CHAPTER 13 Splenectomy
Step 1. Surgical anatomy
♦ The spleen is mobilized by dividing the splenic attachments and ligating the vascular hilum without injury to the nearby stomach or pancreatic tail.
♦ Peritoneal attachments and splenic ligaments can be divided using electrocautery or ultrasonic cutting devices.
♦ The vascular supply requires adequate ligation for proper hemostasis. This can be achieved using energy devices as well as vessel sealing systems, clips, and laparoscopic staplers.
Step 2. Preoperative considerations
Patient preparation
♦ It is important to consider spleen size when preparing a patient for laparoscopic splenectomy. This will determine the port placement as well as the potential need for a hand-assist port.
♦ Any evidence of an accessory spleen seen on preoperative imaging should be noted, particularly for hematologic indications for splenectomy.
♦ Patients with idiopathic thrombocytopenic purpura (ITP) and a preoperative platelet count less than 20,000 should be prepared for intraoperative platelet transfusion. Steroids and intravenous immunoglobulin can be given prior to surgery to temporarily elevate the platelet count.
♦ While the risk for overwhelming postsplenectomy infections (OPSI) is small, it is advised that vaccinations be given 2 to 3 weeks prior to an elective operation. These should include vaccinations for encapsulated organisms: Streptococcus Pneumoniae, Haemophilus Influenza B, and Neisseria Meningitidis.
♦ Hand assistance may be helpful in cases of splenomegaly or when removal of an intact specimen is needed.
Equipment and instrumentation
♦ Standard laparoscopic instrumentation is required, including abdominal access devices (e.g., Veress needle or visualization ports), 12-mm and 5-mm ports; 30-degree endoscope; standard laparoscopic instruments including scissors, graspers, and electrocautery; suction-irrigator; and large endoscopic specimen retrieval bag.
♦ Specialized equipment is also necessary for vessel ligation and hemostasis. A variety of devices can be used, including laparoscopic staplers with vascular loads, clip appliers, ultrasonic coagulation, or bipolar electrocoagulation devices.
♦ Laparoscopic ultrasound may be helpful in locating accessory spleens or identification of vascular supply.
Anesthetic
♦ Laparoscopic splenectomy is performed under general anesthesia.
♦ Typically, sequential compression devices (SCDs) are placed on the lower extremities for deep venous thrombosis (DVT) prophylaxis.
♦ Preoperative antibiotics should be administered. A first-generation cephalosporin, such as cefazolin, is appropriate.
♦ A nasogastric tube is used to decompress the stomach during surgery, but it may be removed at the end of the operation.
♦ A Foley catheter can be placed before surgery and removed at the conclusion if a prolonged operative time is expected.
♦ Invasive monitoring is typically not needed for elective cases unless the patient has significant underlying cardiopulmonary disease.
