Splenectomy

During the development of a fetus (unborn infant still in the uterus), the spleen
is one of the sites of formation of blood cells. This function is taken over by the
bone marrow by the fifth month of pregnancy. The spleen, however, still has the
ability to produce blood cells in the adult under certain conditions.
Anatomy and Physiology
The spleen lies in the left upper part of the abdomen. It is about 6 by
inches (!" by #." cm.) in si$e and weighs to 6 o$. (%& to !'& gm)
((igure !)
The spleen lies beneath the left lower ribs and is attached by ligaments
to the left kidney, colon, stomach and undersurface of the diaphragm. It
may be in)ured by trauma that fractures the overlying ribs
The spleen acts as a filter that removes old, abnormal or damaged
blood cells and bacteria from the blood. It also has a role in immunity
by creating antibodies to help battle infection
The spleen is a source of antibodies and is important in the immune
system of the body for fighting disease
(igure ! * The spleen lies )ust to the left of the stomach
and )ust below the diaphragm. +lood to the spleen goes
through the splenic and short gastric arteries and
drained by the splendid vein (not shown).
Pathology and Indications for Surgery
,lthough not completely essential for life, removal of the spleen has been
associated with increased risk of life threatening infections. Thus there is a
trend towards preserving either whole or part of the spleen, particularly
following trauma. The commonest indications for removal of a spleen are
traumatic in)ury, idiopathic thrombocytopenic purpura and -ypersplenism.
Trauma. The spleen is the commonest organ in)ured in blunt trauma to
the abdomen. In)ury to the spleen is also possible during an operation
in the upper abdomen, (e.g. during stomach, kidney or esophagus
surgery). ,s mentioned before, an attempt to save the spleen is usually
made. The spleen is completely removed only in cases where the
spleen is shattered or there is an in)ury to the main blood vessels of the
spleen
,utoimmune Disorders. In these diseases, the spleen produces
abnormal antibodies that attack and destroy normal blood cells in the
body. This may result in anemia, )aundice or abnormal bleeding.
/urgery is once again indicated in case medical therapy, usually
steroids, is not able to control symptoms.
o Immune (Idiopathic) Thrombocytopenic 0urpura (IT0).
,ntiplatelet antibodies that cause the destruction of platelets
cause this disease
!. The acute form of IT0 occurs primarily in children after
a viral infection
1. The chronic form occurs primarily in adults
. 0atients present with bleeding from various places
such as easy skin bruising, bleeding from the gums,
bloody nose, heaving menstrual bleeding, and
occasionally bowel and urinary bleeding
2. There are markedly decreased platelets on
e3amination of the blood usually along with a normal
bone marrow e3amination. ,ntibodies to platelets can
usually be detected
". Treatment is usually not necessary if the platelet count
is over "&,&&& per milliliter and there are no or minimal
symptoms
0latelet transfusion may be necessary when
bleeding needs to be stopped immediately
4ortisone is given after the diagnosis is made
for about two weeks. The steroids are reduced
slowly when the white blood cell count
e3ceeds "&,&&&
/plenectomy is the main treatment for IT0
when the response to cortisone is not good
o ,utoimmune -emolytic ,nemia. 5ed blood cells coated with
antibodies are caught in the spleen
!. 6ay be seen associated with leukemia, lymphoma or
collagen vascular disease though most cases do not
have a specific cause
1. 0rimary treatment is cortisone
. If steroids fail then splenectomy may be necessary
+lood 4ell Disorders. In these disorders, there is e3cessive destruction
of blood cells by the spleen due to either an inherited abnormal
structure of the blood cells, abnormal molecules within the blood cells
or abnormal damage to blood cells. /plenectomy may be indicated if
there is failure of medical management or if the disease is severe,
re7uiring fre7uent transfusions
o -ereditary /pherocytosis or -ereditary 8lliptocytosis. These
are two diseases in which there is a hereditary abnormality of
the shape of the red blood cells. The abnormal cells get caught
in the circulation of the spleen resulting in destruction of the
