World J Surg (2011) 35:1487–1495
DOI 10.1007/s00268-011-1059-x
Laparoscopic Splenectomy: Standardized Approach
Liane S. Feldman
Published online: 22 March 2011
Ó Société Internationale de Chirurgie 2011
Abstract Laparoscopic splenectomy was first reported in
1991-1992 by several groups. The impact and role of lapa-
roscopy for splenectomy can be considered as significant as
that for gallbladder disease, achalasia, esophageal reflux,
and adrenal disease. In many centers, the laparoscopic
approach is now routine for most cases of elective splenec-
tomy. The laparoscopic approach is associated with reduced
morbidity, especially pulmonary, wound, and infectious
complications. This article reviews a standardized approach
to laparoscopic and hand-assisted splenectomy and covers
indications, operative strategy, and complications. Several
special considerations, including massive splenomegaly,
postsplenectomy thrombosis of the portosplenic venous
system, and accessory spleens are also discussed.
Introduction
The history of splenic surgery has been described by
McClusky et al. [1, 2] as a series of thresholds of
advancements in anatomy, physiology, and surgery. During
the Renaissance, the first threshold was crossed with an
improved understanding of anatomy, enabling splenectomy
to first be applied for splenic injury. Elective splenectomy
developed in the nineteenth and twentieth centuries as
knowledge of the microanatomy and function of the spleen
provided a physiologic rationale. This is exemplified by the
medical student Kaznelson’s 1916 report of the role of
L. S. Feldman (&)
Section of Minimally Invasive Surgery, Division of General
Surgery, McGill University Health Centre,
1650 Cedar Avenue, L9-412, Montreal, QC H3G 1A4, Canada
e-mail: liane.feldman@mcgill.ca
splenectomy for thrombocytopenic purpura based on his
theory that a splenic abnormality resulted in platelet
destruction in the spleen. Splenectomy remained the pri-
mary therapy for immune thrombocytopenic purpura until
the introduction of corticosteroids in the 1950 s. Cases of
overwhelming postsplenectomy infection (OPSI) occurring
after complete splenectomy next focused attention on the
immune function of the spleen and conservative surgical
therapy gained attention, particularly for trauma.
The next significant advance in surgery of the spleen
was the application of laparoscopic techniques. Laparo-
scopic splenectomy was first reported in 1991–1992 by
several groups around the world [3–6]. The benefit of
laparoscopy is based on the fact that an intact splenic
specimen is usually not necessary for adequate pathologic
analysis. This allows for splenic morcellation and removal
through small incisions thereby avoiding the larger incision
otherwise required for open operative exposure. Even when
an intact specimen is required, such as for splenic malig-
nancy, the incision will still be smaller compared to stan-
dard laparotomy and can be placed lower in the abdomen.
The original reports described an anterior approach, similar
to open surgery, with the patient positioned supine. This
represented a technical challenge as the gastrosplenic and
splenorenal ligaments will lie on top of each other [7],
making these planes more difficult to distinguish, particu-
larly considering the early stage of development of lapa-
roscopic surgery at that time. Subsequent advances greatly
facilitated the diffusion of the approach after these initial
reports. The lateral approach [8] enabled easier and safer
access to the splenic hilum when the spleen falls medially
after being mobilized from its lateral attachments. The
wider availability of energy and stapling devices obvi-
ated the need to dissect and ligate the short gastric and
hilar vessels individually [9]. A third advance was the
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recognition of the advantages of a hand-assisted approach
in the presence of significant splenomegaly.
