SURGERY | CASE SERIES

OPEN PARTIAL SPLENECTOMY OPERATIVE

TECHNIQUES AND FOLLOW-UP – A CASE SERIES
FROM A TERTIARY CARE CENTRE IN SOUTH INDIA
Rajeevan Philip Sridhar∗ , Titus D K∗ , Gilbert Samuel Jebakumar∗ , Beulah Roopavathana∗ and Suchita Chase∗
∗ Department of General Surgery Unit 4 Office, 2nd floor, Paul brand building, CMC Hospital, Vellore, India - 632004.

ABSTRACT Introduction: Spleen-preserving surgical techniques have become increasingly common to avoid the fatal
peri-operative and long-term complications following total splenectomy including OPSI. Immune functions of the spleen
are better preserved after partial splenectomy. In this case series, we describe the operative techniques and follow-up
of four patients who underwent open partial splenectomy for benign aetiology. Case Series: Four patients underwent
partial splenectomy for benign aetiology. Left subcostal or Midline laparotomy incision was chosen. After temporary
clamping of splenic vessels, LigaSure™ was used for sectioning splenic parenchyma and Surgicel®Fibrillar™ or pledged
sutures were used to achieve haemostasis. Omentoplasty was done additionally and remnant spleen was anchored
to abdomen wall to prevent torsion. All patients are on follow-up and have not developed OPSI. Conclusion: Partial
splenectomy is a safer and feasible surgical alternative for total splenectomy when indicated for benign aetiology and
appears to be protective against OPSI. A good understanding of vascular anatomy and operative techniques for partial
splenectomy is an essential part of any general surgeon’s armamentarium.
KEYWORDS Partial splenectomy, Overwhelming post-splenectomy infection, Spleen preserving surgery, Splenic cyst

of OPSI after TS is around 4%, and the overall mortality is 2%.

Introduction
Splenectomy is a common general surgical procedure performed
for various haematological and non-haematological indications,
including infection, cysts, benign or malignant tumours, and
trauma. The surgical approach can range from conventional
open technique to laparoscopic or robotic approach based on in-
dication and expertise available at hand. Total splenectomy(TS)
is associated with several peri and post-operative complica-
tions. Asplenic individuals are at high risk of developing fatal
infections with encapsulated organisms. Overwhelming post-
splenectomy infections (OPSI) remains a threat despite vacci-
nation and antimicrobial prophylaxis. The reported prevalence
Copyright © 2021 by the Bulgarian Association of Young Surgeons
DOI:10.5455/IJMRCR.Open-partial-splenectomy-operative-techniques
First Received: March 27, 2020
Accepted: April 27, 2021
Associate Editor: Ivan Inkov (BG);
1
Department of General Surgery Unit 4 Office, 2nd floor, Paul brand building, CMC
Hospital, Vellore, India - 632004; titusdk@gmail.com
[1] To avoid this dreaded complication, spleen-preserving sur-
gical techniques have become increasingly common. Partial
Splenectomy (PS) was formally first described by Morgensten
and Shapiro in 1980, and Poulin performed the first laparoscopic
PS in 1995. [2,3] The splenic reticuloendothelial function is re-
ported to be better preserved after PS. [4] There were several
case reports and series on PS. A systematic review on the same
concluded that PS is a safe procedure with comparable morbid-
ity and mortality.[5] In this case series, we describe the operative
techniques and follow-up of four patients who underwent open
PS for benign aetiology.
Case series
Our general surgery unit is one of the four general surgical
units in a tertiary care centre in South India. Around 25 elective
splenectomy operations are performed in our general surgery
unit in a year, out of which 30% are performed laparoscopically.
In the study period between January 2017 and February 2021,
seven open PS operations were attempted, out of which two
were converted to total splenectomy due to difficult vascular

Rajeevan Philip Sridhar et al./ International Journal of Medical Reviews and Case Reports (2021) 5(7):58-62
Table 1 Patient Characteristics.
Patient 1 Patient 2 Patient 3 Patient 4
Sex Male Female Female Female
Age[Years] 25 38 19 19
Benign epithelial Benign mesothelial Benign epithelial
Etiology Splenic hamartoma
cyst cyst cyst
Tumour/Lesion
14 6 15 5
size[cm]
Superior pole and
Tumour location Superior pole Posterior Midportion
interpole
Operative
150 120 165 120
time[min]
Blood loss[ml] 450 450 350 200
One unit in
Blood transfusion Nil post-operative Nil Nil
period
Post-operative
10 days 4 days 5 days 8 days
hospital stay
Intraoperative Rent in diaphragm –
complications sutured primarily Nil Nil Nil
Left pleural
Post-operative effusion – USG Urinary tract
complications guided drain Nil Nil
infection
placed
Pneumococcal 1 day prior to 1 day prior to 2 weeks prior to 2 weeks prior to
Vaccination time operation operation operation operation
Readmission No No No No
Mortality No No No No
Follow up 2 years 2 years 9 months 3 months

Figure 2: Patient 2 at two-year follow-up with ultrasound imag-

ing showing adequate splenic remnant.