cells and anemia (low number of red cells in the blood
!. The patient may have )aundice (yellow coloration of the
skin), gallstones and an enlarged spleen
1. 9aboratory tests shows an increase of bilirubin in the
blood (a breakdown product of red cells that results in
yellowish discoloration), round or oval red blood cells
and a low blood hemoglobin (the iron containing
protein in red blood cells that give the cells their red
color)
. 5emoval of the spleen prevents the breakdown of bed
blood cells and corrects the anemia. In -ereditary
/pherocytosis, splenectomy is indicated in almost all
patients and cholecystectomy is performed if
gallstones are present. In -ereditary 8lliptocytosis,
most patients are without symptomatic anemia, but
when there are symptoms splenectomy corrects the
anemia
o Thalassemia. This is a hereditary anemia caused by a defect in
the formation of hemoglobin
!. This results in severe anemia, enlargement of the liver
and spleen and gallstones
1. Initial treatment fre7uently includes the intravenous
in)ection of an iron chelating agent, a chemical that
binds free iron in the blood so that the body can get rid
of the iron
. In severe cases, removal of the spleen removes the
primary site causing red cell breakdown, thus reducing
the number of blood transfusions needed to correct the
anemia and also gets rid of the discomfort caused by a
very large spleen
o Thrombotic Thrombocytopenic 0urpura (TT0). TT0 is fairly rare
and caused by damage to the cells lining blood vessels
(thrombotic, blood clot forming: thrombocytopenic, decrease
platelets: purpura, purple patches in the skin due to little
hemorrhages)
!. This results in widespread small clots developing in the
smaller blood vessels. ,s a result there is a decrease
in platelets (small blood cells that are involved In blood
clotting), hemolytic (red blood cell breakdown) anemia,
fever and kidney and nervous system damage
1. TT0 is a medical emergency that has to be rapidly
treated
. Treatment is primarily replacing the blood plasma
(blood without the red cells) using fresh fro$en plasma
from the blood bank over appro3imately a !*1 week
period. 4ortisone and aspirin are usually added to the
treatment
2. /plenectomy has been used when the response to
plasma e3change has been inade7uate
6yeloproliferative Disorders. These comprise a variety of conditions
where the spleen, and liver produce blood cells )ust like the bone
marrow, a function that stopped as a fetus. These blood cells may be
abnormal and may cause pain due an enlarged liver or spleen,
abnormal bleeding or blood clotting and )aundice. The spleen is
removed to help relieve symptoms
Tumors. The spleen may be involved in lymphoma or leukemias. ;hile
the spleen used to be removed in the past for diagnosis or to determine
e3tent of the cancer, it is now treated with chemotherapy (drugs) or
radiotherapy (<*ray). It is removed only if the patient develops
hypersplenism. =ther tumors of the spleen, although rare, may need
splenectomy as treatment
-ypersplenism associated with other conditions. -ypersplenism is a
condition where the spleen undergoes a marked increase in normal
spleen function
o This may cause a painful increase in si$e of the spleen
o There may be an abnormal destruction of blood cells
o -ypersplenism may be a complication of several other
diseases that may re7uire splenectomy.
!. 0ortal hypertension in which there is obstruction of the
veins of the liver and spleen usually associated with
alcoholic disease of the liver or pancreas that may
cause painful enlargement of the spleen or bleeding
into the stomach. The diagnosis is usually made by
ultrasound, and treatment is usually splenectomy
1. 9eukemia
. Inflammation conditions of the spleen such as
(elty>s syndrome (associated with rheumatoid arthritis)
?aucher>s disease (associated with abnormal
metabolism of sugar)
6iscellaneous conditions.
o /plenic artery aneurysm and splenic cysts * some patients may
be born with an abnormal dilation of the splenic artery or they
may have abnormal fluid collections within the spleen.
/plenectomy may be indicated if the aneurysm ruptures
(usually in pregnancy) or if the cysts are large or cause
symptoms
o /plenic abscesses * The spleen may be a site of a pus filled
collection due to an infection in the spleen or from infected
debris elsewhere in the body (usually the heart or kidneys).
