Elective Splenectomy

Preoperative considerations

Vaccination

• Timing
  • Completed 2/52 prior to elective splenectomy
  • Prior to discharge for trauma splenectomy
• Should vaccines depend on local protocols
  • Pneumococcal (Pneumovax)
    • Need to repeat in 5 years
  • Haemophilus influenzae Type B
    • Once only
  • Meningococcal ACYW-135
    • Various formulations, some need boosters
  • Seasonal Influenza
    • Yearly

Changes in immune function with Splenectomy

• No mechanical filter (red pulp)
  • No filtration of rigid particles
    • Including parasitised RBCs
• No removal of opsonised encapsulated organisms
  • Strep Pneumoniae (pneumococcus)
  • Haemophilus influenzae Type B
  • Neisseria Meningitidis (meningococcus)
• All patients with asplenia are at risk for severe and overwhelming sepsis

Prophylactic Antibiotics

• Prophylactic ABX not generally recommended unless
  • Child <5 (give untill age 10)
  • Immunocompromised
  • Penicillin G or amoxicillin are antibiotics of choice
    • Or erythromycin if allergy
• Back pocket script
  • To be used at any signs of fevers/sepsis
  • Suggest Augmentin
  • Or ciprofloxacin if allergy
  • Should take antibiotics ASAP and present to local emergency department
• Prophylactic antibitoics during procedures
  • Follow usual protocols for procedures
  • If surgery of paranasal sinuses or resp tract
  • Use amoxicillin

Other considerations

• Correct any anaemia, thrombocytopenia and coagulopathy
  • May include pre-operative IG or steroids – will be in conjunction with a haematologist.
• If the size of the spleen is large may want to pre-operatively embolize the spleen.

Laparoscopic splenectomy

Contraindications to laparoscopic approach

• Massive splenomegaly.

• Portal hypotension.

• Pregnancy.

• CI to pneumoperitoneum.

• Risks similar to open

  • Mortality 0.7%
  • Morbidity 8-12% (post-op bleed 1%, pancreatitis or fistula 0.6%, subphrenic abscess 0.5%)
  • Disadvantage – More likely to miss accessory spleen
  • CI: Severe cardiopulmonary disease, Cirrhosis, pregnancy, trauma (massive splenomegaly – past ½ way mark from costal margin to umbilicus)

https://www.youtube.com/watch?v=Wf7mMqeD-Zg&ab_channel=ColorectalDiseaseJournal

Acute/Open splenectomy

• Wear a headlight

• Abx

• Midline/ subcostal – fixed subcostal retraction

• If trauma – generous midline, 4 quadrant packing, control obvious haemorrhage, anaesthetist time to catch-up

• If get major bleeding from spleen at any stage – compress hilum

• Large & elective

  • Consider embolising artery on way to theatre

• Step 1

  • With left hand gently retract spleen to midline
  • Right hand - Divide lateral attachments (Splenophrenic and Splenorenal ligaments)
    • Can often break splenophrenic ligament with hand, both should be avascular unless portal hypertension

• Step 2

  • Mobilize spleen and tail of pancreas as a unit from lateral to medial, by placing fingernails of right hand against the kidney and dissecting in the plane between kidney and tail of pancreas

• Step 3

  • Assistant elevates spleen – deal to gastrosplenic ligament
  • Serially clamp, tie, and cut short gastrics
  • Greater curvature of stomach may get caught in clamps
  • If concerned - oversew stomach side with seromuscular stitches to prevent subsequent gastric leak
  • Try to preserve gastroepiploic arcade

• Step 4

  • Divide Splenocolic ligaments/ Adhesions to omentum
  • NB: Don’t need to mobilise splenic flexure

• Step 5

  • Draw spleen out of wound
  • Inspect splenic bed and look for other injuries in LUQ - diaphragm, tail of pancreas, kidney, stomach, left lobe of liver
  • Place pack in splenic bed
  • Decide if splenectomy needed
  • Other options include hemostatic agents, splenorrhaphy, and partial splenectomy

• Step 6

  • Serially ligate (double) (or transfix) and divide the splenic vessels (usually several branches present), arteries and veins separately, if possible (dissect & isolate with right angles), and remove spleen
  • Identify & preserve pancreatic tail – ligating vessels close to hilum will do so

• Step 7

  • Check hemostasis
  • Check for splenules
    • Role of autotransplantation controversial
    • Cut spleen into pieces and place them in omental pouches
  • No drains unless there is an associated pancreatic or kidney injury
  • Anterior & posterior layer closure

Laparoscopic Dissection

• The divide spleno-colic ligament to expose the inferior pole of the spleen.
• The lateral spleno-phrenic ligaments are divided followed by the spleno-renal ligaments
• The greater curvature of the stomach is grasped and the spleen retracted laterally to expose the gastro-splenic ligament (which have the short gastrics).
• The lesser sac is entered and the short gastrics controlled with ligasure.
• The hilum is then dissected.
• The tail of the pancreas should be visualised.
• A vascular stapler is used to control the hilar vessels.
• At this point the spleen is hanging usually by some remaining superior spleno-phrenic ligaments which need to be divided
• The camera port is then incised and the spleen is removed (may require morcelation depending on the size and pathology).
• A drain can be left if you are worried about pancreatic fistula.

Comlpications

1. Immediate a. Haemorrhage
2. Early a. Left basal pneumonia b. Gastric stasis c. Acute gastric dilatation d. Thrombocytosis e. Pancreatic leak from damage to tail f. Pancreatic fistula g. Gastric necrosis h. Pancreatic pseudocyst i. SMV thrombosis j. Abscess
3. Late a. OPSI b. Splenosis (It is an acquired condition and is defined as autoimplantation one or more focal deposits of splenic tissue in various compartments of the body) c. AV fistula if splenic artery and vein are clamped together

OPSI

• Overwhelming post splenectomy infection
• Annual risk of 4% in children and <1% in adults
  • Greatest risk is first 2 years post splenectomy.
• Due to
  • Impaired phagocytosis,
  • Decreased IgM
  • Decreased opsonisation
• Common pathogens include streptococcus pneumoniae, H influenzae, N meningitis, E coli, Staph Aureus, Strep Pyogenes, and malaria.
• Clinically – very rapid progression
• Management
  • Urgent broad spectrum antibiotics, even before cultures
    • Vancomycin, ceftriaxone, ciprofloxacin
    • Or Meropenem if cephalosporin allergy

Recommended vaccinations in New Zealand

• Haemophilius influenzae
• Flu (every year)
• Pneumococcal vaccine
• Meningococcal vaccine
• Tetanus
• Diptheria.
• Pertussis

Note: The above vaccinations are all on the schedule for all children in New Zealand. They are not, however, all funded for adults and also a lot of them have only recently been added to the schedule. So you should assume adults are not vaccinated and with children you need to check there vaccine record.

With pneumococcal and meningococal vaccines, you often need multiple spaced doses as well.

Prophylactic antibiotics.

• Children younger than 5 years of age, or children for the first year after splenectomy.
• Daily amoxicillin is generally recommended for patients with ongoing immunosuppression.
• Non-immunosuppressed patients are generally given a back-pocket script for amoxicillin and told to take them and present to he ED if they have a fever.

Blood film post splenectomy:

• Howell-Jolly bodies (nuclear remnants which are usually removed by the spleen)
• Pappenheimer bodies (removed from reticulocytes in spleen)
  • Can also be seen in iron-loading anaemias
• Acanthocytes
• Target cells
• Spherocytes
• Stomatocytes
• Thrombocytosis
• Platelet anisocytosis
• Lymphocytosis