Splenectomy for Disease — Open

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Benign hematologic conditions: Immune thrombocytopenic purpura (ITP), erythrocyte structural abnormalities (hereditary spherocytosis, elliptocytosis), hemolytic anemia due to erythrocyte enzyme deficiency (pyruvate kinase, glucose–6–phosphate dehydrogenase), hemoglobinopathies (sickle cell disease, thalassemias)
  • Malignancy: Lymphoma, leukemia, nonhematologic tumors of the spleen
  • Miscellaneous benign conditions: Splenic cysts, abscess, wandering spleen
  • Splenic trauma
CONTRAINDICATIONS
  • Limited life expectancy
  • Prohibitive operative risk
EQUIPMENT
  • Anesthetic equipment
  • Operating table
  • Instrument table
  • Electrocautery device
ANATOMY
POSITIONING
  • Supine
  • Legs straight
  • Arms at 90-degree angles
  • Foley
TECHNIQUE
  • Make a left subcostal incision unless a massive spleen is present, which requires a midline incision to facilitate exposure and mobilization.

Clinical Pearls: Be generous on the size of the incision.
  • Decide whether to ligate the splenic artery first or to start by mobilizing the spleen and commit to that approach.

Clinical Pearls: Large spleens usually have multiple infarctions and significant adhesions to surrounding structures in the left upper quadrant. Profuse bleeding should be anticipated in this scenario, and a better approach is to first identify and ligate the splenic artery at the mid pancreas before mobilizing the spleen.

  • Dissect the spleen free from its peritoneal attachments (splenorenal, splenophrenic, splenocolic, and gastrosplenic ligaments).
  • Ligate or staple, and divide the splenic artery, splenic vein, and short gastric vessels at the hilum.

Clinical Pearls: Avoid injury to the stomach or the tail of the pancreas by dissecting close to the splenic hilum. Be careful not to incorporate part of the pancreatic tail in the staple line. Application of a linear stapler with a 2.0-mm cartridge may be used to incorporate splenic artery, splenic vein, and short gastric vessels; this usually requires three to four cartridge loads.
  • Inspect the stomach and the tail of the pancreas to exclude injury, and close the incision in layers.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Monitor bleeding.
  • If the platelet count increases to more than 1 million, aspirin can be given.
  • Children should receive maintenance antibiotic treatment until age 18 years.
  • Discuss medical alert bracelet.
  • Ensure vaccinations given or planned to be given against Haemophilus influenzae, meningococcus, and pneumococcus.
  • Prescription for antibiotics (usually penicillin or erythromycin if allergic) to take as soon as any sign of illness appears or for prophylaxis before dental work or surgical procedures of any kind.
  • Malaria precaution if traveling.
  • Pain control.
  • Progressive increase in activity.
COMPLICATIONS
  • Bleeding: Higher risk in those with myeloproliferative disorders
  • Postsplenectomy thrombocytosis: Higher risk in those with myeloproliferative disorders
  • Left lower lobe atelectasis, pneumonia, and pleural effusion
  • Wound infection
  • Incisional hernia
  • Subphrenic abscess
  • Pancreatic fistula/pseudocyst
  • Gastric fistula/perforation
  • Overwhelming postsplenectomy infection: Risk is greater in children and patients with hematologic malignancies
RESULT ANALYSIS
  • Splenectomy for ITP is associated with a complete response in 66% and complete or partial response in 88% of adult patients.
  • Randomized studies in patients with chronic myelogenous leukemia have demonstrated no survival benefit when splenectomy is performed during the early chronic phase.
  • Most grade I and II splenic injuries can be managed without surgery.
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