The spleen may need to be removed to get rid of the infection
Diagnosis
0atients may present with a variety of symptoms depending on the
disease that is present.
The spleen can usually not be felt on e3amination even when enlarged
The enlarged spleen may cause pain in the left upper abdomen
83cessive destruction of blood cells may leave one anemic with
e3cessive tiredness or weakness or may cause )aundice
There may be abnormal bleeding with spontaneous patchy bruises
over the body called purpura or petechiae, or e3cessive bleeding from
a minor in)ury
0atients may have an increased incidence of infections particularly of
the skin or lungs
+lood clots may develop in the vessels of the arms and legs
+lood tests may confirm the destruction of red blood cells (anemia),
platelets (abnormal bleeding) or white blood cells (increased infection) @
9aboratory tests may also detect abnormal antibodies in autoimmune
disorders like IT0
,bnormal looking cells may be seen in some of the blood cell disorders
like thalassemia and spherocytosis
Altrasound may show the si$e of the spleen and evidence of blood
around the spleen after in)ury
Diagnostic 0eritoneal 9avage in which a small incision in the abdomen.
/terile saline is in)ected into the peritoneum (the sac that contains the
stomach and bowel) and then drained. If the drained saline contains
blood, this is proof of bleeding inside the abdomen
4omputeri$ed Tomography /can. The spleen is easily seen on 4T
scan and can demonstrate spleen si$e, in)ury to the spleen, tumors,
cysts or pus cavities within the spleen ((igure 1, and 1+)
,rteriography. , catheter is inserted into the splenic artery and an 3*ray
is taken after a dye is in)ected. This may demonstrate an obstruction to
blood flow to the spleen or a splenic artery aneurysm
(igure 1, * 4T scans of the
abdomen of two patients with
splenomegaly (enlarged spleen). ,.
0atient showing moderate
enlargement of the spleen.
(igure 1+ * 0atient with a huge
spleen. 4ourtesy /. /adi7, 6D

Surgical Procedures
0reoperative preparation
o +lood should be available for transfusion during surgery as the
spleen has an e3tensive blood supply and may bleed
considerably during the procedure
o 0latelets may be needed either before or during the operation
in cases of IT0. 0latelets are usually transfused after the
splenic artery is clamped to prevent the platelets from being
removed by the spleen
o /teroids such as cortisone may be necessary
o 0olyvalent pneumoccocal vaccine should be given 1* weeks
before surgery to all patients over 1 years of age due to the
increased incidence of infections after the procedure, In cases
of emergency splenectomy for trauma, vaccination should be
given as soon as possible
o In cases in which there is a very large spleen sometimes a
catheter is placed into the splenic artery before surgery and
material in)ected to block the artery. This can shrink the spleen
and significantly reduce bleeding at the time of surgery
?eneral anesthesia is usually used
=pen splenectomy
o ,n incision is made either below the lowest rib on the left side
or an up and down incision is made in the middle of the upper
abdomen
o In non*emergency cases the splenic artery, which runs along
the upper border of the pancreas, is sometimes located and
tied off first. This loss of blood flow to the spleen makes it
shrink and bleed less making the operation easier in patients
with large spleens or hypersplenism ((igure ,)
o The ligaments that attach the spleen to surrounding structures
are divided bringing the spleen forward and towards the
midline. 4are must be taken in dividing the ligaments between
the stomach and the spleen since several small blood vessels
may run through these ligaments
o The main artery and vein are then are tied off and divided.
4are must be taken at this point also to avoid in)ury to the
pancreas, as the tail of the pancreas is close by ((igure +)
o In cases of abnormal splenic function, the surgeon also takes
care to look for accessory or e3tra spleens, which may be
found in up to 1&B of the population These must be removed
or the disease process may recur f. +efore closing the wound
with sutures, drains may be placed in this area of the removed
spleen, especially in cases of surgery near the tail of the
pancreas
o , tube is placed into the stomach through the nose to keep the
stomach drained for a few days
(igure , * /plenectomy * (irst the
splenic artery is clamped and tied off
with suture. +lood within the spleen
drains into the splenic vein thus
reducing its si$e.
