2. Historical background
• “An organ of mystery” (Galen)
• “Unnecessary” (Aristotle)
• “An organ that hinders the speed of runners”
(Pliny)
• “An organ that produce laughter and mirth”
(Babylonian Talmud)
3. Open splenic surgery
• 1st
splenectomy: 1549, Adrian Zacarelli
• 1st
partial splenectomy: 1590, Franciscus
Rosetti
• 1st
splenectomy in the USA: 1816, O’Brien
• 1st
repair of lacerated spleen: 1895, Zikoff
(Russian)
4. Laparoscopic splenectomy
• In 1992, several reports of laparoscopic
splenectomies started emerging in small
series.
• Laparoscopic splenectomy has become a
useful alternative to open splenectomy.
5. Spleen Anatomy
• Most common
relationship of artery
and vein is artery
anterior
• Other positions occur
• Main artery divides
into hilar branches
over the pancreatic
tail
6. Spleen Anatomy
• Major Ligaments
– Gastrosplenic
• Short gastrics
– Splenorenal
(lienorenal)
– Splenocoloic
• Minor Ligament
– Splenophrenic
– Pancreaticosplenic
7. Anatomy
Blood SupplyBlood Supply
• Splenic arterySplenic artery (pattern of terminal branches)
– Distributed type: (70%)
– Short trunk w/ many long branches over ¾ of the
medial surface of the spleen.
– Magistral type: (30%)
– Long main trunk dividing near the hilum into short
terminal branches.
• Short gastric arteryShort gastric artery
8. Anatomy
• The most common anomaly of splenic
embryology is the accessory spleen..
• 80% in the splenic hilum and vascular
pedicle
9. Spleen Anatomy
Locations of Accessory Spleens
A Splenic hilum
B Along splenic vessels
C Splenocolic ligament
D Perirenal omentum
E Small bowel mesentery
F Presacral area
G Uterine adnexa
H Peritesticular region
10. Splenic Function
• Immune function
– Filtering function
– Opsonin production
– Clearance of
encapsulated organisms
– Clearance of metastatic
cells
• Erythrocyte
maintenance
• Platelet reservoir
• Storage organ for factor
VIII
11. Indications for Splenectomy
• Most common indication is trauma totrauma to spleenspleen,
whether iatrogenic or otherwise
• Most common elective splenectomy is ITP
– followed by
• hereditary spherocytosis
• autoimmune hemolytic anemia
• thrombotic thrombocytopenic purpura.
13. Change of Indications
Decrease Increase
• Decline of staging
laparotomy for
Hodgkin’s disease
• Increase of splenectomies
for hereditary
spherocytosis and
myeloproliferative
disorders
• Significant Increase
indication for ITP
• New indication: Hairy cell
leukemia, Felty’s
syndrome, AIDS
15. Preoperative Considerations
• Splenic artery embolizations:
– Advantages:
• Reduced operative blood loss from devascularized
spleen
• Reduces spleen size for easier dissection and removal.
– Disadvantages:
• Acute left sided pain (limited duration)
– This is mitigated by general anesthesia ---> OR
• pancreatitis
• Currently no consensus
16. Preoperative Considerations
• Pneumovax, haemophilus, meningococcus
vaccinations 2 weeks pre-op
• Corticosteroids
• Availability of blood and platelet products
• Preoperative IgG administration to patients
with ITP and critically low platelet counts
• Perioperative antibiotics
• Pre-operative embolization- controversial
17. Preoperative Considerations
• Vaccination::
– Splenectomy imparts <1 to 5% fulminant infection
(overwhelming post-splenectomy infections)
– Vaccination against encapsulated bacteria 2 wks
before surgery.
18. Preoperative Considerations
• Vaccination:
– Common bacteria:
• Streptococcus pneumoniaeStreptococcus pneumoniae
• Hemophilus influenzae type BHemophilus influenzae type B
• MeningococcusMeningococcus
• Grp A streptococcus
• Capnocytophaga canimorsus (related to dog bites)
• Grp B streptococcus
• Enterococcus sp.
• Bacteroides sp.
• Salmonella sp.
• Bartonella sp.
19. Preoperative Considerations
• Vaccination::
– in emergency splenectomy, trauma, give vaccine
3rd
day
– booster injections every 5 – 6 yrs regardless of the
reason for splenectomy for pneumococcal
– annual influenza immunization
20. Preoperative Considerations
• Deep venous Thrombosis Prophylaxis:
– Specially in splenectomy for myeloproliferative
disorders (MPD).
