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.
image Serologic tests are also available to verify the presence of parasites.
image Spillage or rupture of a hydatid cyst may cause anaphylaxis and contaminate the entire peritoneal cavity with infective scolices.
image Splenectomy is the treatment of choice for parasitic cysts; however, injections of 3% normal saline, alcohol, and 0.5% silver nitrate are alternative treatments.
image Pseudocysts account for around 80% of all nonparasitic cysts and are usually the result of splenic trauma.

• Symptoms are related to size.

image Patients complain of shoulder and left upper quadrant pain.

• Partial splenectomy is an option for splenic preservation; successful percutaneous drainage has been reported as well, but its durability is limited.

Step 3: Operative Technique

Laparoscopic Splenectomy

♦ The colon should be decompressed with either an enema or a laxative on the day before surgery, which will aid in visualization of the spleen.
♦ A nasogastric tube should be used to decompress the stomach, and a Foley or Credé maneuver is used to empty the bladder before prepping and draping the patient.
♦ The patient should be placed in the supine position.

image A roll under the patient’s left side to elevate the flank may be helpful (Fig. 29-2).

• During trocar placement, the bed is tilted to the patient’s left to level the field.
• The bed is tilted to the patient’s right during dissection to keep the spleen elevated as the viscera falls away from the operative field.
• Tilting the table into the reverse Trendelenburg position may also be helpful.

♦ A 10- to 12-mm umbilical trocar should be placed, and a 5-mm 30- to 70-degree laparoscope is used to identify the spleen.

image The 10- to 12-mm trocar is useful for placing the stapler and bag retrieval device.
image The location for placement of other ports is variable and based partly on the size of the spleen.

• In general, one 5-mm trocar is placed in the midabdomen between the xiphoid and umbilicus.
• Two other stab wounds may be used for introduction of instruments without actual placement of trocars.

image The locations of these puncture sites may be variable, but they work well with one in the subxiphoid position and another between the 5-mm trocar and the umbilicus trocar (Fig. 29-3).

♦ Both surgeon and assistant will operate from the patient’s right side.

image The assistant will work with an instrument in the subxiphoid position and a laparoscope in the 5-mm trocar site.
image The surgeon will operate from the two more caudal entry sites.

♦ Initially the omental attachments to the caudal aspect of the spleen are divided using a cautery device (Fig. 29-4).
♦ The short gastric vessels are then identified in the gastrosplenic ligament by placing traction on the greater curve of the stomach.

image These vessels are usually divided with an energy device.
image The division of the short gastric vessels is carried up as cephalad as possible.

• In the more cephalad position, the distance between the greater curvature of the stomach and the spleen may be quite small, and care must be taken to avoid injury to the stomach.

♦ After the short gastric vessels have been divided, the spleen is retracted medially to expose the suspensory ligaments. These avascular ligaments are divided so that the only remaining area of attachment is the hilum.
♦ The spleen is elevated using the cephalad trocar to expose the hilum.

image The splenic artery and vein is identified beyond the tail of the pancreas.
image They can be ligated between ligatures or clips, cautery device, or a vascular load of staples (Fig. 29-5).

♦ A bag device is inserted into the 10- to 12-mm port site for removal of the spleen (Fig. 29-6).

image The volume of the spleen is such that removal through the port site intact is not possible.
image The spleen can be morcellized using a sponge stick or other instruments.

• Care should be taken not to break the bag.

♦ The abdomen should be re-examined for hemostasis and for any accessory spleens; all port sites are closed appropriately.

image The stab incisions may be closed with skin sutures or Steri-strips.

image

Figure 29-2

image

Figure 29-3

image

Figure 29-4

image

Figure 29-5

image

Figure 29-6

Open Splenectomy

♦ Open splenectomies are not done as commonly any longer, but there are circumstances when this approach is needed.

image The open approach may be better for extremely large spleens and is better used in emergencies.

♦ A nasogastric tube should be used to decompress the stomach.
♦ A left subcostal or small upper midline incision is preferred for elective splenectomy.

image A large midline incision is customary for emergent splenectomy secondary to trauma.

