Christopher T. Siegel and Raymond Onders

Introduction

Nontraumatic splenectomy is usually indicated for patients with benign or malignant hematologic disorders who are not responding to medical therapy. Indications include idiopathic thrombocytopenic purpura (ITP) or other hematologic disorders that lead to splenic sequestration of platelets and red blood cells; patients with thrombotic thrombocytopenic purpura (TTP), hereditary spherocytosis, autoimmune hemolytic anemia, or symptomatic thalassemias may also respond to splenectomy. Splenectomy may also be a treatment option for malignancies such as primary lymphoma or metastatic disease to the spleen.

Surgical Principles

The key to safe splenectomy is understanding the anatomy surrounding the spleen (Fig. 17-1). The spleen must be safely mobilized from all the surrounding structures to prevent common perioperative complications related to the splenic anatomy, including gastric injury or leak during division of short gastric vessels; pancreatitis or pancreatic fistula from the pancreatic tail during mobilization of the splenic hilum; colon injury during division splenic flexure; left pleural effusion or left pulmonary atelectasis from excessive diaphragm manipulation; and bleeding from short gastric vessels, splenic artery, or splenic vein.

During the postoperative period, splenic vein thrombosis can lead to inferior mesenteric vein or portal vein thrombosis, with serious consequences (Fig. 17-2, A). The most serious long-term complication of splenectomy is sepsis, which can be decreased with preoperative immunization for the common encapsulated organisms, including meningococcal, pneumococcal, and Haemophilus influenzae type B infections, either 2 weeks before or on the last day of admission after surgery.

In the preoperative period, radiologic imaging can be obtained in patients with an enlarged spleen to assist in surgical planning (Fig. 17-2, B). The surgical approach to splenectomy often depends on the size of the spleen. Clinical data for elective splenectomies support a purely laparoscopic approach for spleens less than 20 cm in size and a hand-assisted or open approach for larger spleens.

Laparoscopic Surgical Technique

The patient is placed in a right lateral position with the surgeon on the patient’s right side and the patient flexed at the waist to open up the space between the costal margin and the iliac crest. Three or four ports are placed subcostally, with the camera port in the center to facilitate the triangulation for dissection. A 5-mm port is placed in the epigastric area, and a 12-mm port in the anterior axillary line will be used for the endoscopic staplers. These ports can be moved lower depending on the size of the spleen.

Initially and throughout each stage of the procedure, accessory spleens are searched for and removed if identified. Dissection is done with an ultrasonic energy source beginning at the lower pole of the spleen, mobilizing the splenic flexure by dividing the lienocolic ligament. The goal of the mobilization is to be able to place a vascular stapler safely across the hilum of the splenic structures, as shown in Figure 17-1. The gastrosplenic ligament and the short gastric vessels are divided. The posterior and lateral splenophrenic attachments are also divided. These are usually avascular unless the patient has portal hypertension.

At this point, the splenic hilum can clearly be seen, and a vascular stapler can be placed perpendicular to the vessels before firing. At times, it may take several reapplications of the stapler to divide completely all the branches to the upper pole of the spleen. Once the splenic artery is divided, if there is significant thrombocytopenia and bleeding is a concern, platelets can now be given.

Once the last retroperitoneal attachments have been divided, the spleen can be placed into a specimen bag and removed from the abdominal cavity by either extending the incision or morcellating the specimen with ring forceps. The abdominal cavity is evaluated again for evidence of accessory spleens and bleeding. Drains are not usually placed.

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