– 40% risk for PVT (portal vein thrombosis)
– Anorexia
– Abdominal pain
– Leukocytosis & thrombocytosis
● Early diagnosis w/ contrast-enhanced CT scan
● Anticoagulation Prophylaxis
21. SPLENECTOMY
• Open Splenectomy:
–Indication:
• traumatic rupture of the spleen (most
common)
• massive splenomegaly
• ascites
• portal hypertension
• multiple prior operations
• extensive splenic radiations
• possible splenic abscess
22. Partial Splenectomy
• Indicated:
– children (risk of splenectomy sepsis)
– Lipid storage disorders (Gaucher’s disease)
– Some blunt & penetrating splenic injuries
• Open or laparoscopic
• Bleeding from cut surface of the spleen is
controlled by:
– cauterization
– argon coagulation
– application of hemostatic agents (cellulose gauze /
fibrin glue)
23. Relative Contraindications to
Laparoscopic Approach
• Active hemorrhage with hemodynamic
instability
• Non-platelet coagulopathy
• Contraindications to pneumoperitoneum
• Splenomegaly
• Pregnancy
• Extensive previous upper abdominal surgery
24. Laparoscopic versus open
splenectomy
• Earlier discharge
• Less pain
• Earlier resumption of oral intake
• Fewer blood transfusions
• Similar operative time with increased
experience
25. Three Areas of Controversy
• Massive splenomegaly
• Splenic rupture
• Higher recurrence?
26. Massive splenomegaly
• Technical challenge
– Difficulty to manipulate the spleen
– Difficulty in the extraction of the spleen
• Options
– Totally laparoscopic splenectomy
– Hand port assisted
28. Laparoscopic Splenectomy for
Ruptured Spleen
• The patient has to be hemodynamically stable
(on going bleeding requiring large blood
transfusion)
• Use of 10mm suction/irrigation device
• Early control of splenic hilum
• Hand port could be helpful
29. Prevention of Residual Function
• Extreme care to avoid parenchymal rupture
and cell spillage
• Systematic and careful exploration of the
abdominal cavity for accessory spleens
30. SPLENECTOMY
• Open Splenectomy:
–Position:
• Supine:
–midline incision for rupture or massive
splenomegaly or for staging Hodgkin’s.
–Left subcostal incision
• for elective splenectomies
39. Post-op Considerations
• Removal of NGT and foley prior to extubation
• Up in chair for a few hours the night of
surgery
• Liquid diet begun on the first post-op day
• Ambulate in the hall on the first post-op day
• Discharge on the first or second post-op day
40. Accessory spleens (AS)
• Long term follow up is essential because a
small accessory spleen can hypertrophy after
splenectomy and be detected via CT scan or
scintigraphy
41. Changes in blood after
splenectomies
1. Appearance of Howell-Jolly bodies &
siderocytes
2. Leukocytosis
3. Increased platelet counts
43. Complications of Splenectomies
• Pancreatic complications: due to intra-op trauma
to tail of pancreas
– Pancreatitis
– Pseudocyts
– Pancreatic fistula
• Thromboembolic phenomena (5-10%)
– For pt. w/ hemolytic anemia / myeloproliferative
disorders and splenomegaly
• Subcutaneous heparin & low-dose anticoagulantion
therapy postop
44. Complications of Splenectomies
• Overwhelming Postsplenectomy Infection
(OPS):
− lifetime risk of severe infection (1-5%)
− incidence similar among children & adult but
mortality is higher in children.
− mortality is highest in hematologic conditions:
• Thalassemia major
• Sickle cell
− lowered due to pneumococcal vaccine
45. Complications of Splenectomies
• Overwhelming Postsplenectomy Infection
(OPS):
− Loss the ability to filter and phagocytize bacteria
and parasitized blood cells
− infection to encapsulated bacteria or parasites
− Loss a significant source of antibody production:
• Streptococcus pneumoniae (most common infection
50-90%)
• Haemophilus influenzae type B
• Meningococcus
• Grp A streptococcus
46. Complications of Splenectomies
• Overwhelming Postsplenectomy Infection
(OPS):
– Risk Factors:
• Splenectomies for hematologic indications
• Compromised immune system:
− Hodgkin’s.
− taking chemotherapy / radiation therapy
• Children usually develops w/in 2 yrs postsplenectomy
47. Complications of Splenectomies
• Overwhelming Postsplenectomy Infection
(OPS):
− Immunoprophylaxis:
• Pneumococcal vaccine – booster injection every 5-6yrs
• Annual influenza immunization
− Antibiotic prophylaxis usually single daily dose of
penicillin or amoxillin for children for 1st
− asplenic children receive daily prophylaxis with oral
penicillin VK or amoxicillin until at least age five and for
at least one year following splenectomy