The impact and role of laparoscopy on the performance of
splenectomy can be considered as significant as that for
gallbladder disease, achalasia, esophageal reflux, and adre-
nal disease [9]. The laparoscopic approach is associated with
reduced morbidity, especially pulmonary, wound, and
infectious complications [10]. Early concerns that the lapa-
roscopic approach may lead to poorer outcomes for hema-
tologic diseases due to missed accessory spleens and splenic
injuries resulting in splenosis [11] have been largely allayed
with the publication of large series that reported long-term
outcomes similar to those of open surgery [12]. Although
there remains a role for open splenectomy in specific cir-
cumstances, a consensus statement from the European
Association for Endoscopic Surgery based on a sys-
tematic literature review states ‘‘the laparoscopic approach
is preferable to the open approach for most indications
because it reduces complications and shortens recovery
(Grade B)’’ [13].
In many centers around the world, the laparoscopic
approach is now used routinely for most cases of elective
splenectomy. This article describes a standardized approach
to laparoscopic and hand-assisted splenectomy, including
indications, operative strategy, and complications. Several
special considerations, including massive splenomegaly,
postsplenectomy thrombosis of the portosplenic venous
system, and accessory spleens are discussed separately.
Indications and contraindications for laparoscopic
splenectomy
Splenic surgery is indicated in an interesting and wide
variety of disease processes, with no two patients exactly
alike in terms of spleen size, anatomic variations, number
and location of accessory spleens, presence of perisplenic
inflammation, underlying disease state, and comorbid
conditions. Splenectomy is performed for a clinical indi-
cation rather than a specific diagnosis, and the parameter
that will be used to monitor response should be identified
(e.g., an increase in blood counts, a decrease in abdominal
pain) [14]. For example, in immune thrombocytopenia
purpura (ITP), splenectomy is performed to decrease the
risk of bleeding or the side effects of medical therapies, not
to achieve a normal platelet count. The clinical benefit of
splenectomy should balance, or preferably outweigh, the
potential long-term risks and sequelae, including post-
splenectomy sepsis and increased risk of thrombotic com-
plications [15]. Risks may also depend on the underlying
condition such as the shift of storage cells from the spleen
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to other organs, like the liver or bone marrow, that may
occur after splenectomy for myeloid metaplasia [16].
At the McGill University Health Centre, over 175 sple-
nectomies for hematologic disorders have been performed
in the past 10 years. The most common diagnoses included
immune thrombocytopenias (*40%), lymphoprolifera-
tive disorders (*25%), hemolytic anemia (*10%), and
myeloproliferative disorders (*5%). We currently consider
using a laparoscopic approach in virtually all patients
referred for consideration of elective splenectomy. Of the
128 elective splenectomies performed in our practice since
2000, only two were begun as open, and one laparoscopic
splenectomy was converted to open for bleeding. However,
this may represent a referral bias within our institution, as
the 47 open splenectomies performed by colleagues dur-
ing the same time period included a significantly higher
proportion of complex cases and massive splenomegaly.
For example, spleen size was greater than 20 cm in about
10% of our case series compared to 55% of cases performed
by colleagues.
Contraindications to laparoscopic splenectomy include
uncorrected coagulopathy and severe portal hypertension, as
significant venous collaterals may be very difficult to control
laparoscopically. However, splenectomy in the context of
liver cirrhosis has been performed with good results in
patients with Childs class A and class B [17]. Very mas-
sive splenomegaly (C25 cm craniocaudal length) remains a
relative contraindication to a laparoscopic approach as the
technical difficulties in exposure and manipulation of
these organs becomes increasingly difficult, and the
advantages of the laparoscopic approach becomes less
clear because conversion to open, reoperation for bleeding,
and other complications are more frequent. Nonetheless,
good results may be obtained in selected patients as dis-
cussed below.
Patient selection begins with physical examination to
estimate spleen size. The spleen is examined with the
patient supine, arms at the sides. The abdominal exam
begins in the right iliac fossa and advances toward the left
upper quadrant. Spleen size is measured as the number of
centimeters below the costal margin. The normal adult
spleen measures up to 13 cm on its long axis and weigh up
to 250 g. Although the spleen may still be palpable up to
2 cm below the costal margin in a small proportion of
healthy young adults, spleen size decreases with age, and a
palpable spleen is less likely a normal variant in an older
adult. The EAES guidelines define splenomegaly as a long
axis [15 cm, and massive splenomegaly as a long axis
[20 cm [13]. Poulin et al. [7] add another category for
spleens, [30 cm (‘‘megaspleens’’), as these pose particular
technical challenges that limit the use of laparoscopic
approaches.