♦ After identifying the spleen, dorsal and medial traction should be placed on the spleen to stretch and define the splenorenal and splenophrenic ligaments.
♦ The incision begins at the caudal omental attachments, extends into the lesser sac, and continues to the stomach and short gastric vessels.
♦ The dissection around the spleen laterally should continue until the suspensory ligaments have been transected and the spleen is delivered to the level of the wound.
♦ After complete mobilization of the spleen, traction is placed on the gastrosplenic ligament to expose the short gastric vessels. These are divided with sutures or an energy device.
♦ The splenic artery is then identified at the superior border of the pancreas, and the artery and vein are separately divided and ligated.
♦ In some cases the tail of the pancreas will extend into the hilum; in these patients it is recommended to divide the vessels after they have branched to avoid a pancreatic injury.
♦ Once the spleen is removed, the field is inspected for hemostasis. If no injury to the pancreas occurred, drainage of the splenic fossa is not necessary.
♦ Accessory spleen should be sought out in the lesser sac, the gastrolienal ligament, and greater omentum.

Partial Splenectomy

♦ Partial splenectomy may be done to preserve immune function.
♦ Indications include cystic or solid lesions within the spleen, sickle cell disease, hereditary spherocytosis, and other hemolytic anemias.
♦ The procedure may be done through an open or laparoscopic technique.
♦ Care is taken to divide the hilar vessels close to the spleen at the terminal splenic branches.
♦ Either the upper or lower pole may be preserved.
♦ After the ischemic portion is demarcated by a color change, a cautery device may be used to divide the spleen.
♦ Part of the capsule should be preserved to cover the raw surface to aid in hemostasis.
♦ The outcome of the residual immunologic function remains unclear at this time.

Step 4: Postoperative Care

Thrombocytosis

♦ Postoperatively there may be an increase in platelet number in about half of the patients in the weeks after splenectomy.
♦ In most cases a platelet count greater than 750,000 to 1,000,000 will prompt a consideration for treatment with antiplatelet therapy, including aspirin, low-dose heparin, or low-molecular-weight heparin.

image However, therapy for this is generally unnecessary in children.

Overwhelming Post-Splenectomy Infection

♦ The incidence of overwhelming post-splenectomy infection (OPSI) is difficult to determine.

image The risk appears to be increased after splenectomy for malignancy or hematologic disease compared with that after splenectomy for trauma.
image The risk is higher in young children (i.e., younger than 4 years).
image The risk of fatal OPSI is estimated to be 1 in 300 patient-years for children.

♦ The presenting symptoms of patients with OPSI include fever, chills, sore throat, malaise or myalgia, diarrhea, and vomiting.
♦ Progression may be rapid with development of shock, disseminated intravascular coagulation, respiratory distress, coma, and death within hours of presentation.
♦ Given the devastating effects of OPSI, it is recommended that prophylactic immunization be administered before elective splenectomy whenever possible.
♦ In cases of trauma requiring emergent splenectomy, immunization should be administered during the same hospitalization or in subsequent follow-up in the clinic.

image Penicillin prophylaxis is commonly practiced during the first few years after splenectomy as well.

Step 5: Pearls and Pitfalls

♦ Use gravity to assist with the dissection. Position the child so that the left side is elevated and keep the lateral attachments intact until completing dissection of the medial aspect of the spleen (hilum and short gastrics).
♦ Look for accessory spleens during the procedure in the lesser sac and on the omentum.
♦ Avoid injury to the distal pancreas.
♦ Massive splenomegaly can make laparoscopic splenectomy extremely difficult and dangerous in a small abdomen. An open procedure may be a better approach for these children.

Bibliography

Brunicardi F, Andersen D, Billiar T, et al. Schwartz’s principles of surgery, 8th ed. New York: McGraw-Hill Professional; 2004.

Cameron JL. Current surgical therapy, 8th ed. St. Louis: Mosby; 2007.

Mulholland M, Lillemore K, Doherty G, et al. Greenfield’s surgery: Scientific principles and practice, 4th ed. Baltimore: Williams & Wilkins; 2005.

Netter F. Atlas of human anatomy, 4th ed. Philadelphia: Saunders; 2006.

Townsend C, Beauchamp R, Evers B, Mattox K. Sabiston textbook of surgery, 17th ed. Philadelphia: Saunders; 2004.

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