenectomy
Splenic abscess, cyst, sarcoidosis
Contraindications
Contraindications to open splenectomy are few. For elective open
splenectomy, the only absolute contraindications are uncorrectable
coagulopathy and severe cardiovascular disease that prohibits the
administration of general anesthesia.
Relevant Anatomy
The spleen is an wedge-shaped organ that lies in relation to the 9th and
11th ribs, located in the left hypochondrium and partly in the epigastrium;
thus, it is situated between the fundus of the stomach and the diaphragm.
The spleen is highly vascular and reddish purple; its size and weight are
variable. A normal spleen is not palpable. For more information about the
relevant anatomy, see Spleen Anatomy.
Technique
Open Splenectomy
Open splenectomy is performed as follows.
Incision and entry into abdomen
The incision depends on the size of the spleen, the reason for
splenectomy, and the preference of the surgeon. Generally, in emergency
or trauma situations, an upper midline incision is preferable because it
affords excellent exposure of the abdominal cavity, can be performed
quickly, and provide access for the evaluation and management of other
potential injured organs or structures.
In most patients undergoing splenectomy for a hematologic disorder, a left
subcostal incision is employed, beginning to the right of the midline and
proceeding obliquely to the left approximately 2 fingerbreadths below the
costal margin. This incision yields excellent exposure (see the image
below).
Left oblique abdominal incision showing severe (massive)
splenomegaly in patient with hemolytic disorder.
Mobilization and removal of spleen
Upon entry into the abdominal cavity, dissection is performed with blunt
and sharp technique and with the surgeon's hand following the convex
surface of the organ, leading to identification of the peritoneal attachments.
The spleen is gently grasped and displaced medially toward the incision.
The avascular peritoneal attachments and ligaments are incised with an
electrocautery or Metzenbaum scissors. These suspensory ligaments are
avascular except for the gastrosplenic ligaments, which contains the short
gastric vessels. In patients with portal hypertension, any ligaments may
have vessels that should be ligated.
Attention is then turned to the hilum, where the splenic artery and veins are
identified, carefully dissected, doubly ligated with 0 nonabsorbable suture
(eg, silk), and transfixed with 2-0 silk suture ligatures. To avoid injury to the
pancreas, the dissection is carried out at the hilum in close proximity to the
spleen.
Next, the short gastric vessels are identified and ligated. In hypotensive
patients, the short gastric vessels usually does not bleed, nor does the
splenic bed.
In the case of elective splenectomy, the first step is transection of the
ligamentous attachments, including the splenophrenic ligament at the
superior pole and the splenocolic and splenorenal ligaments at the inferior
pole. This may be accomplished with blunt dissection, an electrocautery,
or, in conditions where the ligaments are thickened, Metzenbaum scissors.
After the ligamentous attachments are transected, the gastric vessels that
run from the spleen to the greater curvature of the stomach are ligated and
divided. A Lembert suture is placed in the gastric wall in a seromuscular
fashion to avoid the complication of gastric fistulization when one is unable
to identify the source of bleeding from the stomach.
After these maneuvers are completed, the spleen is delivered into the
wound with blunt dissection of the posterior attachments. To keep from
entering the splenic vein, care should be taken not to divide the posterior
attachments too far medially. It is also important to avoid axial rotation of
the spleen before securing the splenic vessels with vascular loop or
clamps; such rotation may lead to disruption of the splenic artery or vein.
Dissection is carried out at the hilum in close proximity to the spleen to
avoid injury to the pancreas. Individual ligation of the splenic artery or
arterial branches and the splenic vein or venous branches is generally
preferable. This is accomplished by means of double ligation and
transfixion with nonabsorbable suture ligatures.
In the case of a markedly enlarged spleen (severe splenomegaly), it is
often preferable to place a vascular loop or vascular clamp on the splenic
vessels (see the image below) and double-ligate the vessels with heavy
nonabsorbable suture. One may then proceed with suture ligation using a
transfixed technique. This approach avoids slipped-off sutures and helps
prevent postoperative bleeding.
Placement of vascular loops during dissection is recommended
to help control splenic vessels in cases of severe (massive) splenomegaly.
After removal of the spleen, hemostasis is obtained and confirmed in a
systematic fashion by careful inspection of the left subphrenic area, the
greater curvature of the stomach, and the short gastric vessel area, as well
as the splenic hilum. Inspection of these areas is facilitated by proper
retraction of the stomach and small bowel to allow clear visualization of the
left upper quadrant and surgical bed. Attention is then turned to the surgical
field to check for active bleeding. Any active bleeding is identified and
hemostasis achieved.
When splenectomy is performed for hematologic disease, a thorough
abdominal exploration should be performed to look for any accessory
spleens. Common locations of accessory spleens include the hilum, the
gastrocolic and gastrosplenic ligaments, the greater omentum, the
mesenteric region, and the presacral space. Any accessory spleen is
removed to prevent the recurrence of idiopathic (immune)
thrombocytopenic purpura (ITP).
[12, 13]