World J Surg (2011) 35:1487–1495
Up to half of the spleens that weigh 600–750 g may not
be palpable on physical exam [14]. If the spleen cannot
be felt, an ultrasound is recommended to verify its size,
measuring the maximum length from one organ pole to the
other. If the spleen is palpable, confirming splenomegaly,
a CT scan is done to accurately measure the spleen
and to investigate for conditions that may occur with
splenomegaly, including perisplenic varices, hilar lym-
phadenopathy, splenic infarcts, or perisplenic inflammatory
changes, all of which increase the technical complexity of
splenectomy.
Preparation for laparoscopic splenectomy is done in
collaboration with the hematologist. Coagulopathies and
blood counts are corrected as far as possible. In ITP,
attempts are made to raise platelet counts using intravenous
immunoglobulin (IVIG) or steroids. While laparoscopic
splenectomy for ITP is feasible, even at a very low platelet
count, patients with very low platelet counts are at
increased risk of complications, especially with platelet
counts \20 9 109/l [18]. Platelets are available in the
operating room when platelet count is very low and
transfused if needed, ideally after control of the splenic
hilum.
Informed consent includes a discussion of short-term
and long-term consequences of splenectomy. Complica-
tions such as bleeding, visceral injury (pancreas, stomach,
bowel), and deep venous thrombosis (DVT) are discussed.
The need for conversion to open laparotomy or to a hand-
assist technique to control bleeding or for other compli-
cations is discussed. Risks in the long term, such as sepsis
and the need to seek prompt medical attention if fever
develops, are reviewed. Vaccinations against pneumococ-
cus, Haemophilus influenzae type B, and meningococcus
are given at least 2 weeks before surgery. Pharmacologic
DVT prophylaxis is begun in the operating room in most
patients, unless there is an increased risk of bleeding, in
which case prophylaxis is begun as soon as the bleeding
risk subsides.
Fig. 1 Patient positioning. The patient is positioned in right lateral
decubitus, with the table flexed. a Usual port positioning for
splenectomy without splenomegaly is demonstrated. One 12-mm
and three 5-mm ports are used. b Incision for hand-assisted
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Operative technique
Operative strategy varies mainly with the size of the spleen
and anatomic features of each patient. Most patients are
offered a laparoscopic approach; over the years, an open
splenectomy has been performed on rare occasions for
particular situations such as megaspleen in the context of
coagulopathy or the need to perform concomitant proce-
dures (e.g., nephrectomy for cancer). As stated above, the
size of the spleen in relation to patient body habitus was
estimated by physical exam, with CT used for cases of
suspected splenomegaly. A hand-assist approach is planned
in the face of massive splenomegaly, large perisplenic
varices, or lymphadenopathy in the splenic hilum. Patient
positioning and port placement are consequently altered, as
described below.
Fully laparoscopic splenectomy
Patient positioning and trocar placement (Fig. 1)
Prior to positioning the patient, an orogastric tube is placed
to decompress the stomach. The patient is positioned in
right lateral decubitus at approximately 70° with pressure
points padded. The table is flexed to increase the distance
between the costal margin and the iliac crest. A reverse
Trendelenburg position is used to further improve exposure
to the left upper quadrant. The surgeon and assistant work
on the right side of the table. A 5-mm 30° laparoscopic and
four trocars are used, three 5-mm and one 12-mm. An open
technique is used to place the first 12-mm trocar approxi-
mately 5 cm below the anterior costal margin on a line
drawn from the umbilicus to the costal margin. Ultimately,
this port will be used to insert the linear cutting stapler for
hilar control and for specimen retrieval. In cases where the
spleen is enlarged, care must be taken to place the first
trocar below the level of the spleen to avoid trocar injuries.
