Background
Open splenectomy is performed in two major clinical scenarios: trauma and hematologic disease. The spleen is one of the most frequently injured intraperitoneal organs, and management of splenic injuries may require splenectomy or, rarely, splenorrhaphy.
The spleen is a wedge-shaped organ that lies in relation to the ninth and 11th ribs, located in the left hypochondrium and partly in the epigastrium; thus, it is situated between the fundus of the stomach and the diaphragm. The spleen is highly vascular and reddish purple; its size and weight are variable. A normal spleen is not palpable. For more information about the relevant anatomy, see Spleen Anatomy.
The spleen's key function is the removal of old red blood cells (RBCs), defective circulating cells, and circulating bacteria. In addition, the spleen helps maintain normal erythrocyte morphology by processing immature erythrocytes, removing their nuclei, and changing the shape of the cellular membrane. Other functions of the spleen include the removal of nuclear remnants of RBCs, denatured hemoglobin, and iron granules and the manufacture of opsonins (properdin and tuftsin).
The current trends are toward nonoperative management of the spleen after trauma [1, 2] and toward laparoscopic splenectomy for hematologic disorders. [3, 4] Today, most elective splenectomies are done laparoscopically, except in the case of severe splenomegaly. [5] Even in the setting of massive splenomegaly, there is evidence to suggest that the laparoscopic approach is safe and feasible. [6, 7, 8, 9] However, the benefits of laparoscopic splenectomy vis-a-vis open splenectomy in the setting of splenomegaly have not been definitively established. [10, 11]
Indications
The most common indications for open splenectomy in an adult are the following:
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Traumatic splenic rupture [12]
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Blood dyscrasias
Splenic rupture is usually caused by blunt or penetrating trauma (see the first, second, and third images below); delayed rupture of the spleen [13, 14] (see the fourth image below) and spontaneous splenic rupture [15, 16] occur rarely. An analysis by the National Trauma Data Bank (NTDB) found high failure rates and prolonged hospital stays when high-grade splenic injuries were managed conservatively (ie, with nonoperative management). [17]
CT scan of abdomen demonstrating large delayed rupture of subcapsular hematoma of spleen in symptomatic polytrauma patient previously managed with percutaneous angioembolization.
Surgical management of splenic rupture is indicated for patients who have hemodynamic instability or shock on admission, those who have associated injuries necessitating operative intervention, and those in whom nonoperative management has failed. [18]
Patients with various hematologic disorders may benefit from splenectomy. Splenomegaly (see the image below) is observed in conditions such as idiopathic (immune) thrombocytopenic purpura (ITP), [19] thrombotic thrombocytopenic purpura (TTP), and hereditary spherocytosis. Of these, ITP is the most common indication for elective splenectomy. In hereditary spherocytosis, the RBCs have a tendency to be trapped and destroyed in the spleen. The main features of this disease include anemia, reticulocytosis, jaundice, and splenomegaly.
Severe (massive) splenomegaly occupying most of left abdominal cavity in patient with symptomatic hematologic disorder after failure to respond to medical therapy.
Generally, the operation should be delayed until the patient is at least 6 years old to minimize the risk of overwhelming postsplenectomy sepsis (OPSS; also referred to as overwhelming postsplenectomy infection [OPSI]). [20, 21, 22, 23] After removal of the spleen, the erythrocytes achieve a normal life span, and the jaundice, if present, disappears in a timely manner. Other, less common hematologic indications for splenectomy include thalassemia and sickle cell anemia.
Other disorders for which splenectomy may be indicated include the following:
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Hodgkin disease - In patients who are refractory to medical therapy, splenectomy is indicated to decrease pain, fullness, and hypersplenism
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Felty syndrome (rheumatoid arthritis, splenomegaly, and neutropenia) - Symptomatic splenomegaly and neutropenia can be corrected by splenectomy
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Splenic abscess, cyst, sarcoidosis
Open and laparoscopic splenectomy have been performed in conjunction with esophagogastric devascularization in patients with portal hypertension due to liver cirrhosis. [24]
Contraindications
Contraindications for open splenectomy are few. For elective open splenectomy, the only absolute contraindications are uncorrectable coagulopathy and severe cardiovascular disease that prohibits the administration of general anesthesia.
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CT scan of abdomen showing grade IV splenic injury.
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Resected traumatized spleen with multiple lacerations.
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Severe (massive) splenomegaly occupying most of left abdominal cavity in patient with symptomatic hematologic disorder after failure to respond to medical therapy.
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Left oblique abdominal incision showing severe (massive) splenomegaly in patient with hemolytic disorder.
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CT scan of abdomen demonstrating grade IV injury of spleen.
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Placement of vascular loops during dissection is recommended to help control splenic vessels in cases of severe (massive) splenomegaly.
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CT scan of abdomen demonstrating large delayed rupture of subcapsular hematoma of spleen in symptomatic polytrauma patient previously managed with percutaneous angioembolization.