If the patient requires platelet transfusion, it should be administered after
ligation of the splenic artery.
Completion and closure
Drains are not routinely required, except in cases where an injury of the tail
of the pancreas is suspected or confirmed.
The abdominal incision is closed by approximating the linea alba with 1-0
polypropylene monofilament sutures in a continuous fashion. The left
subcostal incision is approximated in layers with 1-0 absorbable sutures.
The skin edges are approximated with staples. In injured patients, the
abdomen should not be closed until the coagulopathy that is frequently
associated with major trauma has been corrected.
Partial Splenectomy and Splenorrhaphy
In Gaucher disease, partial splenectomy is performed by isolating and
ligating the segmental vessels to the affected segment, then resecting the
segment. Closure is accomplished by approximating the splenic
parenchyma with suture material and an omental patch, using a hemostatic
agent, or applying an argon-beam coagulation device.
Splenorrhaphy is still used to manage small lacerations or other injuries
that are localized to 1 pole of the spleen. Horizontal mattress sutures
placed over pledgets are commonly used. Omentum or a local hemostatic
agent (eg, fibrin glue) may be used as an adjuvant in achieving hemostasis.
Complications of Procedure
Intraoperative complications include pancreatic, vascular, colon, stomach,
and diaphragmatic injuries. These are reported with both open and
laparoscopic splenectomy.
Early postoperative complications include pulmonary complications
(atelectasis to pneumonia), subphrenic abscess, ileus, portal vein
thrombosis,
[14]
thrombocytosis, thrombotic complications, and wound
complications (hematomas, seromas, and wound infections).
Late postoperative complications include splenosis and overwhelming
postsplenectomy infection (OPSI).
[16, 22]

Autotransplantation of the spleen is no longer recommended. Although the
splenic remnants survive, adequate phagocytosis of encapsulated bacteria
is lost as a consequence of the disruption of normal anatomic
vascularization.
Periprocedural Care
Preprocedural Planning
Before open splenectomy, a Foley catheter should be placed. An orogastric
or nasogastric tube should be inserted during intubation and removed
postoperatively as clinically indicated. Sequential compression devices are
used before the operation begins. Preoperative antibiotics are given within
60 minutes of the skin incision. The skin is prepared and draped with
aseptic technique in the standard surgical fashion.
Equipment
Open splenectomy requires a laparotomy set with abdominal retractors and
good lighting.
Patient Preparation
General anesthesia is required. The patient is placed in the supine position,
with the arms extended. The surgeon stands on the patient's right side with
the assistant opposite.
Monitoring and Follow-up
Trauma patients should be vaccinated in the postoperative period during
the hospital stay because they may have unreliable follow-up once
discharged. In elective cases, vaccination 2 weeks before the procedure is
recommended. Recommended immunizations include pneumococcal and
meningococcal vaccinations and Haemophilus influenzae vaccination.



Image 1 of 7
CT scan of abdomen showing grade IV splenic injury.



Image 2 of 7
Resected traumatized spleen with multiple lacerations.



Image 3 of 7
Severe (massive) splenomegaly occupying most of left abdominal cavity in patient with
symptomatic hematologic disorder after failure to respond to medical therapy.



Image 4 of 7
Left oblique abdominal incision showing severe (massive) splenomegaly in patient with
hemolytic disorder.



Image 5 of 7
CT scan of abdomen demonstrating grade IV injury of spleen.



Image 6 of 7
Placement of vascular loops during dissection is recommended to help control splenic
vessels in cases of severe (massive) splenomegaly.



Image 7 of 7
CT scan of abdomen demonstrating large delayed rupture of subcapsular hematoma of
spleen in symptomatic polytrauma patient previously managed with percutaneous
angioembolization.