Long-acting local anesthesia is infiltrated into the proposed
laparoscopic splenectomy in case of splenomegaly. The position of
the enlarged spleen is demonstrated. The 12-mm port is placed below
the level of the palpable spleen. The hand-port incision is in the
midline
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incisions. Pneumoperitoneum to 12 mm Hg is generally
sufficient. Under direct laparoscopic vision, two 5-mm
trocars are placed in the upper abdomen, one subxiphoid
toward the costal margin and one midepigastric in the
midline. The third 5-mm trocar is placed lateral to the
initial trocar, a few centimeters below the costal margin.
Often the colonic attachments need to be mobilized in
order to insert this fourth overall trocar. Trocar placement
may need to be adjusted based on the size of the spleen.
Search for accessory spleens
The camera is kept at the 12-mm port and the surgeon
operates through the two upper ports. The medial and lat-
eral surfaces of the spleen and perisplenic tissue are
inspected for accessory spleens prior to initiating any dis-
section; these are removed as they are found.
Entry into lesser sac and division of the short gastric
vessels
The spleen is gently retracted laterally through an instru-
ment placed through the lateral port. The shaft of the
instrument is placed along the spleen with its tip at the
diaphragm, allowing for gentle retraction without paren-
chymal injury. The stomach is retracted by the surgeon’s
left hand, and the lesser sac entered by incising the gas-
trosplenic ligament where it is widest and thinnest, that is,
along the greater curve of the stomach at the level of the
lower splenic pole (Fig. 2). The short gastric vessels and
gastroepiploic vessels are contained within this ligament.
The dissection of the short gastrics is usually accomplished
with ultrasonic dissection of the ligament. The stomach and
spleen are closest to each other at the apex of the gastro-
splenic ligament [19]. Exposure at the upper pole of the
spleen is obtained by progressive gentle retraction of the
Fig. 2 Medial dissection with entry into lesser sac and division of the
short gastric vessels. The gastrosplenic omentum is widest inferiorly
and then gets narrower at the upper pole of the spleen where the short
gastric vessels are shortest
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stomach medially and the spleen laterally. It is important to
avoid injury to the stomach when controlling the upper-
most short gastric vessels. The vessels may be very short
and easily injured with excessive traction with the ultra-
sonic energy device. At the upper pole of the spleen, the
spleen tip is elevated to expose the posterior layer of the
gastrosplenic ligament, which is opened until hilar bran-
ches are identified (Fig. 3).
Once the lesser sac is opened, the hilar vessels and tail
of the pancreas are usually visible, unless the patient is
very obese. The anatomy of the splenic artery is highly
variable and with inconsistent branching patterns. In cases
of massive splenomegaly, the main splenic artery can be
identified along the superior border of the pancreas, dis-
sected free from surrounding tissue, and controlled with a
large locking clip to decrease splenic volume and the risk
of hemorrhage.
The lower pole of the spleen is then gently elevated and
branches of the gastroepiploic vessels are dissected and
controlled with ultrasonic energy.
Dissection of lateral attachments
The scope is moved to the lateral port and the surgeon now
operates through the middle two ports. Gentle retraction of
the spleen with the shaft of a blunt-tipped instrument in the
surgeon’s left hand provides exposure of the lateral peri-
toneal attachments of the spleen (Fig. 4). These are incised
layer by layer with ultrasonic energy or monopolar hook
electrosurgery up toward the left crus of the diaphragm.
