Open Splenectomy

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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 andhematologic disease. The spleen is one of the most frequently injuredintraperitoneal organs, and management of splenic injuries may requiresplenectomy or, rarely, splenorrhaphy. The current trends are towardnonoperative management of the spleen after trauma [21] and towardlaparoscopic splenectomy for hematologic disorders.[20] Today, mostelective splenectomies are done laparoscopically, except in the case ofsevere 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 spleenhelps maintain normal erythrocyte morphology by processing immatureerythrocytes, removing their nuclei, and changing the shape of the cellularmembrane. Other functions of the spleen include the removal of nuclearremnants of RBCs, denatured hemoglobin, and iron granules and themanufacture of opsonins (properdin and tuftsin).

Indications

The most common indications for open splenectomy in an adult aretraumatic splenic rupture and blood dyscrasias.

Splenic rupture is usually caused by blunt or penetrating trauma (see thefirst, second, and third images below); delayed rupture of the spleen[2,3] (see the fourth image below) and spontaneous splenic rupture [4, 5] occurrarely. An analysis by the National Trauma Data Bank (NTDB) found highfailure rates and prolonged hospital stays when high-grade splenic injurieswere managed conservatively (ie, with nonoperative management).[6]
http://emedicine.medscape.com/article/1829892-overview#showallhttp://emedicine.medscape.com/article/1829892-overview#showallhttp://emedicine.medscape.com/article/1829892-overview#showall


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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 havehemodynamic instability or shock on admission, those who haveassociated 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 asidiopathic (immune) thrombocytopenic purpura (ITP), thromboticthrombocytopenic purpura (TTP), and hereditary spherocytosis. Of these,ITP is the most common indication for elective splenectomy. In hereditary
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spherocytosis, the RBCs have a tendency to be trapped and destroyed inthe 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 6years old to minimize the risk of overwhelming postsplenectomy sepsis

(OPSI).[8, 9, 10, 11]

After removal of the spleen, the erythrocytes achieve anormal life span, and the jaundice, if present, disappears in a timelymanner. Other, less common hematologic indications for splenectomyincludethalassemiaandsickle cell anemia.

Other disorders for which splenectomy may be indicated include thefollowing:

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 bysplenectomy

Splenic abscess, cyst, sarcoidosisContraindications

Contraindications to open splenectomy are few. For elective opensplenectomy, the only absolute contraindications are uncorrectablecoagulopathy and severe cardiovascular disease that prohibits theadministration of general anesthesia.

Relevant Anatomy

The spleen is an wedge-shaped organ that lies in relation to the 9th and11th 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
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variable. A normal spleen is not palpable. For more information about therelevant anatomy, seeSpleen 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 forsplenectomy, and the preference of the surgeon. Generally, in emergencyor trauma situations, an upper midline incision is preferable because itaffords excellent exposure of the abdominal cavity, can be performedquickly, and provide access for the evaluation and management of otherpotential injured organs or structures.

In most patients undergoing splenectomy for a hematologic disorder, a leftsubcostal incision is employed, beginning to the right of the midline andproceeding obliquely to the left approximately 2 fingerbreadths below thecostal margin. This incision yields excellent exposure (see the imagebelow).

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 bluntand sharp technique and with the surgeon's hand following the convexsurface 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 anelectrocautery or Metzenbaum scissors. These suspensory ligaments areavascular except for the gastrosplenic ligaments, which contains the shortgastric vessels. In patients with portal hypertension, any ligaments mayhave vessels that should be ligated.
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Attention is then turned to the hilum, where the splenic artery and veins areidentified, carefully dissected, doubly ligated with 0 nonabsorbable suture(eg, silk), and transfixed with 2-0 silk suture ligatures. To avoid injury to thepancreas, the dissection is carried out at the hilum in close proximity to thespleen.

Next, the short gastric vessels are identified and ligated. In hypotensive

patients, the short gastric vessels usually does not bleed, nor does thesplenic bed.

In the case of elective splenectomy, the first step is transection of theligamentous attachments, including the splenophrenic ligament at thesuperior pole and the splenocolic and splenorenal ligaments at the inferiorpole. 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 anddivided. A Lembert suture is placed in the gastric wall in a seromuscularfashion to avoid the complication of gastric fistulization when one is unableto identify the source of bleeding from the stomach.

