Overview
Definition:
Open splenectomy is a surgical procedure involving the complete removal of the spleen
It is typically performed through a laparotomy incision.
Epidemiology:
Splenectomy is performed in various clinical scenarios including trauma, hematologic disorders, and splenic tumors
Incidence varies based on the underlying pathology
It is a relatively common elective and emergency surgical procedure.
Clinical Significance:
Splenectomy is crucial for managing life-threatening splenic conditions, improving outcomes in certain hematological diseases, and controlling hemorrhage from splenic trauma
Understanding the procedure, its indications, and potential complications is vital for surgical residents preparing for DNB and NEET SS examinations.
Indications
Absolute Indications:
Splenic rupture with hemodynamic instability
Non-compressible splenic hilum bleeding
Suspicion of splenic malignancy requiring definitive diagnosis and treatment.
Relative Indications:
Certain hematological disorders like hereditary spherocytosis, immune thrombocytopenic purpura (ITP), thalassemia major, sickle cell disease, and hypoplastic anemia
Splenic infarcts causing severe pain
Splenic cysts or abscesses
Splenic pseudocysts
Splenic masses.
Contraindications:
Absolute contraindications are rare but may include severe coagulopathy or overwhelming sepsis not amenable to control
Relative contraindications include significant comorbidities that increase surgical risk.
Preoperative Preparation
History And Physical Examination:
Detailed history focusing on bleeding disorders, infections, and previous abdominal surgeries
Physical examination to assess for anemia, jaundice, organomegaly, and signs of infection.
Laboratory Investigations:
Complete blood count (CBC) to assess hemoglobin, platelets, and white blood cell count
Coagulation profile (PT, INR, aPTT)
Blood grouping and cross-matching for at least 4-6 units of packed red blood cells
Liver function tests (LFTs)
Renal function tests (RFTs)
Serum electrolytes
Urinalysis
Chest X-ray and ECG.
Imaging Modalities:
Ultrasound of the abdomen can identify splenomegaly and splenic lesions
CT scan of the abdomen with intravenous contrast is the gold standard for evaluating splenic size, architecture, and detecting masses, trauma, or other pathologies
MRI may be used in select cases.
Vaccinations:
Prophylactic vaccination against encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenzae type b, Neisseria meningitidis) should be administered at least 2 weeks before elective splenectomy if possible
If urgent, vaccinations should be given postoperatively
Annual influenza vaccination is also recommended.
Antibiotic Prophylaxis:
Administer broad-spectrum antibiotics (e.g., cefazolin or piperacillin-tazobactam) intravenously 30-60 minutes before incision to prevent surgical site infections.
Procedure Steps
Approach:
Typically performed via a midline or left subcostal (Kocher) incision
Laparoscopic splenectomy is an alternative but this section focuses on open technique.
Exposure:
Adequate exposure of the spleen is achieved by retracting the abdominal contents
The gastrocolic ligament is divided to access the splenic hilum.
Mobilization Of The Spleen:
The spleen is mobilized by dividing the gastrosplenic ligament, short gastric vessels, and the splenocolic ligament
Care must be taken to avoid injury to the pancreatic tail.
Ligation Of Vessels:
The splenic artery and vein are identified, ligated, and divided at the hilum
It is often preferable to ligate the splenic artery first to reduce splenic engorgement and bleeding.
Splenectomy:
Once all vascular pedicles are secured, the spleen is gently delivered from the abdominal cavity
The specimen is sent for histopathological examination.
Hemostasis And Drainage:
Meticulous hemostasis is ensured
A surgical drain may be placed in the splenic bed, particularly if there is significant oozing or concerns about pancreatic leak.
Closure:
The abdominal incision is closed in layers.
Postoperative Care
Monitoring:
Close monitoring of vital signs, urine output, and hemodynamic status
Frequent assessment for bleeding, abdominal distension, and signs of infection.
Pain Management:
Adequate analgesia is provided, often with patient-controlled analgesia (PCA) or epidural anesthesia initially, transitioning to oral analgesics
Attention to pain control over the pancreatic tail is important.
Fluid And Electrolyte Balance:
Intravenous fluids are administered to maintain euvolemia
Electrolyte levels are monitored and corrected as needed.
Early Ambulation:
Encourage early ambulation to prevent deep vein thrombosis (DVT) and pulmonary complications.
Dietary Advancement:
Diet is advanced as tolerated, starting with clear liquids and progressing to a regular diet
Patients with pancreatic tail manipulation may have delayed oral intake.
Antibiotics:
Postoperative antibiotics are typically discontinued within 24-48 hours unless infection is suspected
Long-term prophylactic antibiotics may be considered in asplenic patients, particularly those with other risk factors for infection.
Complications
Early Complications:
Hemorrhage from the splenic bed or injured vessels
Intra-abdominal abscess formation
Pancreatitis or pancreatic fistula due to injury to the pancreatic tail
Subphrenic hematoma
Atelectasis and pneumonia
Deep vein thrombosis (DVT) and pulmonary embolism (PE).
Late Complications:
Overwhelming Post-Splenectomy Infection (OPSI) is the most serious late complication, characterized by rapid onset of sepsis, often with high mortality
OPSI is caused by encapsulated bacteria
Thrombocytosis can occur, increasing the risk of venous thromboembolism.
Prevention Strategies:
Meticulous surgical technique to avoid injury to adjacent organs, especially the pancreas
Careful ligation of vascular pedicles
Vigilant postoperative monitoring for bleeding and infection
Patient education regarding OPSI risk, symptoms, and prompt medical attention
Adherence to vaccination schedules
Long-term prophylactic antibiotics in select high-risk patients.
Prognosis
Factors Affecting Prognosis:
The prognosis depends heavily on the underlying reason for splenectomy
For trauma and benign conditions, prognosis is generally good after recovery
For malignancy, prognosis is dictated by the stage and type of cancer.
Outcomes:
Most patients recover well from open splenectomy
Long-term management focuses on preventing OPSI
Life expectancy is generally not significantly affected in the absence of complications or underlying malignancy.
Follow Up:
Regular follow-up with the primary physician or surgeon is recommended
Patients should be educated on the lifelong risk of OPSI and advised to seek immediate medical attention for fever or signs of infection
Annual influenza vaccination is crucial
Patients should always inform healthcare providers about their asplenic status.
Key Points
Exam Focus:
Indications for splenectomy (hematological disorders, trauma, malignancy)
Surgical anatomy of the spleen and its vascular supply
Potential complications, especially OPSI and its management
Importance of vaccinations in asplenic patients
Differentiating open from laparoscopic approaches.
Clinical Pearls:
Always consider the pancreatic tail when mobilizing the spleen
Ligate the splenic artery before the vein to reduce bleeding and engorgement
Meticulous hemostasis is paramount
Educate patients thoroughly about OPSI risks and management.
Common Mistakes:
Inadequate exposure leading to blind clamping of vessels
Injury to the pancreatic tail
Failure to recognize and manage early signs of OPSI
Insufficient preoperative vaccination or delayed postoperative vaccination
Failure to inform the patient about the lifelong implications of asplenia.