The spleen will start to fall medially so it is important to
continue following the spleen, staying 1–2 cm from the
edge of the spleen as it is mobilized rather than continuing
Fig. 3 Dissection of posterior layer of gastrosplenic ligament at
upper pole of the spleen. Dissection of this layer from the medial
aspect facilitates entry into the lesser sac when the lateral dissection is
undertaken
World J Surg (2011) 35:1487–1495
Fig. 4 Dissection of lateral attachments of the spleen. Note the
presence of an accessory spleen over the tail of the pancreas
Fig. 5 Elevation of the upper pole with a handle of peritoneum
allows for exposure of the posterior layer of the gastrosplenic
ligament which is opened to reenter the lesser sac from lateral to
medial
in a lateral direction. The edge of peritoneum remaining
on the spleen can be grasped with the left hand and used
to elevate the upper part of the spleen to further expose
the posterior layer of the gastrosplenic ligament (Fig. 5).
This must be opened to reenter the lesser sac from the
lateral side of the spleen and free the upper pole fully.
There may be hilar branches in this layer, however, that
may not be amenable to control with energy devices, but
a window superior to these vessels usually can be opened
safely into the lesser sac. Mobilization of the upper pole
greatly facilitates proper manipulation of the spleen for
subsequent control of the hilar vessels using the linear
cutting stapler.
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Fig. 6 The pancreas often lies very close to the spleen, and hook
dissection is helpful in freeing these attachments superficially, taking
care not to cause bleeding from the hilar vessels below. The goal is to
create enough space to safely pass a linear cutting stapler
Control of the hilar vessels
The splenic vessels will be controlled and divided en masse
with a linear cutting stapler. Prior to application of the
stapler, the pancreas is identified. In the majority of cases,
the pancreas lies very close to the spleen and pancreatic
injury often results in a fistula. As stated above, ideally the
spleen is elevated by grasping the rim of peritoneum left on
the spleen after the lateral dissection and the edge of the
tail of the pancreas is identified. Careful, fine dissection of
additional attachments overlying the hilar vessels between
the pancreas and spleen using monopolar hook electro-
surgery can increase the distance between the spleen and
pancreas and facilitate safe stapling (Fig. 6). Conversion to
a hand-assist technique can help with this dissection if
necessary.
With the spleen fully mobilized, the hilum is controlled
using a linear cutting stapler; generally, 2.5-mm staples are
chosen. The stapler is angled to allow it to pass as close as
possible along the spleen, further decreasing the chance of
pancreatic injury. Care is taken to avoid injuring the
splenic parenchyma or hilar vessels with the stapler as it is
manipulated into position. Full mobilization of the spleen,
especially the upper pole, greatly facilitates safe applica-
tion of the stapler. Conversion to a hand-assist technique
should be considered if difficulty manipulating the stapler
around the hilum is encountered. After the stapler is closed
in position, the spleen is manipulated to allow medial
visualization and ensure proper stapler positioning, then the
stapler is fired. Several staple reloads may be required to
complete the hilar transection. The staple line is inspected
for significant bleeding. Small pumping vessels along the
staple line can usually be controlled with a metal clip.
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More diffuse oozing is usually amenable to control with
oxidized cellulose or fibrin glue. Suturing is rarely needed.
Extraction of the spleen
The detached hilum is grasped and the spleen manipulated
into a retrieval bag placed through the largest port. The
trocar is removed and the bag is pulled out of this incision.
In most cases, an intact specimen is not required for
pathologic analysis and the spleen is morcellated in the bag
to allow for removal. The 12-mm incision is enlarged
somewhat to allow for easy passage of a ring forceps into
the bag and the specimen is fragmented with the forceps,
suction device, and fingers. Care is taken to avoid any
tearing of the bag or spillage of splenic tissue that may
result in splenosis. If an intact specimen is required, the
12-mm port is enlarged as needed.
