Splenectomy

For trauma splenectomy see separate topic under 'trauma'

Indications

• See separate topics

Approach

• Laparoscopic preferred where possible

	Advantages	Disadvantages
Laparoscopic	Reduced hospital stay Faster overall recovery Similar oncological/haematological long-term outcomes Safe in pregnancy if required	Longer operating time Hard for large spleens Not good in trauma
Open	Strongly indicated with spleens >22cm craniocaudally, >19cm width, or estimated weight >1600g Preferred with estimated weight >500g Preferred with portal hypertension - higher bleeding risk

Pre-op planning

• Review CT
• CT is unreliable for detecting accessory splenic tissue
• Planning with haematologist if required - steroids, platelets, immunoglobulins
• Vaccinations at least 14 days before elective splenectomy, or 14 days after emergency splenectomy
  • See separate topic for vaccination 'spleen register'
• Consider pre-op embolisation… although I don't think this is actually done

Positioning

• Laparoscopic
  • Positioned 60 degree right lateral decubitus, with some reverse Trendelenburg
    • Alternative supine, with surgeon on the left or between the legs, and assistant on the right
  • From there, can use either approach below
  • Often use a linear cutting stapler for the vessels, but be wary of damage to pancreatic tail
• Open
  • Supine with both arms out
  • Surgeon on right
  • Ask for left side up on entry

Technique open

• Anterior approach (probably the best approach in elective scenarios with early control of vessels)
  • Open gastrocolic omentum below gastroepiploic arcade
  • Identify splenic artery by incising peritoneum at superior border of pancreas
  • Splenic artery mobilised with care, and ligated in continuity
  • Splenic vein identified more laterally, near the hilum
  • From there, can revert to posterior approach
• Posterior approach (may be better with very large spleens, as accessing the vessels initially can be hard)
  • Mobilise splenic flexure of the colon
    • Divide splenorenal ligament
    • Divide splenocolic ligament
  • Retract spleen cephalad and medially and divide the lateral peritoneal attachments of the spleen, leaving a cuff of peritoneum on the spleen to facilitate later retraction. Then place a large pack in LUQ.
  • Identify, control and divide the short gastrics being careful to avoid the pancreatic tail
  • Dissect out main vascular pedicle and divide it about 2cm proximal to the hilum, looking for branches that may be coming off the artery even more proximally and will then need to be separately controlled and divided
  • Finally, divide the phreno-splenic ligament and remove the spleen (may need to be morcellated)
• Search for accessory splenic tissue
  • Retract stomach to the right to examine gastrosplenic ligament
  • Examine splenocolic ligament, greater omentum, and phrenosplenic ligament
  • Examine small and large bowel mesenteries, pelvis and adnexal tissues
  • Open gastrosplenic ligament and confirm that the pancreatic tail is free of splenic tissue
  • See 'spleen anatomy' for diagram of full potential locations
• Drain if needed, especially if concern for pancreatic tail

Technique laparoscopic

• Need at least one 12mm port for stapler
• Divide splenic attachments with energy device from lateral side
• Medial dissection, inferior to superior
  • Identify tail of pancreas carefully
  • Ligate short gastrics
• Divide hilum - usually vascular stapler
• Lift spleen anteriorly to divide remaining posterior attachments
• Insert large EndoCatch and slip over the lower pole, then divide the superior attachments to allow the spleen to drop into bag
• Close

Complications

• Early
  • Bleeding
  • Pneumonia or left effusion
  • Pancreatic leak/fistula
    • Upper abdominal pain, leucocytosis
    • Percutaneous drainage +/- ERCP/sphincterotomy
  • Gastric perforation - generally requires re-operation
  • Thromboembolism
• Late
  • Post-splenectomy thrombocytosis
  • Overwhelming post-splenectomy infection
    • Seen in younger patients, especially those with thalassaemia minor, sickle cell anaemia, ITP, lymphoma, or otherwise immunosupressed
    • Most infections occur >2 years after splenectomy
    • Overall incidence around 3%
    • Typically caused by encapsulated organisms