Splenectomy, a procedure to remove the entire spleen, is performed for a number of indications. It is important to understand the anatomy and physiology of the spleen prior to performing a splenectomy. Splenectomy can be performed via open, laparoscopic, or robotic techniques depending on the patient and diagnosis.
In order to successfully perform a splenectomy, it is important to understand the anatomy of the spleen. The spleen is located in the left upper quadrant of the abdomen. The spleen lies under the left posterolateral aspects of 9th-11th ribs. The spleen is surrounded by the stomach, pancreas, colon, and left kidney. The size and weight of the spleen can vary among individuals. On average, the length, width, and thickness of a spleen measure approximately 12 cm, 7 cm, and 3 cm. The average weight of a spleen is 150 grams. The spleen is attached by multiple ligaments, including the gastrosplenic ligament and splenorenal ligament.
The gastrosplenic ligament extends from the greater curvature of the stomach to the hilum of the spleen. This ligament contains the short gastric arteries and the left gastroepiploic artery. The splenorenal ligament extends from the anterior surface of the left kidney to the splenic hilum. This ligament contains splenic arteries.
The splenic artery, a branch of the celiac trunk, is the sole arterial supply to the spleen. The splenic artery courses along the upper border of the body and tail of the pancreas. The splenic artery then bifurcates to the short gastric and the left gastroepiploic artery, which supplies the stomach prior to entering the splenic hilum. The short gastric then supplies the gastric fundus, and the left gastroepiploic artery supplies the stomach along the greater curvature. The venous tributaries join to form the splenic vein at the splenic hilum, The splenic vein travels behind the pancreas and joins the superior mesenteric vein behind the neck of the pancreas to form the portal vein.
The lymphatics of the spleen drain into the hilum lymph nodes and into the retropancreatic lymph nodes.
Accessory spleens are quite common. Approximately 10-30% of individuals have accessory spleens. Most commonly, they are located at the splenic hilum. Other locations include the pancreatic tail, gastrosplenic or splenorenal ligaments, and even the mesentery.
The most common indications for splenectomy include:
There are no absolute contraindications in performing a splenectomy. However, there are special considerations that must be taken into account prior to performing a splenectomy, especially in patients with splenomegaly or portal vein hypertension.
When the spleen exceeds anywhere from 1000 to 2000 grams, laparoscopic splenectomy becomes difficult due to the limited working space in performing dissection around the surrounding structures and even extracting the specimen from the abdomen. Studies have shown longer operative times, more blood loss, and more frequent conversion to open for those with splenomegaly compared to the normal-sized spleen. Splenic artery embolization can be considered to reduce the size of the spleen to perform a laparoscopic splenectomy.
Patients with portal hypertension are at risk of hemorrhaging due to the presence of esophagogastric varices along with thrombocytopenia. Studies have shown longer operative times, more blood loss, and more frequent conversion to open for these individuals.
Splenectomy can be performed using a laparoscopic approach or open laparotomy. The laparoscopic approach can be performed standard laparoscopic approach, hand-assisted-laparoscopic approach, and now robotic-assisted.
For a splenectomy, the following personnel is required:
Patients undergoing splenectomy need to be vaccinated against encapsulated organisms. Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae are the three most common organisms that patients are at risk for developing an overwhelming post-splenectomy infection (OPSI). The overall lifetime risk for developing OPSI is approximately 5%, with mortality reaching up to 50%.
Patients typically present with nonspecific symptoms, which include fatigue, muscle aches, vomiting. Following, patients deteriorate within hours. Patients undergoing elective splenectomy should receive vaccinations against these organisms approximately two weeks prior to surgery to allow an adequate immune response. Patients who undergo splenectomy for traumatic injuries should receive vaccination approximately two weeks after surgery. However, individuals often receive vaccines prior to discharge due to noncompliance and loss of follow up in this patient population.
There are many ways to perform a splenectomy. The splenectomy can be performed open or laparoscopically.
Key steps in the open approach:
Key steps in the laparoscopic approach:
Major complications can occur, including:
A multidisciplinary approach is crucial in patients undergoing splenectomy as it is a major procedure associated with both intraoperative and postoperative complications. It is imperative to understand the risks involved in a splenectomy. A joint collaboration between primary care physicians, hematologists, anesthesiologists, surgeons, and pharmacists is needed in the preoperative planning.
Prior to surgery, the patient should have the following done:
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