Inspection and hemostasis
After the specimen is removed, the abdomen is reinsuf-
flated and the dissection area reinspected to ensure
hemostasis. The greater curve of the stomach, diaphrag-
matic surface, and staple lines are inspected. Some patients
with underlying coagulopathies or severe thrombocytope-
nias may benefit from transfusion of plasma or platelets or
other blood products in the face of diffuse oozing. This can
also be addressed through the use of adjunctive hemostatic
agents such as tissue glues or sealants.
Drains are not placed routinely, but a closed suction
drain is placed if the pancreas was injured or transected.
Postoperative care
Oral intake with fluids can commence after recovery from
anesthesia and quickly progress as tolerated. NSAIDs are
useful adjuncts for multimodal analgesia if there is no
hematologic contraindication. Pharmacologic DVT pro-
phylaxis is utilized unless there is a hematologic contra-
indication. While median hospital stay after splenectomy
for a small spleen is 2 days, about 30% of patients are
discharged after an overnight admission in the absence of
any adverse events. An abdominal ultrasound with Doppler
is performed 1 week postop in order to identify asymp-
tomatic portal and splenic vein thromboses (see below).
Hand-assisted laparoscopic splenectomy
The hand-assist approach is a useful adjunct in laparo-
scopic splenectomy and is used liberally in cases of sig-
nificant splenomegaly, mainly to facilitate manipulation of
the spleen for dissection of the upper pole and hilar control.
It is used in difficult cases such as when there are hilar
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lymph nodes or perisplenic inflammation to enhance safety.
Also, if an incision will be required to remove a large
specimen, it makes sense to use that incision during the
procedure. Conversion from fully laparoscopic to hand-
assisted splenectomy may avoid conversion to full lapa-
rotomy. However, there are drawbacks to this approach:
reduced working space taken up by the hand and the need
to ensure that the hand is out of the way of the scope. To
balance the advantages and disadvantages, we generally
start all cases fully laparoscopically, adding the hand when
the limit for exposure and manipulation of very large
spleens is reached. The majority of the operative strategy is
the same as outlined above, with the differences outlined
below.
A midline incision from just below the umbilicus and
extending 7 cm superiorly is marked prior to patient
positioning (Fig. 1b). The patient is positioned in lateral
decubitus, but with less lateral rotation (i.e., at about 45°).
The initial trocar is placed below the level of the palpable
spleen to avoid injury. The three additional trocars are
placed according to operative findings, generally with one
5-mm port in the upper midline, one 5-mm port in the
midepigastrium, and one 5-mm port placed lateral to the
initial port.
The dissection proceeds laparoscopically as described
above until the point where manipulation of the spleen to
expose the attachments or vasculature becomes difficult.
Usually the medial dissection is completed laparoscopi-
cally. The splenic artery can be identified, dissected, and
controlled with a locking clip to decrease the size of a large
spleen. The hand usually will be placed to facilitate the
lateral dissection where exposure is limited due to splenic
size or inflammatory adhesions. The surgeon’s left hand is
placed through the midline incision to help with exposure
and provide gentle blunt dissection. When the spleen is
mobilized, the hand is used to encircle the hilum and guide
the stapler into position. A large sterilized ziplock bag is
used to extract specimens that may not fit into commer-
cially available bags. Manipulation of the specimen into
the bag can be challenging and can be made easier by using
the hand-assist technique.
Special considerations
Splenomegaly
Challenges in laparoscopic splenectomy when significant
splenomegaly is present arise from the decreased working
space and the increased risk of bleeding due to large ves-
sels, perisplenic varices, or perisplenic inflammation.
