The most common indications for splenectomy are irreparable traumatic rupture and hematologic disorders. In splenic injury, nonoperative protocols have resulted in significant improvements 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. Although in the past emergency splenectomy may have been needed occasionally in severe thrombocytopenia associated with hemorrhagic complications, today this is almost never the case because nearly all patients will have improvement in platelet counts in response to steroids, intravenous immune globulin, or Rho D immune globulin.
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 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, patients with stage I and II Hodgkin’s disease who were considered candidates for primary radiation therapy would undergo staging laparotomy (pathologic staging) to rule out the presence of occult subdiaphragmatic disease. Staging laparotomy is no longer routinely performed because of the morbidity of laparotomy and a recognition of the effectiveness of salvage chemotherapy in patients who fail primary radiation therapy, which have permitted the increased use of clinical staging as the basis for treatment of these patients.
Minimally invasive splenectomy is clearly the procedure of choice when technically feasible for elective splenectomy. It should be considered in all elective splenectomy patients. Relative contraindications may be considered in certain cases of previous surgery or a large spleen. Coagulopathy is not a contraindication, and patients actually may do better with the minimally invasive approach.
It is necessary to consider the nature of the disease for which splenectomy is indicated in order to plan 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. Patients with primary splenic neutropenia, pancytopenia, or other types of hypersplenism are transfused as indicated based on their general condition and the information gained from 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 patients should be operated on ...