Figure 1: CECT of Abdomen (Patient 1) showed a large cyst in

the superior pole and an inferior branch supplying the rest of
the normal spleen.

Rajeevan Philip Sridhar et al./ International Journal of Medical Reviews and Case Reports (2021) 5(7):58-62

Figure 3: Residual spleen size in patient 4 was about 25% of
its original size, which was wrapped in Surgicel® and was an-
chored to the lateral abdomen wall to prevent torsion.
anatomy. One patient had only marsupialization of the splenic
cyst done. PS was successfully performed in four patients. Gen-
eral patient characteristics are as described in Table 1.
The first patient had a 14x11x12 cm cystic lesion in the supe-
rior pole of the spleen. Contrast-enhanced Computed Tomogra-
phy (CECT) of the abdomen showed a large cyst and an inferior
branch supplying the rest of the normal spleen [Figure 1]. He
had a left subcostal incision. Splenic parenchyma sectioning was
performed with LigaSure™, and pledged sutures with Surgi-
cel®Fibrillar™ were used to achieve haemostasis. More than
25% of the spleen was left behind, which was supplied by the
inferior branch of the splenic artery. Omentum was draped over
the remnant spleen. Intraoperatively, the patient had an inadver-
tent tear in the diaphragm, which was repaired primarily. He
had a 1.6 gm haemoglobin drop following the operation. Post-
operatively, he developed infected left pleural effusion managed
with antibiotics and image-guided drainage. He had completed
follow-up at 2 years with repeat ultrasound showed adequate
residual spleen.
The second patient presented with a 4 x 6 x 5 cm sized cyst
in the posterior aspect of the superior pole of the spleen. She
had a left subcostal incision. LigaSure™ was used for section-
ing splenic parenchyma, and Surgicel®Fibrillar™ was used as a
haemostatic agent. Additionally, the omentum was placed over
the splenic remnant. Her post-operative period was uneventful,
and she had a 1.6 gm drop in haemoglobin following the opera-
tion. She was transfused one pint of blood in the post-operative
period. She was followed up at 2 years with ultrasound imaging
showing adequate splenic remnant [Figure 2]. The third patient
presented with a 14.6 x 11.5 x 13.1 cm cystic lesion in the upper
and interpole region. She had a midline laparotomy incision.
After mobilisation of the spleen and dissection of vessels, infe-
rior pole vessels were preserved. Sectioning of the spleen was
performed with LigaSure™. Haemostasis was achieved with
electrocautery, and Surgicel® was applied to the raw cut surface,
and omentum was placed over it. Her post-operative period
was uneventful, and she had only a 0.1 gm drop in haemoglobin
following the operation.
Our fourth patient had a 5 x 5 x 5 cm splenic hamartoma
in the mid-portion of the spleen. A left subcostal incision was
used. Splenic vessels were temporarily clamped to reduce blood
loss. A single branch of the artery and a concomitant vein sup-
plying the superior pole were preserved. LigaSure™ was used
for sectioning the spleen. Residual spleen size was about 25%
of its original size wrapped in Surgicel® and was anchored to
Rajeevan Philip Sridhar et al./ International Journal of Medical Reviews and Case Reports (2021) 5(7):58-62
the lateral abdomen wall to prevent torsion, as shown in Fig-
ure 3. She had a haemoglobin drop of 1 gm% following PS.
Post-operatively, she had a urinary tract infection treated with
a culture-sensitive antibiotic. She was well at her follow-up at
three months.
Discussion
Splenectomy refers to the surgical removal of the spleen per-
formed for various indications in elective and emergency setup.
It can be performed as a life-saving procedure in a trauma pa-
tient, can be a therapeutic procedure in certain haematological
conditions and tumours of the spleen, can be performed for
benign etiologies, including infections/cysts spleen, as well as
performed for diagnostic purposes. [5] It is a known fact that
patients with asplenia are at high risk of developing severe
life-threatening infections caused by encapsulated bacteria. [1]
Splenectomy increases the risk of OPSI throughout the lifespan
of the individual. However, the highest risk is reported to be dur-
ing the first three years. [5] Post-splenectomy prevalence of OPSI
is 0.1-0.5%, with mortality rates of up to 50%. [6] Also, following
splenectomy operation, there exists an increase in intravascular
haemolysis and subsequent vascular derangement leading to
increased long-term risks of hypertension, vascular thrombosis,
pulmonary hypertension, and cardiovascular disease. [7,8] Due
to the above reasons, it becomes imperative to look for alternate
surgical approaches which can preserve splenic function.
PS is a technically challenging surgical procedure designed
to resect enough spleen to achieve the desired effect based on
the indication while preserving splenic immune function. PS
with preservation of 25% of the normal spleen is protective in