Retrieval of the specimen can also be challenging. In
addition, splenomegaly often occurs in the context of other
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diseases and comorbidities such as malignant disorders of
the immune system (e.g., lymphoma, chronic lymphoid
leukemia), extramedullary hematopoiesis (e.g., myelofi-
brosis), portal hypertension, and infections, increasing the
risks of surgical complications. It is not surprising that the
risk of conversion, transfusion, morbidity, long operating
time, and prolonged hospital stay is higher in the presence
of splenomegaly. The risk of morbidity seems to increase
with spleen size [15 cm [20]. However, a similar pattern
of increasing morbidity with increasing spleen size is also
evident for open splenectomy, where increased age and
underlying diagnoses are more predictive of morbidity than
spleen size [21]. We found similar rates of morbidity after
laparoscopic (mostly hand-assisted) or open splenectomy
for splenomegaly 15–25 cm, but with shorter hospital stay
after laparoscopic splenectomy (3 vs. 6 days). However,
this advantage of laparoscopy with respect to hospital stay
was lost if any complication occurred [22]. In a random-
ized trial comparing hand-assisted to open splenectomy for
splenomegaly, including spleens as large as 29 cm, benefits
for the hand-assist approach included less pain and shorter
hospital stay. There were few complications in either group
[23]. Compared to conventional laparoscopy, the hand-
assist approach is associated with fewer conversions to
laparotomy and may be associated with fewer complica-
tions [24–26].
Thus, for most cases of splenomegaly, including very
large spleens, hand-assisted laparoscopic splenectomy is
the preferred approach. However, controversy remains as
to whether there is a tipping point for spleen size where
laparoscopy is simply not possible or the benefits of lapa-
roscopy are lost or the procedure is even dangerous due to
very high conversion risk or high risk of morbidity. Early
series reported that a (conventional) laparoscopic approach
was ‘‘futile’’ for spleens larger than 30 cm [27] or that
weigh more than 3 kg [28]. Splenic artery embolization
immediately before laparoscopic splenectomy may be a
useful adjunct [27]. Reso et al. [29] reported no conversion
to open surgery and acceptable morbidity in 19 patients
with spleens 20–35 cm in length when splenic artery
embolization was performed. However, there are other case
series of hand-assisted splenectomy for megaspleens[3 kg
without the use of splenic artery embolization that also
report low conversion to open and acceptable morbidity
[30, 31]. Of note, splenectomy for spleens larger than
25 cm is relatively rare; in our institution, of the 90 sple-
nectomies performed for hematologic disease over a 6-year
period, only 5 were for spleens larger than 25 cm [22].
Laparoscopic splenectomy for these megaspleens is chal-
lenging and should be undertaken only after considerable
experience with laparoscopic splenectomy, and taking
radiologic, disease-specific, and patient-specific factors
into consideration.
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Postsplenectomy portal/splenic vein thrombosis
Surgery is associated with a risk for venous thromboem-
bolic disease in general, usually localized to the lower
extremities, with risk levels well defined for specific patient
populations. Portal/splenic vein thrombosis (PSVT) is a
specific thrombotic complication associated with splenec-
tomy. The reported incidence of PSVT ranges from 0 to
52% and varies with study design, patient population,
threshold for investigation, and diagnostic modality [32].
The risk of PSVT may be higher after laparoscopic com-
pared to open splenectomy, although the overall risk of
thrombosis (including DVT and PE) is similar for both
procedures [32]. While the specific underlying cause is not
known, splenectomy is associated with a hypercoaguable
state [33] and elevated risk of thrombosis in the long-term
[15], suggesting that the spleen is involved with removal of
prothrombotic factors. The thrombocytosis often seen after
splenectomy may also influence the thrombotic risk. Stasis
in the stump of a large splenic vein may promote local
thrombosis that can then embolize or extend proximally.
Clinical risk factors include splenomegaly, malignancy,
and hereditary hemolytic anemia, although PSVT has been
reported in other conditions [32, 33]. It is unclear whether
thromboprophylaxis has an effect on the incidence of
PSVT, but its use is recommended [13]. Patients at highest
risk may benefit from extending the period of prophylaxis
beyond the inpatient period [13].
Timely identification of PSVT is important to prevent
progression to potentially lethal early complications such
as bowel ischemia or chronic complications like cav-
ernous transformation and extrahepatic portal hypertension.
