Chapter 18. Splenectomy

• Splenic trauma with hemorrhage.
• Splenic cysts or splenic mass.
• Splenic abscess.
• Hematologic disorders.
  • Idiopathic thrombocytopenic purpura.
  • Hemolytic anemia.
  • Hereditary spherocytosis.
  • Other hereditary or autoimmune anemias.
• Severe hypersplenism.
• Perisplenic malignancy.
• Splenic artery aneurysm.
• Splenic vein thrombosis with left-sided portal hypertension.

• Portal hypertension due to liver disease.
• Thrombocytopenia is not a contraindication of splenectomy.
  • Although preoperative transfusion is not recommended, intraoperative transfusion may be required should coagulopathic bleeding occur.

Expected Benefits

• Cessation or prevention of life-threatening hemorrhage.
• Treatment of hematologic disorders, malignancy, or symptomatic mass or hypersplenism.

Potential Risks

• Post-splenectomy sepsis.
• Bleeding.
• Infection (wound or intra-abdominal abscess).
• Pancreatitis or pancreatic leak.
• Damage to surrounding structures (stomach, diaphragm, colon, etc).
• Recurrence of primary disease (thrombocytopenia, etc).

• Self-retaining retractor (eg, Bookwalter, Thompson, Upper Hand, etc).
• Bipolar cautery, LigaSure, harmonic scalpel, or similar instrument is needed for the laparoscopic procedure and may be used for the open procedure as well.

• Patients should be vaccinated against encapsulated organisms preoperatively.
  • Pneumococcus.
  • Meningococcus.
  • Haemophilus influenzae.

• Laparoscopic splenectomy is preferentially performed in the right lateral decubitus position but may also be performed with the patient supine.
• Open splenectomy is performed in the supine position.

Laparoscopic Splenectomy

• Figure 18–1: The gastrosplenic ligament contains the short gastric vessels and must be divided to obtain access to the splenic vessels, whereas the splenophrenic and splenorenal ligaments are relatively avascular.
• Figure 18–2A, B: Laparoscopic splenectomy can be performed either in the supine (Figure 18–2A) or right lateral decubitus (Figure 18–2B) positions using similar port placement. The lateral decubitus position is preferred.
• Figure 18–3: The gastrosplenic ligament is transected using bipolar cautery or harmonic scalpel to ensure hemostasis of the short gastric vessels, thereby obtaining access to the splenic vessels.
• Figure 18–4: Next, the relatively avascular splenocolic and splenorenal ligaments are divided along with the other attachments, freeing the spleen.
• Figure 18–5: A vascular stapler is used to divide the splenic artery and vein. The artery is always divided before the vein.
• The specimen is placed into an endoscopic retrieval bag. Depending on its size, the spleen may require maceration with a ring forceps or finger before it can be removed from the body.

Open Splenectomy

• Figure 18–6: Open splenectomy may ...