The most common indications for splenectomy are irreparable traumatic rupture and hematologic disorders. In splenic injury, nonoperative protocols result in a significant improvement in splenic salvage in both children and adults. However, in severe splenic injury, particularly in severe multisystem trauma, splenectomy is indicated. In some cases, splenic salvage is warranted. The most common hematologic disorders requiring splenectomy include immune (idiopathic) thrombocytopenic purpura, thrombotic thrombocytopenic purpura, and hereditary spherocytosis. Prior to splenectomy, clinical evaluation should be performed by an experienced hematologist and a bone marrow biopsy may be necessary to exclude unexpected bone marrow disorders not improved by splenectomy. Whereas in the past emergency splenectomy may have been occasionally needed in severe thrombocytopenia associated with hemorrhagic complications, today this is almost never needed, as nearly all patients will have improvement in platelet counts in response to steroids, intravenous immune globulin or Rho D immune globulin (winrho). Splenectomy may be indicated in cysts and tumors. Symptomatic benefit may follow splenectomy in certain other conditions, such as secondary hypersplenism, Felty's syndrome, Banti's syndrome, Boeck's sarcoid, or Gaucher's disease. In these latter patients, the surgeon should work in consultation with an experienced hematologist and medical specialists. In the past either total or partial splenectomy was indicated as part of the procedure of “staging” to determine the extent of Hodgkin's disease. Historically stage I and II Hodgkin's disease, traditionally, those patients who are considered candidates for primary radiation therapy, would undergo staging laparotomy (pathologic staging) to rule out definitively the presence of occult subdiaphragmatic disease. An appreciation of the risks of laparotomy and a recognition of the effectiveness of salvage chemotherapy in patients who fail primary radiation therapy have permitted the increased use of clinical staging as the basis for treatment of these patients.
Laparoscopic splenectomy is clearly the procedure of choice when technically feasible for elective splenectomy. It should be considered in all elective splenectomy cases. Relative contraindications may be considered in certain cases of previous surgery or a large spleen. Coagulopathy is not a contraindication and may actually do better with the laparoscopic approach.
It is necessary to consider the nature of the disease for which splenectomy is indicated in order to give the proper preoperative treatment. In congenital hemolytic icterus, preoperative transfusion is contraindicated, even in the presence of the most severe anemia, because of the likelihood of precipitating a hemolytic crisis. In cases of thrombocytopenic purpura, platelet transfusions may be given the morning of operation if indicated. The patient with primary splenic neutropenia, panhematopenia, or other types of hypersplenism is transfused as indicated by his general condition and the information gained from the clinical studies. Antibiotic therapy is given in the presence of neutropenia. Large amounts of blood should be available in cases of suspected traumatic rupture of the spleen, and the patient should be operated on as soon as his condition permits. Prompt splenectomy may be a lifesaving procedure in some patients with a blood dyscrasia, especially those with primary thrombocytopenic purpura. Previous steroid therapy should be continued preoperatively and during the early postoperative period.
General anesthesia is usually satisfactory and may be supplemented with muscle relaxants. Patients who have severe anemia should receive little premedication, and ample oxygen should be administered with the anesthetic. In the presence of a low platelet count, great care is taken to avoid trauma to the mouth and upper respiratory passages, since hemorrhage may occur.
The patient is placed in a supine position. The spleen is made more accessible by tilting the table to lower the feet.
The skin is prepared in the routine manner. Gastric intubation is avoided in portal hypertension or in the presence of a low platelet count, i.e., thrombocytopenic purpura, in order to avoid initiating hemorrhage. However, in other indications it can be used to ensure a collapsed stomach and an improved exposure.
Two types of incision are commonly used: a liberal incision midline from the xiphoid down to the level of the umbilicus (Figure 1, A), or a left oblique subcostal incision (Figure 1, B). The vertical incision is usually employed. In the presence of proven gallstones, the incision is placed in the midline to facilitate removal of the diseased gallbladder, if the splenectomy has progressed satisfactorily and was uneventful.
If a bleeding tendency exists in the presence of blood dyscrasias, it is necessary to exercise rigid control of all bleeding points. In the very ill and anemic patient the general oozing may be controlled by pressure with warm, moist gauze pads, so that the abdomen may be opened and the splenic artery ligated as soon as possible. This will often effect a marked decrease in the bleeding tendency as soon as the artery is clamped. In the absence of acute intra-abdominal hemorrhage or an acute hemolytic blood crisis, the abdomen is explored. The gallbladder should be carefully palpated if the splenectomy has been indicated for hemolytic jaundice, since gallstones frequently occur in such patients. The pelvic organs in the female are palpated carefully for evidence of other pathology that might be responsible for excessive blood loss from the reproductive system. Enlarged lymph nodes should be biopsied and any accessory spleens removed.
