Continuing Education Activity

Splenectomy is mainly performed for hematological disorders along with traumatic injuries. Splenectomy can be performed via the open traditional laparotomy approach or laparoscopic or robotic-assisted approach. This activity reviews the indications, contraindications, and techniques of performing a splenectomy and highlights the role of the interprofessional team in managing patients who undergo splenectomy.

Objectives:

• Identify the important indications for splenectomy.

• Describe the equipment, personnel, preparation, and technique in regards to splenectomy.

• Review the appropriate evaluation of the potential complications of a splenectomy.

• Summarize the importance of improving care coordination amongst interprofessional team members to improve outcomes for patients undergoing splenectomy.

Introduction

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.[1]

Anatomy and Physiology

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 the 9th to 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.[2]

Accessory spleens are quite common. Approximately 10-30% of individuals have accessory spleens. Most commonly, they are located at the splenic hilum.[3] Other locations include the pancreatic tail, gastrosplenic or splenorenal ligaments, and even the mesentery.[4]

Indications

The most common indications for splenectomy include:[5]

• Blood and reticuloendothelial disorders
• Hemolytic (hemolytic anemia, thalassemia)
• Hematological malignancy (acute leukemia, chronic myeloid or lymphocytic leukemia, Lymphoma)
• Myeloproliferative disorders (polycythemia vera, myelofibrosis)
• Thrombocytopenic disorders (immune thrombocytopenic purpura)

• Infective complications (hydatid, malaria)
• Inflammatory disorders (Felty syndrome)
• Neoplastic 
• Cryptogenic disorders 
• Congestive disorders (portal hypertension)
• Metabolic storage disorders (amyloidosis, Gaucher disease) 
• Splenic trauma

Contraindications

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.[6] Splenic artery embolization can be considered to reduce the size of the spleen to perform a laparoscopic splenectomy.[7]

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.[8]

Equipment

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.

Personnel

For a splenectomy, the following personnel is required:

• Operating surgeon
• First assistant
• Surgical technician
• Circulating nurse
• Anesthesiologist

Preparation

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.[9]

Technique or Treatment

There are many ways to perform a splenectomy. The splenectomy can be performed open or laparoscopically.

Key Steps in the Open Approach[10]

• Place the patient in the supine position
• Time-out to verify correct patient, procedure, site, and any additional information
• Endotracheal intubation 
• Ensure adequate lines/tubes (arterial lines, foley catheter, nasogastric tube or orogastric, sequential compression devices) placement
• Prep and drape the abdomen in a sterile fashion
• Make a vertical midline incision extending from the xiphoid process to the pubic symphysis or a left subcostal incision approximately two fingerbreadths below the costal margin extending from midline to anterior axillary line deepened through the skin, subcutaneous tissue, fascia layers, into the peritoneal cavity
• Inspect all four quadrants of the abdomen
• Placement of Omni/Bookwalter retractor to aid in visualization
• Lysis of adhesions
• Incise the gastrocolic ligament to enter into the lesser sac
• Divide and ligate the gastrosplenic and splenocolic ligaments 
• Mobilize the spleen medially to expose the retroperitoneal attachments
• Divide and ligate the splenorenal and splenophrenic ligament
• Ligate the splenic artery and vein near the hilum using suture ligation or vascular load stapler. Avoid injuries to the pancreatic tail when dividing the vessels.
• Carefully pass the spleen off the field. Careful to prevent any spillage which can lead to splenosis (breakage and implantation of splenic tissue in other places)
• Obtain hemostasis
• If pancreatic injuries are noted, consider placing a closed-suction drain.
• Examine for the accessory spleen. The most common location to be found is in the hilum. Resect any accessory spleens
• Close the fascia and reapproximate the skin edges with staples or running subcuticular

Key Steps in the Laparoscopic Approach:[10]

• Place the patient in the supine position.
• Time-out to verify correct patient, procedure, site, and additional information
• General anesthesia induction
• The patient can be placed in a supine position or in the right lateral decubitus position. Ensure that all pressure points are padded properly
• Ensure lines/tubes (arterial lines, foley catheter, nasogastric tube or orogastric, sequential compression devices) placed properly
• Prep and drape the abdomen in a sterile fashion
• Entry into the abdomen using Veress needle, Hassan cannula, or Optical view trocar
• Establish pneumoperitoneum 
• Place the laparoscopic and inspect the abdomen to ensure no injuries from initial trocar placement.
• Place additional ports along the left costal margin.
• Inspect the abdomen
• Divide the splenocolic ligament
• Dissect the peritoneal attachments
• Entry into the lesser sac, and divide the short gastric arteries.
• Dissect the splenic hilum and ligate the splenic vessels using a vascular stapler. Avoid injuries to the pancreatic tail when dividing the vessels.
• Divide the remaining attachments
• Place the spleen in an endoscopic retrieval bag and remove it through the trocar.If the spleen is too large, morcellation with ring forceps may be required. Careful to prevent any spillage which can lead to splenosis
• Inspect the abdomen and obtain good hemostasis
• Evacuate the pneumoperitoneum and remove all the trocars
• Fascia closure of port sites to prevent incisional hernias and reapproximate the skin incisions

Complications

Major complications can occur, including:

• Bleeding can occur due to injury from the splenic capsule or the short gastric vessels during mobilization. When bleeding occurs, one should consider converting to an open procedure to adequately control hemostasis. Without adequate hemostasis, patients can develop a large hematoma, which is at risk for developing into an infection. Bleeding can also occur, especially in patients with myelodysplastic disorders such as myelofibrosis, chronic granulocytic leukemia. Platelets are not functional in these disorders. It is important to consider platelet transfusion despite a normal count.[5][11]
• Injury to the surrounding structures: pancreas, stomach, colon. Up to 15% of laparoscopic splenectomy has reported pancreatic injuries. Pancreatic injuries can lead to acute pancreatitis, pancreatic fluid collection, and possible pancreatic fistula.[12]
• Subphrenic abscess. This can occur from infected hematoma or injury to the stomach or colon, requiring drainage and antibiotics. Patients, particularly with immune thrombocytopenic purpura, are at risk for developing a subphrenic abscess.[5]
• Thromboembolic complications occur in up to 10% of patients. Patients can develop portal vein thrombosis, deep vein thrombosis, to pulmonary embolism. Splenic and portal vein thrombosis can present with decreased appetite, vague abdominal pain, nausea, and malaise. Symptoms can present anywhere approximately 8 to 12 days postoperatively. Laboratory findings can show elevated leukocyte and platelet counts. Diagnosis can be made using Doppler ultrasonography or computed tomography with intravenous contrast. If suspicion is high, patients should be started on anticoagulation. Patients with massive splenomegaly (greater than 3000 grams) and myeloproliferative disorders are at risk.[13]
• Splenosis
• Missed accessory spleen 
• Overwhelming post-splenectomy sepsis
• Conversion from laparoscopic splenectomy to open procedure

Enhancing Healthcare Team Outcomes

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 preoperative planning.

Prior to surgery, the patient should have the following done:

• Discuss with the hematologist regarding splenectomy as a treatment for a hematological disorder
• Discuss with a surgeon to discuss the possible surgical options, including open approach, laparoscopic approach, or even robotic-assisted approach. Explain the risks and benefits of each approach.
• Discuss with pharmacy regarding the vaccines and timing to administer these vaccines to prevent OPSI
• Discuss with an anesthesiologist the risks of general anesthesia. Ensure blood products are ordered and available intraoperatively in case if transfusion is needed.