After these maneuvers are completed, the spleen is delivered into thewound with blunt dissection of the posterior attachments. To keep fromentering the splenic vein, care should be taken not to divide the posteriorattachments too far medially. It is also important to avoid axial rotation ofthe spleen before securing the splenic vessels with vascular loop orclamps; 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 toavoid injury to the pancreas. Individual ligation of the splenic artery orarterial branches and the splenic vein or venous branches is generallypreferable. This is accomplished by means of double ligation andtransfixion 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 splenicvessels (see the image below) and double-ligate the vessels with heavynonabsorbable suture. One may then proceed with suture ligation using atransfixed technique. This approach avoids slipped-off sutures and helpsprevent postoperative bleeding.


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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 asystematic fashion by careful inspection of the left subphrenic area, thegreater curvature of the stomach, and the short gastric vessel area, as wellas the splenic hilum. Inspection of these areas is facilitated by properretraction of the stomach and small bowel to allow clear visualization of theleft upper quadrant and surgical bed. Attention is then turned to the surgicalfield to check for active bleeding. Any active bleeding is identified and

hemostasis achieved.When splenectomy is performed for hematologic disease, a thoroughabdominal exploration should be performed to look for any accessoryspleens. Common locations of accessory spleens include the hilum, thegastrocolic and gastrosplenic ligaments, the greater omentum, themesenteric region, and the presacral space. Any accessory spleen isremoved to prevent the recurrence of idiopathic (immune)thrombocytopenic purpura (ITP).[12, 13]

If the patient requires platelet transfusion, it should be administered afterligation of the splenic artery.

Completion and closure

Drains are not routinely required, except in cases where an injury of the tailof the pancreas is suspected or confirmed.

The abdominal incision is closed by approximating the linea alba with 1-0polypropylene 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, theabdomen should not be closed until the coagulopathy that is frequentlyassociated with major trauma has been corrected.
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Partial Splenectomy and Splenorrhaphy

In Gaucher disease, partial splenectomy is performed by isolating andligating the segmental vessels to the affected segment, then resecting thesegment. Closure is accomplished by approximating the splenicparenchyma with suture material and an omental patch, using a hemostaticagent, or applying an argon-beam coagulation device.

Splenorrhaphy is still used to manage small lacerations or other injuriesthat are localized to 1 pole of the spleen. Horizontal mattress suturesplaced over pledgets are commonly used. Omentum or a local hemostaticagent (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 veinthrombosis,[14]thrombocytosis, thrombotic complications, and woundcomplications (hematomas, seromas, and wound infections).

Late postoperative complications include splenosis and overwhelmingpostsplenectomy infection (OPSI).[16, 22]

Autotransplantation of the spleen is no longer recommended. Although thesplenic remnants survive, adequate phagocytosis of encapsulated bacteriais lost as a consequence of the disruption of normal anatomicvascularization.

Periprocedural Care

Preprocedural Planning

Before open splenectomy, a Foley catheter should be placed. An orogastricor nasogastric tube should be inserted during intubation and removedpostoperatively as clinically indicated. Sequential compression devices areused before the operation begins. Preoperative antibiotics are given within60 minutes of the skin incision. The skin is prepared and draped withaseptic technique in the standard surgical fashion.


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Equipment

Open splenectomy requires a laparotomy set with abdominal retractors andgood 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 withthe assistant opposite.

Monitoring and Follow-up

Trauma patients should be vaccinated in the postoperative period duringthe hospital stay because they may have unreliable follow-up oncedischarged. In elective cases, vaccination 2 weeks before the procedure isrecommended. Recommended immunizations include pneumococcal and

meningococcal vaccinations and Haemophilus influenzaevaccination.
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Image 1 of 7

CT scan of abdomen showing grade IV splenic injury.

Image 2 of 7

Resected traumatized spleen with multiple lacerations.


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Image 3 of 7

Severe (massive) splenomegaly occupying most of left abdominal cavity in patient withsymptomatic hematologic disorder after failure to respond to medical therapy.


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Image 4 of 7

Left oblique abdominal incision showing severe (massive) splenomegaly in patient withhemolytic disorder.


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Image 5 of 7

CT scan of abdomen demonstrating grade IV injury of spleen.


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Image 6 of 7

Placement of vascular loops during dissection is recommended to help control splenic

vessels in cases of severe (massive) splenomegaly.


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Image 7 of 7

CT scan of abdomen demonstrating large delayed rupture of subcapsular hematoma of

spleen in symptomatic polytrauma patient previously managed with percutaneousangioembolization.
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Open Splenectomy