Splenectomy

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CHAPTER 29 Splenectomy

Vincent Mortellaro, Elizabeth A. Beierle, Mike K. Chen

The need for splenic surgery in children is limited primarily to hematologic diseases, tumors, cysts, hypersplenism, and trauma.

Step 1: Surgical Anatomy

♦ The spleen is positioned anterior to the costodiaphragmatic recess, lateral to the greater curvature of the stomach, adjacent to the tail of the pancreas, anterior to the left kidney, and superior or posterior to the splenic flexure of the colon.
♦ The parietal peritoneum adheres to the splenic capsule along its lateral border opposite the hilum. These attachments make up the suspensory ligaments of the spleen, which tend to be avascular.
♦ The splenorenal ligament extends from the left kidney to the hilum of the spleen and is where the splenic vessels and tail of the pancreas are invested.
♦ The gastrosplenic ligament contains the short gastric vessels.
♦ The splenic artery arises from the celiac trunk and travels along the superior edge of the pancreas, where it branches to form the short gastric, left gastroepiploic, and terminal splenic branches (Fig. 29-1).

image The terminal splenic arteries branch in the splenorenal ligament before entering the splenic hilum.
♦ The splenic vein forms in the splenorenal ligament and runs inferior to the artery and posterior to the pancreas. It joins the superior mesenteric vein behind the head of the pancreas to form the portal vein.

image The inferior mesenteric vein generally drains into the splenic vein but may occasionally drain directly into the superior mesenteric vein.

image

Figure 29-1

Step 2: Preoperative Conditions

Hematologic Disorders

Immune Thrombocytopenic Purpura

♦ Immune thrombocytopenic purpura (ITP) is characterized by a low platelet count, normal bone marrow, and an absence of other diseases that can cause thrombocytopenia.
♦ Splenectomy is used primarily only in patients with refractory severe symptomatic thrombocytopenia failing medical therapy.

image Indications include patients with ITP for 6 weeks and a platelet count of less than 10,000, irrespective of bleeding symptoms.
image Another indication is duration of ITP for 3 months and an incomplete response to primary therapy with a platelet count of less than 30,000.
image Other indications include pregnant second-trimester women for whom primary therapy has failed and who have platelet counts of less than 10,000 or less than 30,000 with bleeding symptoms.

♦ The success rate of splenectomy is about 65%, with the best results occurring in patients who had predominantly splenic sequestration.

Hereditary Spherocytosis

♦ An autosomal dominant disease resulting from a deficiency of spectrin, which leads to membrane abnormalities.

image The red blood cells are small, rigid, and have increased osmotic fragility.

♦ Splenectomy is performed to correct the anemia, but removal of the spleen does not normalize the red blood cell morphology.
♦ Hemolysis results in a higher incidence of pigmented gallstones, and workup for cholelithiasis should be completed before splenectomy. If gallstones are present, the gallbladder may be removed at the time of splenectomy.

Sickle Cell Disease

♦ Elongated crescent-shaped erythrocytes are unable to deform within the microvasculature, resulting in thromboses and microinfarctions.
♦ Although most patients with sickle cell disease are autosplenectomized, some require splenectomy for acute sequestration crisis and hypersplenism.

Thalassemias

♦ Thalassemias are autosomal dominant defects in hemoglobin synthesis that result in hemolytic anemia.
♦ As with sickle cell disease, hypersplenism and acute splenic sequestration are indications for splenectomy.

Tumors

♦ Splenectomy was formerly used to assist in the staging of Hodgkin’s lymphoma. However, with the increasing accuracy of noninvasive imaging, including computed tomography (CT) scan, lymphangiography, and positron emission tomography scans, the number of staging splenectomies performed has decreased.
♦ In non-Hodgkin’s lymphoma, massive splenomegaly is an indication for splenectomy when the bulk of the spleen contributes to pain, fullness, and early satiety.

Cysts

♦ Cystic lesions in the spleen are divided into true cysts lined by epithelium and pseudocysts.
♦ True cysts are further subdivided into parasitic and nonparasitic cysts.

image True nonparasitic cysts are thought to be congenital and benign.

• Most true cysts are asymptomatic and symptoms are related to size.
• Larger cysts can lead to shortness of breath, early satiety, and back and shoulder pain.
• The diagnosis is best made with CT scan in the case of a true nonparasitic cyst; partial splenectomy is an option for preservation of splenic function.

image Most parasitic cysts are due to Echinococcus, which can be identified by the presence of calcifications and daughter cysts seen on CT scans.
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