(igure + * The short gastric arteries
are then tied off followed by the splenic
vein. The spleen is then removed. C D.
?ordon
9aparoscopic /plenectomy
o , laparoscope is a tube that contains fiber optics with a lens at
one end and a television camera at the other
o This surgery may take an hour or two longer than the regular
method, but patients have shown to have a shorter hospital
stay after the operation
o The indications for this operation are the same as the open
method: however, it should not be used with an e3tremely large
spleen or if there is bleeding from the spleen
o 9aparoscopic splenectomy is usually done under general
anesthesia
o The patient is placed on the right side with hisEher left side up,
or flat on the operating table with the legs spread apart
o (our to five small incisions (appro3 ! cm. in si$e) are made on
the abdomen for the introduction of the laparoscope and
several long, thin instruments
o /imilar to the regular techni7ue, the ligaments holding the
spleen in place are divided, and then the main blood vessels
are stapled across and divided. The spleen is usually placed in
a bag and then broken into fragments while in the bag to allow
it to be removed through one of the small incisions
Complications
4omplication related to anesthesia
5espiratory complications
o ,telectasis * The operation may cause pain on deep breathing
so that a patients may fail to take ade7uate deep breaths
causing collapse of small segments of the lungs, called
atelectasis
o This may give rise to fever and can progress to pneumonia
In)ury to surrounding structures * The spleen lies ad)acent to several
organs that may be in)ured in the course of the surgery such as the
pancreas, stomach, colon and diaphragm
Infection
o /ubphrenic abscess * Infection in the bed of the removed
spleen may lead to a pus filled cavity under the diaphragm.
This abscess cavity may be diagnosed and sometimes drained
via a 4T scan. In some cases drainage may re7uire re*
operation
o =verwhelming 0ost/plenectomy /epsis (=0//)
!. This is probably the most feared complication after a
splenectomy. The increased risk of infection after a
splenectomy gives rise to this syndrome where the
patient may have over a "&B chance of dying
1. , patient, who may have been previously healthy,
usually suffers a respiratory infection that may
progress within hours to shock, coma and death
. /pecific bacteria usually cause the infections, and
therefore, it is usually mandatory to give patients
vaccinations to these bacteria before the operation. In
emergency situations like trauma, the vaccinations
should be given as soon as possible after the operation
o 0eritonitis (infectious or non*infectious inflammation of the
lining of the abdomen)
o ;ound infection
+leeding
Thrombocytosis * a marked increase in platelets leading to increased
clotting in blood vessels
0ancreatitis as a result of in)ury to the pancreas. This may lead to a
fistula (tract) from the pancreas through the skin
In)ury to the stomach that may lead to a hole in the stomach wall
Deep vein thrombosis (clots in the veins if the pelvis of legs) that may
lead to pulmonary embolus (clot going to the lung)
Death
Post-operative care
Depending on the severity of the surgery, the patient may be sent to a
regular surgical room or may be sent to the surgical intensive care unit
to be more closely monitored
The nasogastric tube is left in place and connected to suction to keep
the stomach empty. The tube is removed when stomach and bowel
function returns to normal, usually in 1 * days
(luids are given by vein (intravenously, I.F.)
,ntibiotics are usually given I.F.
=3ygen may be given by nasal catheter
Deep breathing and coughing are stressed
0atients are gotten up to sit and walk as they are able
?radually the diet is increased from li7uids to soft food and then more
solid foods
The wound is kept clean to prevent infection
The patient usually returns to the surgeon>s office in one to two weeks
after discharge
+lood tests, 4T scans and other diagnostic tests may be necessary to
follow any problems
0atients are usually discharged on the *2 day postoperatively.
0atients are usually given instructions to take an antibiotic before minor
surgeries, or as soon as they notice a mild fever. ,lthough not proven
to be necessary, their vaccination may need to be repeated every !&
years
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