However, early clinical symptoms may be mild and non-
specific, including fever, abdominal pain, diarrhea, nausea,
and vomiting. Prospective studies using routine contrast-
enhanced CT scan or color Doppler imaging report a much
higher incidence of postsplenectomy PSVT than symptom-
atic thromboses. We performed routine Doppler imaging
1 week after elective laparoscopic splenectomy for hema-
tologic disease in 40 patients and diagnosed PSVT in 6
asymptomatic patients. An additional two patients devel-
oped symptoms consistent with PSVT (fever and diarrhea)
and were diagnosed within the first week, resulting in a
1-week incidence of 8/40 (20%, 95% CI = 8–32%). Four
involved the portal vein or its branches only. Patients were
anticoagulated and ultrasound was repeated at 1-4 months,
demonstrating complete resolution in four patients and
partial resolution in four patients. Although splenomegaly,
malignancy, and thrombocytosis all increased the risk of
PSVT, 3 of 17 patients who underwent splenectomy for
ITP also developed PSVT. Two of these three patients with
ITP were lupus anticoagulant positive and both developed
PSVT [34].
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Until additional sensitive and specific risk factors for
PSVT are identified and validated, we currently perform
routine Doppler ultrasound surveillance 1 week post sple-
nectomy and anticoagulate patients with any diagnosed
PSVT. Whether patients with small asymptomatic intra-
hepatic portal vein thrombosis should be anticoagulated
is unclear [35] but it is our current practice. Additional
imaging is performed earlier or later, with a high index of
suspicion if symptoms like fever, nausea, anorexia, diar-
rhea, or abdominal pain develop. Whether patients at high
risk should undergo more intensive prophylaxis for venous
thromboembolism after splenectomy requires more rigor-
ous study [32].
Accessory splenic tissue
To minimize the chance of recurrent disease due to residual
splenic tissue, a careful search for accessory spleens is
undertaken during splenectomy. An accessory spleen
should be retrieved in at least 15% of patients, with about
70% of accessory spleens found in the hilar area. However,
accessory spleens can occur in more unusual locations such
as the greater omentum, tail of the pancreas, mesentery, or
gonadal tissue [7]. There has been concern that laparo-
scopic splenectomy has a higher risk of missing accessory
spleens [11], although the retrieval rate in most series is
comparable to that of open splenectomy [36], and hema-
tologic outcomes are similar to those of open surgery [12].
The role for preoperative imaging with CT or scintigraphy
to detect accessory spleens is not clear. Preoperative CT
scan may detect accessory spleens but is not routinely used
because the sensitivity may be low [37].
Removal of accessory splenic tissue is particularly
pertinent in ITP. The 5-year failure rate for patients who
underwent laparoscopic splenectomy for ITP is approxi-
mately 28% [12], and a search for residual splenic tissue
using CT imaging and/or radiolabelled red blood cell scan
is undertaken in patients who do not respond or who
relapse. Remedial surgery is considered in patients in
whom residual splenic tissue is found, with variable results.
Remedial surgery can be performed laparoscopically.
Perioperative localization using CT-guided injection of
methylene blue at the accessory spleen site, preoperative
intravenous injection of 99 m-technetium-labeled heat-
damaged red blood cells [38], or wire localization [39] may
all help identify the accessory spleen(s) intraoperatively.
Summary
With standardization of the lateral approach, availability of
enabling instrumentation, and selective use of hand-assist
techniques, laparoscopic splenectomy can be offered to
123
World J Surg (2011) 35:1487–1495
the great majority of patients requiring splenectomy for
hematologic disease. Although the degree of difficulty and
potential for complications increases with spleen size and
patient comorbidity, very few absolute contraindications
remain and the benefits of laparoscopy have been extended
to patients previously considered to have contraindications
for this approach.
Acknowledgment The author thanks Zac Kenny from McGill
Molson Medical Informatics Project for creating Fig. 1.
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