preventing fatal complications of OPSI, especially in a resource-
limited setting where vaccine availability is an issue. [9] Animal
experiments have shown survival advantage to being directly re-
lated to the amount of reminder splenic tissue with preservation
at least 30 percent of the whole splenic tissue mass protected
against experimental pneumococcal sepsis.[10,11] Further stud-
ies are required to quantify the term “optimal size of the splenic
remnant”, considering the indication for splenectomy. [12]
Technical challenges in performing PS include understanding
the vascular anatomy prior to operation and imaging such as
CECT for studying the same. Splenic vascular dissection may
be performed in several ways, with the most common approach
nowadays being the splenic artery/vein-sparing dissection of
the splenic hilum to selectively revascularize the intended seg-
ment. The other method is the division of splenic artery and
vein, with the perfusion of the splenic remnant provided by
collateral vessels [short gastric vessels or left gastroepiploic
artery]. [12] Temporary clamping by bulldog clamps or loops al-
lows identification of the section line and helps reduce bleeding.
[4] Preoperative arterial embolization can include radiological
coil embolization of the tumour and the feeding arteries of the
splenic pole in question.[13,14] This helped in safer parenchymal
dissection and reduced the requirement of peri-operative blood
transfusions. [15] Detachable clips have also been safely used to
temporarily clamp splenic vessels for the same purpose. [13]
Sectioning splenic parenchyma may be carried out in several
ways, such as using sharp or blunt dissection, electrocautery, ul-
trasonic dissectors, mechanical linear stapler, harmonic scalpel,
or radiofrequency ablator.[12,16] Hemostasis of the raw surface
is achieved with electrocautery devices, pledgets placement, or
omentoplasty.[16,17] Bleeding splenic vessels are handled with
sutures, metallic clips, electrocautery, or argon beam. [12] Hemo-
static agents such as Surgicel® or FloSeal® have been success- Authors’ contributions
fully used for haemostasis in PS.[12,18] Fixation of the splenic
RPS was the junior consultant involved in patient care and has
remnant to the greater curvature of the stomach or abdomen wall
contributed to the analysis of acquired data, drafting the article,
can be done to prevent torsion. Other methods described in the
and revising it critically for important intellectual content. TDK
literature to avoid torsion of splenic remnant include prosthesis
was the senior consultant involved in patient care. TDK had
or transposition in the retroperitoneal space.[12,19] Vaccination
contributed in the conception and design of the case series, ac-
is recommended 2 weeks before elective splenectomy or 2 weeks
quisition of data, drafting the article, and revising it critically for
after splenectomy in the emergency setting.[20]
important intellectual content. BR, GSJ and SC were involved
All our cases were confirmed to be benign aetiology based
in the PS operations and patient care. SC was the head of the
on the imaging. We were able to leave behind at least 25% of the
General Surgery Unit which managed the patients mentioned
residual spleen. There are several techniques described in the lit-
in this case series. BR, GSJ and SC had contributed to the con-
erature for performing PS while minimising blood loss. [12] Our
ception and design of the case series, data acquisition, drafting
mean operating time was 139 min, and the mean intraoperative
the article, and revising it critically for important intellectual
blood loss in our case series was 362.5 ml. Sound understanding
content.
of the operative technique and stepwise approach yields better
operative outcomes. We used the following techniques to stan-
dardise the PS procedure and reduce intraoperative blood loss. Acknowledgements
Left subcostal or midline laparotomy incision was chosen based
We want to acknowledge the Department of Radiology and
on the size of the spleen and surgeon preference. Adequate
Department of Pathology, Christian Medical College, Vellore,
mobilisation of the spleen was performed initially, followed by
India, who were involved in treating the patients mentioned in
clamping of the splenic artery with a vascular clamp. Then the
this case series.
branch supplying the normal spleen/splenic remnant is isolated
and preserved. LigaSure™ was used for sectioning the spleen
and ligating the smaller vessels. After releasing the vascular Conflict of interest
clamp, we used various techniques such as pledged suture, Sur-
There are no conflicts of interest to declare by any of the authors
gicel®Fibrillar™ wrapping of splenic raw surface, and omentum
of this study.
placement to reduce the bleeding or hematoma formation. Only
one patient required blood transfusion in the post-operative
period in our case series. Mean haemoglobin drop after PS pro- References
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