Table 73-11 Operative Indications for Splenectomy and If Total or Partial

Splenectomy Is Indicated

Figure 73-13. Lateral mobilization permits the spleen to reach the surface of a midline wound despite the presence of intact hilar

vessels.

The operative technique for open splenectomy involves either a midline abdominal incision or a left

subcostal incision. For patients with massive splenomegaly defined as >1,500 g in adults and >1,000 g

in children, a long midline incision should be employed.158 The components of the splenectomy include

division of the avascular lateral and posterior attachments to mobilize the spleen (splenophrenic,

splenorenal, and splenocolic ligaments), ligation of the short gastric vessels separating the upper half of

the spleen from the greater curvature of the stomach, and ligation of splenic hilar vessels in a controlled

manner to avoid injury to the pancreatic tail. Although one approach particularly for small spleens that

are mobile is to initially divide the lateral attachments and place packs in the left upper quadrant to

elevate the spleen and then proceed with the vascular dissection (Fig. 73-13), this should be discouraged

particularly in patients who are thrombocytopenic or patients with massive splenomegaly. In this

situation, splenectomy should start by obtaining vascular control before manipulating the spleen, which

can lead to capsular rupture and significant blood loss.

The preferred operative approach in patients with splenomegaly159 and hypersplenism would be to

first divide the attachments of the left lateral segment of the liver and retract this to the right side of

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the abdomen exposing the greater curvature of the stomach. Then, starting at the mid portion of the

greater curvature of the stomach, the branches of the left gastroepiploic artery and vein including short

gastric vessels are ligated sequentially, completely dissociating the stomach from the superior portion of

the spleen (Fig. 73-14). Through this window into the lesser sac created by dissecting the short gastric

vessels, the splenic artery can be identified at variable locations along the superior border of the

pancreas. A loop of this tortuous artery at its most superior or cranial portion is safest as at those points

it is farthest away from the splenic vein as well as away from pancreatic parenchyma. The artery may

be simply ligated once or twice with heavy silk ties at that location and does not need to be divided. By

dividing short gastric arteries as well as ligating the main splenic artery, the vast majority if not all of

blood flow into the spleen is controlled before manipulating the spleen to mobilize it. If capsular

disruption occurs, the amount of blood loss thus is greatly minimized. Following vascular control, the

lateral and posterior attachments are divided and the spleen is elevated to near the level of the

abdominal wall musculature ventrally. The splenic hilum can then be dissected tying vessels in a

controlled manner. Upon completion of splenectomy, the use of drains in the surgical bed is not

routinely indicated unless there is concern for or confirmed pancreatic injury.

Figure 73-14. Technique for elective splenectomy. A: The inferior pole is reflected laterally by the assistant’s fingers, exposing the

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lower edge of the hilar pleritoneal envelope. B: The hilar peritoneum is opened, here shown progressing from inferior to superior.

C: Individual vessels are identified and suture is ligated.

For patients with ITP, platelets should not be given until the spleen is either removed or at least until

the arterial inflow is controlled because of clearance of transfused platelets by the spleen in this disease.

Similarly, for this disease as well as other diseases in which the spleen is the site of platelet or blood cell

destruction, it is important to identify and remove accessory spleens. The majority of the accessory

spleens occur in the splenic hilum and they can also occur in the omentum, along the superior border of

the pancreas, in the bowel mesentery, and in the pelvis in some situations. The incidence of accessory

spleens and open splenectomy ranges between 15% and 30%.

Partial splenectomy can be performed on the basis of the segmental blood supply to the spleen. The

spleen is mobilized with good visualization. The inferior segmental arteries are generally ligated and

the artery and veins are ligated as a predemarcation of blood flow to the spleen. The splenic

parenchyma is then transected and the cut to the surface can be controlled using materials that induce

coagulation or the argon beam coagulator.160,161

In the past 5 to 10 years, the standard practice for an elective splenectomy in many large centers has

become a laparoscopic approach.23,162,163 Even patients with massive splenomegaly are frequently now

being approached with a laparoscopic splenectomy with the use of a hand port.163 In one series, there

were no conversions in 49 patients with splenomegaly defined as splenic length >17 cm or spleen

weight >600 g, although in 12 patients with splenic length >22 cm, a hand-assisted approach was

used.164 Another series noted a higher incidence of conversion to an open procedure when the spleen

weighed more than 2,000 g.165

The technique of laparoscopic splenectomy can either be typically performed with patients in the

supine position with a roll under their hips to prop that portion of the abdomen up approximately 30

degrees or it can be done with the patient in the lateral decubitus approach. Typically one 12-mm port

and two or three 5-mm ports (depending upon the size of the spleen) are positioned below the costal

margin from the subxiphoid area to the anterior axillary line (and laterally off the tip of the 11th rib for

the additional port in cases of larger spleens). The omental, inferior attachments and the short gastric

vessels are divided with a harmonic scalpel device. It has been reported that careful exposure of the

splenic hilum with the direct ligation of the vessels is a much safer technique than the laparoscopic

equivalent of a trauma splenectomy in which the hilum is staples without precise vessel dissection.166

