Open Splenectomy Scott F. Gallagher, Larry C. Carey, Michel M. Murr

Indications and Contraindications

Indications ■ Trauma ■ Blood dyscrasias, e.g., idiopathic thrombocytopenic purpura ■ Symptomatic relief, e.g., Gaucher’s disease, chronic myeloid or lymphatic leukemia ■ Splenic cysts and tumors

Contraindications ■ No absolute contraindications for splenectomy ■ Limited life expectancy and prohibitive operative risk

Contraindications to ■ Previous open upper abdominal surgery Laparoscopic Splenectomy ■ Uncontrolled coagulation disorder ■ Very low platelet count (<20,000/100ml) ■ Massive splenic enlargement, i.e., spleen greater four times normal size or larger ■ Portal hypertension

Preoperative Investigation and Preparation

■ Imaging studies to estimate the size of the spleen or extent of splenic injury and other abdominal injuries in trauma cases ■ Interpretation of bone marrow biopsy, peripheral blood smear, and ferrokinetics in coordination with a hematologist ■ Discontinue anticoagulants (such as aspirin, warfarin, clopidogrel and vitamin E) ■ Patients routinely given polyvalent pneumococcal vaccine, Haemophilus influenzae b conjugate vaccines and meningococcal vaccines on the same day at least 10–14days prior to splenectomy (given postoperatively in trauma cases) ■ Prophylactic antibiotics (cefazolin or cefotetan) ■ Perioperative DVT prophylaxis ■ Perioperative steroids should be administered to patients on long-term steroid therapy 954 SECTION 7 Spleen Procedure

STEP 1

The standard supine position is employed with an optional small roll/bump under the left flank. The patient should be well secured to the operating table should it become necessary to tilt the table to improve visualization of the operative field. Mechanical retractors greatly enhance exposure and the primary surgeon should stand on the right side of the patient; the first assistant opposite the surgeon on the left side of the patient. There are two standard incisions for open splenectomy: a supraumbilical midline or left subcostal with or without midline extension. A midline incision is usually employed in trauma cases. Examine each patient following induction of anesthesia to estimate the location of the splenic hilum and the tip of the spleen, so the incision location optimizes exposure. The principle of retraction is that of moving the incision over the operative field. Two points of retraction include one retractor to gently hold the colon in the lower abdomen and counterretraction to lift the left portion of the incision superiorly and out of the operative field. The standard order of steps is arranged to minimize blood loss, minimize the size of the spleen and maintain adequate exposure while performing the deepest and most challenging dissection. Identify the splenic artery near its origin from the celiac axis, which is accessed through the gastrohepatic ligament (A, B). Open Splenectomy 955 STEP 2

Upon entering the peritoneal cavity and again before closing, a thorough search for accessory spleens should be conducted, especially if the indication for splenectomy is hematological. Open the gastrosplenic ligament through an avascular area and then proceed to dissect the short gastric vessels. These may be secured with hemoclips or ligatures. The last several vessels in the gastrosplenic ligament are of particular note. These branches are often quite short, so care must be taken to utilize adequate tissue for hemostasis without injuring the greater curvature of the stomach. The LigaSure (R) device, the harmonic/ultrasonic scalpel or a linear stapler can also be utilized for dividing the gastrosplenic ligament as is employed during laparoscopic splenectomy. 956 SECTION 7 Spleen STEP 3 Dividing the splenic attachments

While dividing splenic attachments, always attempt to stay closer to the spleen than to the opposite structure. Proceeding inferiorly along the gastrosplenic ligament typi- cally includes dividing the left gastroepiploic artery. Taking down the splenic flexure and the splenocolic attachment usually facilitates this dissection (A). The spleen is then gently and progressively retracted medially with the surgeon’s left hand ( B). Using a laparotomy pad under the retracting hand, it is a relatively simple maneuver for the surgeon to identify the peritoneal attachments and provide ex- posure with the left index finger. The attachments are divided with curved scissors proceeding from the inferior pole to the superior pole and then dividing the splenorenal ligament as the spleen is gradually rotated medially and anteriorly. Care should be taken with any blunt dissection as the splenic capsule is relatively thin and even small tears can result in moderate bleeding. Likewise, care should be taken as proceeding posteriorly around the inferior pole in order to avoid the adrenal gland.

A

B Open Splenectomy 957 STEP 4 Control of the splenic hilum

Once all of the splenic attachments have been divided the splenic hilum can be addressed definitively. Lift the spleen up and out of the retroperitoneum. This maneuver serves to clearly identify and separate the splenic vessels from the tail of the pancreas as shown. Laparotomy pads packed into the retroperitoneum can assist with elevating the spleen into the incision while controlling oozing in the retroperitoneum. With the assis- tant holding the spleen, the surgeon can separate the tail of the pancreas from the splenic vessels in order to protect the tail of the pancreas prior to dissecting and applying curved clamps. The surgeon divides the splenic artery and vein proximal to their bifurcation between clamps and applies a suture ligature to each after removing the spleen. We first clamp the artery, which is typically anterior to the splenic vein, and then squeeze the spleen in order to promote autotransfusion of splenic blood prior to clamping the vein. Once the spleen is removed and all of the named vessels have been doubly ligated, the operative field can be inspected for hemostasis. The abdomen is closed with or without a closed suction drain. 958 SECTION 7 Spleen Postoperative Tests

■ Monitor in high dependency unit ■ Monitor platelets and hemoglobin

Complications

■ Bleeding ■ Pancreatitis ■ Pancreatic fistula ■ Colonic or gastric perforation ■ Subphrenic abscess ■ Wound infection ■ Atelectasis ■ Left pleural effusion ■ Postsplenectomy sepsis ■ Thrombocytosis Open Splenectomy 959 Tricks of the Senior Surgeon

■ If bleeding is excessive and control of the splenic artery has not already been secured, or is not immediately feasible, the splenic artery and veins are easily controlled by gentle pressure applied between the second and third fingers of the surgeon’s right hand. ■ Control of the splenic artery is most easily accomplished near its origin through the gastrohepatic ligament posterior to the lesser curvature of the stomach (see STEP 1), which is particularly useful during splenorrhaphy. ■ Another approach to the splenic hilum is anteriorly which carries increased risk as the splenic vein is immediately posterior to the splenic artery near the hilum and the tail of the pancreas is also intimately associated to the splenic hilum. ■ A linear stapler, as with laparoscopic splenectomy, is particularly useful when expeditious division of the hilum is necessary to control hemorrhage. ■ For patients in whom difficulty gaining vascular control is anticipated, for those with enormous splenomegaly or those with portal hypertension, splenic artery embolization done immediately prior to the operation can reduce splenic sequestration, congestion and bleeding. ■ Early ligation of the splenic artery diminishes blood loss, maximizes the amount of blood in the spleen returning to the patient, decreases the size of the spleen, improves ease of handling, facilitates removal and improves transfusion efficiency of blood products sooner rather than later during the procedure, if necessary. ■ Make a thorough search for accessory spleens before and after the spleen is removed, especially when operating for hematological indications. Accessory spleens are found in 15–35% of patients undergoing splenectomy and higher in those with hematological diseases. In order of decreasing frequency, accessory spleens are found in the splenic hilum, the splenorenal ligament, the greater omentum, the retroperitoneum near the tail of the pancreas, and the splenocolic ligament. Less commonly, accessory spleens are found in the mesentery of the small and large intestine, as well as the pelvis, in particular the left ureter and left adnexa, and left gonads. ■ Mobilize the splenic flexure and the rest of the colon whenever necessary. Be just as careful protecting the colon and the stomach to prevent injury to either hollow viscus.