The colon is packed downward out of the field of operation by warm, moist gauze, and the first assistant maintains downward traction with a large S retractor. A Babcock forceps is applied to the stomach, and a retractor is placed under the rib margin on the left to facilitate the exposure of the spleen.
The exact procedure depends upon many factors: the size and mobility of the spleen, the presence of extensive adhesions between the spleen and the parietal peritoneum, the length of the splenic pedicle, the presence of active bleeding from a ruptured spleen, or the patient's poor general condition as a result of blood dyscrasia. The approach to the immobilization and control of the blood supply of the spleen must be individualized in each case. A thorough understanding of the attachments and blood supply of the spleen is essential (Figure 2).
When splenectomy is indicated for blood dyscrasias, a careful search should be made for an accessory spleen both before and after the spleen is removed and hemostasis is effected (Figure 2). A routine search is made in the following order: the hilar region, A; the splenorenal ligament, B; the greater omentum, C; the retroperitoneal region surrounding the tail of the pancreas, D; the splenocolic ligament, E; and the mesentery of the large and small intestines, F (Figure 2). If accessory spleens are found in two or more locations, one is usually in the hilus. In some cases of blood dyscrasias the clinical course of the patient may suggest recurrence of the disease because of a retained accessory spleen. In such instances not only should the sites mentioned above be searched but the search should also be extended to the adnexa in the pelvis. The spleen must not be lacerated, nor should remnants be left within the abdomen because of the danger of seeding, which may result in splenosis.
The diagram in Figure 2 illustrates the anatomic relationships of the spleen. As traction is exerted on the stomach medially, an avascular area in the gastrosplenic ligament may be incised, giving direct entrance to the lesser sac. Several blood vessels in the gastrosplenic ligament are divided and ligated to provide adequate exposure of the splenic artery. Along the upper margin of the pancreas, the tortuous course of the splenic artery can be palpated. The peritoneum over the vessel is incised carefully, and a long right-angle clamp is introduced beneath the artery to isolate it and to facilitate its ligation. The splenic vein is immediately beneath the artery. One or more 00 silk sutures are drawn beneath the artery and carefully tied (Figure 3). Preliminary ligation of the splenic artery has many advantages. It allows blood to drain from the spleen, providing an autotransfusion. The spleen tends to shrink, making its removal easier and with less blood loss. Finally, blood transfusions can be given immediately to the patient with hemolytic anemia. This preliminary step does not prolong the procedure and tends to ensure a safer splenectomy with minimal blood loss.
After the splenic artery has been secured, the remainder of the gastrosplenic ligament is divided between small curved clamps (Figure 4). Great care is exercised, especially toward the upper margin of the spleen, to avoid injuring the gastric wall during the application of clamps, for in this area the gastrosplenic ligament is sometimes extremely short. This is especially true when the spleen is very large or in the presence of portal hypertension. Failure to secure the uppermost vein in the gastrosplenic ligament can result in serious blood loss. Because of the danger of postoperative bleeding following gastric dilatation, the vessels along the greater curvature should be ligated with a transfixing suture that includes a bite of the gastric wall. In addition, in this area several vessels commonly extend from the hilus of the spleen over to the posterior wall near the greater curvature high on the fundus. At the inferior margin of the spleen, fairly sizable vessels, the left gastroepiploic artery and vein, commonly will be encountered in the gastrosplenic ligament (Figure 4). The contents of the clamps are ligated on both the gastric and splenic sides, since the division of the gastrosplenic ligament will leave a large opening directly into the lesser sac.
The preliminary ligation of the major splenic artery makes mobilization of the spleen easier and safer. The surgeon passes the left hand over the spleen in an effort to deliver it into the wound (Figure 5). Dense adhesions may be present between the spleen and the peritoneum of the abdominal wall or the left diaphragm; however, the spleen can usually be mobilized after a few avascular adhesions and the gastrosplenic ligament have been divided.
As the spleen is mobilized, the surgeon passes the fingers over its margin to expose the splenorenal ligament, which should be incised carefully (Figure 6). The peritoneal reflection in this area is usually rather avascular; however, it is necessary to ligate many bleeding points in the presence of portal hypertension. Usually, the index finger can be inserted into the peritoneal opening, and by blunt dissection with the index finger of the left hand, which extends over the surface of the spleen, the margin of the spleen can be freed easily (Figure 7). This must be done gently since the capsule may be torn, resulting in troublesome bleeding or seeding of splenic tissue.
After the posterior margin of the spleen has been mobilized, the spleen may be brought well outside the abdomen; however, if dense adhesions between the spleen and the parietal peritoneum are encountered, it is easier to incise the overlying peritoneum and carry out a subperitoneal resection, which leaves a large, raw space. This may be safer than attempting to free the spleen with sharp dissection. Warm, moist packs may be introduced into the splenic bed to control oozing. Active bleeding points should be controlled with electrocautery.