Once the vessels are ligated, the spleen is placed into a large plastic bag and brought to the port and

this allows careful morselization of the spleen without having to enlarge the incision and without

fracture and spillage elsewhere in the abdomen. The laparoscopic approach has been successfully

applied for cases of massive splenomegaly167 and partial splenectomy.168 In some cases, the use of a

handport can facilitate safe removal of the spleen, particularly when very enlarged. In one study, there

was no difference in morbidity between patients receiving conventional laparoscopic resection and

those facilitated by a hand port, although the length of hospital stay and duration of surgery were

longer in the latter group, likely attributable to the fact that those patients tended to be older, have

larger spleens, and carry a malignant diagnosis.169 More recently, the single incision/single-port

laparoscopic surgery approach has also been successfully applied for splenectomy but remains a

technically more demanding approach with less well-defined benefits over conventional laparoscopy.170

Similarly, robotic-assisted splenectomy has been reported with successful outcomes and low conversion

rates, but its benefit over conventional laparoscopy remains to be defined.171

Laparoscopic splenectomy has also been reported for removal of the wandering spleen.157 In this

indication, it is actually a much easier operation as the spleen is free and the hilum is very easily

exposed. The removal of accessory spleens can be done laparoscopically as well and reports indicate

that adding a hand port for palpation can assist in this type of procedure.172 In one study, laparoscopy

was found to be more sensitive than CT scan for identification of accessory spleens.173

A recent new technique has been added to treatment of splenic disorders that is radiofrequency

ablation.174,175 Radiofrequency ablation was developed in the mid-1990s primarily to treat liver lesions.

There are a variety of commercial products that essentially destroy tissue indiscriminately by heating to

100°C. The largest experience is with either primary or metastatic tumors in the liver but this has also

been utilized in treatment of bone metastasis, kidney lesions, lung lesions, and breast cancer. Recent

reports indicate that radiofrequency ablation probes can be used successfully as a minimally invasive

technique to treat splenic disorders such as thalassemia. There also may be a role for radiofrequency

ablation in terms of treating trauma to the spleen as a way to control severe injuries

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hemostatically.175,176

Sequelae of Splenectomy and Hyposplenism

Splenectomy can have an impact on immune function and coagulative state in patients. The impact of

splenectomy in immune function is most importantly manifested by the phenomenon of overwhelming

postsplenectomy sepsis.177,178 This was initially recognized as an important epidemiologic phenomenon

in the early 1950s and multiple studies of splenectomized patients define key features of this increased

susceptibility to infection. It is clear that the risk of postsplenectomy sepsis is inversely related to

age.179 The younger the child is the more impact and greater risk of developing overwhelming

postsplenectomy sepsis.180 This feature has clinical implications as elective splenectomies are not

performed for patients with hereditary erythrocyte syndromes until after the ages of 6 to 10 years. In

adults, there is still anywhere between a 40% to 60% increased risk of sepsis compared with patients

with normal splenic function. These postsplenectomy septic episodes typically occur within the first 2

years of splenectomy in 80% of the cases. In adults, the reason for the splenectomy also relates to the

incidence of sepsis. In trauma, the instance of sepsis in a large series was 1.4% whereas in thalassemia

the incidence was 24.8%. Patients with any associated immunodeficiency such as malignancies or

patients undergoing chemotherapy for treatment of Hodgkin disease are also at increased risk for sepsis.

The mortality rate of postsplenectomy sepsis is between 50% and 60% in most series.

8 The types of organisms that account for infection are typically encapsulated organisms. These

bacteria may have special features that allow them to be opsonized and cleared from a circulation by

the spleen making them more dangerous in hyposplenic or splenectomized patients. The most common

organism causing postsplenectomy sepsis is Streptococcus pneumoniae, which accounts for 50% of septic

episodes in most series. In decreasing order of frequency, other bacteria associated with

postsplenectomy sepsis are Hemophilus influenza, Neisseria meningitidis, β-hemolytic streptococcus,

Staphylococcus aureus, Escherichia coli, and Pseudomonas species.179 The current recommendations for

patients who are having elective splenectomy would be to vaccinate susceptible individuals to

pneumococcus strains (Table 73-12).179 This is ideally done 2 weeks before the operation if possible, but

should be done at any time preoperatively or even postoperatively if the patient was not vaccinated.

Recent studies have shown that administration of vaccine with the first postoperative visit does not lead

to beneficial immune stimulation. Waiting for 14 days postoperatively is equivalent to waiting 1 month

or longer.181 Therefore, vaccination starting at 2 weeks after an unplanned splenectomy is ideal timing.

There are choices of polyvalent vaccines including pneumovax 23 and Pnu-Immune 23, both of which

provide protection against virtually all common strains of pneumococcus.181 For patients who are at

particularly high risk because they may be immunosuppressed, there are also polyvalent vaccines

against Neisseria meningitides and Haemophilus influenzae type B. Patients younger than 2 years and

patients receiving chemotherapy for malignant disease may not be able to generate an immune response

to vaccines and should be vaccinated either after the age of 2 years or when not receiving

chemotherapy, respectively. Finally, because of the risk of very rapid progression of sepsis in a

postsplenectomy state, patients who have had splenectomy for any reason should be given a Medic-Alert

bracelet.

Table 73-12 Guidelines for Prevention of Postsplenic Sepsis

Two recent studies highlight the incidence of increased relative risk and the number of infections

after splenectomy. The relative risk for infection within 90 days of a splenectomy was 10.2% compared

with 0.6% in the general population. In patients undergoing appendectomy for acute appendicitis a

control group undergoing an abdominal procedure, there was still increased risk of infection in

splenectomy of 10.2% compared with patients who had appendectomy of 4.2%.182 The relative risk of

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