Open Splenectomy

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]

The most common indications for open splenectomy in an adult are the following:

• Traumatic splenic rupture ^[12]
• 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]

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.

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:

• Hodgkin disease - In patients who are refractory to medical therapy, splenectomy is indicated to decrease pain, fullness, and hypersplenism
• Felty syndrome (rheumatoid arthritis, splenomegaly, and neutropenia) - Symptomatic splenomegaly and neutropenia can be corrected by splenectomy
• 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 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.

Before open splenectomy, a Foley catheter should be placed. An orogastric or nasogastric tube should be inserted during intubation and removed postoperatively as clinically indicated. Sequential compression devices are used before the operation begins. Preoperative antibiotics are given within 60 minutes of the skin incision. The skin is prepared and draped with aseptic technique in the standard surgical fashion.

Open splenectomy requires a laparotomy set with abdominal retractors and good lighting.

General anesthesia is required. The patient is placed in the supine position, with the arms extended. The surgeon stands on the patient's right side with the assistant opposite.

Trauma patients should be vaccinated in the postoperative period during the hospital stay because they may have unreliable follow-up once discharged. In elective cases, vaccination 2 weeks before the procedure is recommended. Recommended immunizations include pneumococcal and meningococcal vaccinations and Haemophilus influenzae vaccination.

Incision and entry into abdomen

The incision depends on the size of the spleen, the reason for splenectomy, and the preference of the surgeon. Generally, in emergency or trauma situations, an upper midline incision is preferable because it affords excellent exposure of the abdominal cavity, can be performed quickly, and provides access for the evaluation and management of other potential injured organs or structures.

In most patients undergoing splenectomy for a hematologic disorder, a left subcostal incision is employed, beginning to the right of the midline and proceeding obliquely to the left approximately two fingerbreadths below the costal margin. This incision yields excellent exposure (see the image below).

Mobilization and removal of spleen

Upon entry into the abdominal cavity, dissection is performed with blunt and sharp technique and with the surgeon's hand following the convex surface of the organ, leading to identification of the peritoneal attachments.

The spleen is gently grasped and displaced medially toward the incision. The avascular peritoneal attachments and ligaments are incised with an electrocautery or Metzenbaum scissors. These suspensory ligaments are avascular except for the gastrosplenic ligament, which contains the short gastric vessels. In patients with portal hypertension, any ligaments may have vessels that should be ligated.

Attention is then turned to the hilum, where the splenic artery and veins are identified, carefully dissected, doubly ligated with 0 nonabsorbable suture (eg, silk), and transfixed with 2-0 silk suture ligatures. To avoid injury to the pancreas, the dissection is carried out at the hilum in close proximity to the spleen.

Next, the short gastric vessels are identified and ligated. In hypotensive patients, the short gastric vessels usually do not bleed, nor does the splenic bed.

In the case of elective splenectomy, the first step is transection of the ligamentous attachments, including the splenophrenic ligament at the superior pole and the splenocolic and splenorenal ligaments at the inferior pole. This may be accomplished with blunt dissection, an electrocautery, or, in conditions where the ligaments are thickened, Metzenbaum scissors.

After the ligamentous attachments are transected, the gastric vessels that run from the spleen to the greater curvature of the stomach are ligated and divided. A Lembert suture is placed in the gastric wall in a seromuscular fashion to avoid the complication of gastric fistulization when one is unable to identify the source of bleeding from the stomach.

After these maneuvers are completed, the spleen is delivered into the wound with blunt dissection of the posterior attachments. To keep from entering the splenic vein, care should be taken not to divide the posterior attachments too far medially. It is also important to avoid axial rotation of the spleen before securing the splenic vessels with vascular loop or clamps; such rotation may lead to disruption of the splenic artery or vein.

Dissection is carried out at the hilum in close proximity to the spleen to avoid injury to the pancreas. Individual ligation of the splenic artery or arterial branches and the splenic vein or venous branches is generally preferable. This is accomplished by means of double ligation and transfixation with nonabsorbable suture ligatures.

In the case of a markedly enlarged spleen (severe splenomegaly), it is often preferable to place a vascular loop or vascular clamp on the splenic vessels (see the image below) and double-ligate the vessels with heavy nonabsorbable suture. One may then proceed with suture ligation using a transfixed technique. This approach avoids slipped-off sutures and helps prevent postoperative bleeding.

After removal of the spleen, hemostasis is obtained and confirmed in a systematic fashion through careful inspection of the left subphrenic area, the greater curvature of the stomach, and the short gastric vessel area, as well as the splenic hilum. Inspection of these areas is facilitated by proper retraction of the stomach and small bowel to allow clear visualization of the left upper quadrant and surgical bed. Attention is then turned to the surgical field to check for active bleeding. Any active bleeding is identified and hemostasis achieved.

When splenectomy is performed for hematologic disease, a thorough abdominal exploration should be performed to look for any accessory spleens. Common locations of accessory spleens include the hilum, the gastrocolic and gastrosplenic ligaments, the greater omentum, the mesenteric region, and the presacral space. Any accessory spleen is removed to prevent the recurrence of idiopathic (immune) thrombocytopenic purpura (ITP).[25, 26]

If the patient requires platelet transfusion, it should be administered after ligation of the splenic artery.

Completion and closure

Drains are not routinely required, except in cases where an injury of the tail of the pancreas is suspected or confirmed.

The abdominal incision is closed by approximating the linea alba with 1-0 polypropylene monofilament sutures in a continuous fashion. The left subcostal incision is approximated in layers with 1-0 absorbable sutures. The skin edges are approximated with staples. In injured patients, the abdomen should not be closed until the coagulopathy that is frequently associated with major trauma has been corrected.

In Gaucher disease, partial splenectomy is performed by isolating and ligating the segmental vessels to the affected segment, then resecting the segment. Closure is accomplished by approximating the splenic parenchyma with suture material and an omental patch, using a hemostatic agent, or applying an argon-beam coagulation device.

Splenorrhaphy is still used to manage small lacerations or other injuries that are localized to one pole of the spleen. Horizontal mattress sutures placed over pledgets are commonly used. Omentum or a local hemostatic agent (eg, fibrin glue) may be used as an adjuvant in achieving hemostasis.

Intraoperative complications include pancreatic, vascular, colonic, gastric, and diaphragmatic injuries. These are reported with both open and laparoscopic splenectomy.

Early postoperative complications include pulmonary complications (atelectasis to pneumonia), subphrenic abscess, ileus, portal vein thrombosis,[27]  thrombocytosis, thrombotic complications,[28] and wound complications (hematomas, seromas, and wound infections).

Late postoperative complications include splenosis and overwhelming postsplenectomy sepsis (OPSS, also referred to as overwhelming postsplenectomy infection [OPSI]).[29, 30]

Some evidence has linked splenectomy with the subsequent development of chronic thromboembolic pulmonary hypertension,[31] possibly because of reduced reticuloendothelial cell clearance leading to elevated microparticle levels post splenectomy; increased circulating microparticle levels have been associated with thromboembolism and pulmonary hypertension in a dose-dependent fashion.

Autotransplantation of the spleen is no longer recommended. Although the splenic remnants survive, adequate phagocytosis of encapsulated bacteria is lost as a consequence of the disruption of normal anatomic vascularization.