Splenectomy

46
Tomohiro Ishii and Takeo Yonekura

Abstract
Splenectomy is indicated for several hematologic disorders, splenic cyst, abscess, and
trauma. In elective splenectomy, preoperative vaccinations are recommended for preventing
serious infectious complications after the splenectomy. An elective splenectomy except the
patients associated with splenomegaly is usually an uncomplicated operation with minimal
bleeding. Recently, laparoscopic procedures have become a more widely applied modality
particularly for an elective splenectomy. Surgical procedures of splenectomy require a
precise knowledge of anatomy. Mobilization of the spleen is conducted by dissecting the
ligamentous attachments to the abdominal wall and the diaphragm, which is followed by the
dissection between the stomach and the spleen. After these dissections, splenic hilar vessels
are ligated and splenectomy is completed. Care must be taken not to injure the tail of the
pancreas since it lies close to the splenic hilum. The accessory spleen should be sought and
removed in the case of hematological diagnoses to prevent the possible recurrence of
symptoms. In case of splenic trauma where hemostasis is the uppermost and urgent issue,
splenic hilar dissection and clamping should be undertaken initially to achieve temporary
hemostasis. Partial splenectomy can be indicated for selected conditions such as localized
splenic contusion without hemodynamic instability, splenic cyst, and splenic abscess.

Keywords
Open splenectomy ! Partial splenectomy ! Splenic trauma

46.1 Indication rather than total splenectomy may be indicated. Laparoscopic

Splenectomy itself is commonly indicated in children with
medically uncontrollable hematologic disorders, such as idio-
pathic thrombocytopenic purpura, hereditary spherocytosis,
thalassemia major, and sickle cell disease. It is also performed
for splenic tumor, cyst, abscess, and trauma; however, partial
procedures have recently become a more common modality.
Open splenectomy is still preferred for the patients with spleno-
megaly due to technical difficulties; however, the number of
reports describing the safety and feasibility of the laparoscopic
splenectomy for splenomegaly patients is increasing [1].

The figures in this chapter are reprinted with permission from Standard
Pediatric Operative Surgery (in Japanese), Medical View Co., Ltd.,
2013, with the exception of occasional newly added figures that may
appear.
T. Ishii (*) ! T. Yonekura
Department of Pediatric Surgery, Kindai University Faculty of
Medicine, 1248-1, Otoda-cho, Ikoma, Nara 630-0293, Japan
e-mail: ishii@nara.med.kindai.ac.jp
46.2 Anatomy
Ligamentous attachments of the spleen to adjacent organs
include the phrenosplenic ligament to the diaphragm,
splenocolic ligament to the splenic flexure of the colon,
splenorenal ligament to the left kidney, and the gastrosplenic
ligament to the stomach. The first three ligaments maintain

# Springer Japan 2016 289

T. Taguchi et al. (eds.), Operative General Surgery in Neonates and Infants, DOI 10.1007/978-4-431-55876-7_46
290 T. Ishii and T. Yonekura

Phrenosplenic ligament 46.4 Operations

Gastrosplenic ligament
46.4.1 Preparation of the Patient

The patient is placed in the supine, semi-decubitus, or

decubitus position. Immobilization of the patient is impor-
tant for utilizing the intraoperative position change espe-
cially when in the semi- and full decubitus position. In
decubitus position, placement of a roll under the lower
chest may be helpful for better exposure. A nasogastric or
orogastric tube should be inserted for gastric decompression.
Splenocolic ligament

46.4.2 Incision and Exploration

A transverse skin incision from the midline to mid-axillary

Fig. 46.1 Ligamentous attachments of the spleen
Stomach
line is made. A left subcostal incision may provide better
exposure for older patients with a narrow costal margin. A
midline incision should be utilized for splenic trauma cases,
since other intraperitoneal visceral injuries may be coincided
(Fig. 46.3). After the laparotomy, the accessory spleen should
be sought, most often found around the splenic hilum. The tail
Gastrosplenic ligament
containing short
gastric vessels and
gastroepiploic vessels

Pancreas

Lt. Kidney

Splenorenal ligament containing

splenic artery and vein

Fig. 46.2 Splenorenal and gastrosplenic ligaments and their vascular

contents 2

the attachment of the spleen to the retroperitoneal surface

and to the diaphragm, while the gastrosplenic ligament lies 1
between the spleen and the stomach. The splenorenal liga-
ment contains the splenic artery and veins, and the gastro-
splenic ligament contains short gastric and left gastroepiploic
3
vessels (Figs. 46.1 and 46.2).

46.3 Preoperative Immunization

Vaccinations for Streptococcus pneumoniae, Haemophilus

influenzae, and Neisseria meningitidis are mandatory in
elective splenectomy at least 2 weeks before the surgery to
decrease the risk of overwhelming post-splenectomy infec- Fig. 46.3 Skin incision. (1) Transverse incision from the midline to
tion (OPSI) [2]. mid-axillary line. (2) Left subcostal. (3) Midline
46 Splenectomy 291

of the pancreas, the splenocolic ligament, the greater omen-

tum, and the presacral area should also be inspected because
leaving the accessory spleen can cause recurrence of the
symptoms of some hematologic diseases [3]. The gallbladder
should also be palpated to check for gallstones particularly in
patients with hemolytic disease. Cholecystectomy is recom-
mended when the gallstone is identified.

46.4.3 Mobilization of the Spleen

Splenophrenic and splenocolic ligaments are dissected by

using electrocautery with gentle grasping and retracting of
the spleen to caudal and cranial direction. A rough retracting
maneuver may cause the unexpected bleeding from the
splenic surface, therefore should be avoided. This is particu-
larly emphasized in splenomegaly cases. The splenorenal
ligament, which is the lateral attachment to the abdominal
wall, is incised with the help of medial retraction or even
delivery of the spleen out of the abdominal cavity. The
incision should be made near the abdominal wall to prevent
from entering the splenic surface itself incorrectly. The tail Fig. 46.5 Dissection of gastrosplenic ligament
of the pancreas near the splenic hilum and vessels running
into/from the spleen will be visualized by this dorsal mobili-
zation (Fig. 46.4). Placing sponges or gauzes in the postero- 46.4.4 Dissection of the Gastrosplenic Ligament
lateral fossa helps to control hemostasis from the dissected
surface and keep the spleen upward position. The gastrosplenic ligament which contains the short gastric
vessels and the left gastroepiploic vessels is ligated and
divided, or dissected by an energy device (e.g., vessel
sealing system or ultrasonically activated device)
(Fig. 46.5). Medial traction of the greater curvature of the
stomach facilitates the exposure of the ligament. Any possi-
ble gastric wall injury during this dissection should be
oversewn. The anterior dissection is completed by the
release of this ligament.

46.4.5 Ligation of the Splenic Artery and Vein

Now splenic pedicle is isolated and ready to be divided

Fig. 46.4 Dissection of the splenorenal ligament (dorsal dissection)
(Fig. 46.6). Before clamping of the hilar vessels, a gentle
squeeze may be applied to the spleen so that some of the
blood in the spleen returns to the circulation. The artery and
vein are then tied and divided. Care should be taken not to
injure the tail of the pancreas, as it sometimes lies very close
to the splenic hilum. In such circumstances, the splenic
hilum is dissected and the branches of the splenic artery
and vein are individually ligated away from the pancreatic
tail. The stapler device can also be used to divide the pedicle
as a whole. Again, the injury of the tail of the pancreas
should be avoided during the stapling.
292
Fig. 46.6 Division of splenic hilum
46.4.6 Re-exploration of the Abdominal Cavity
The splenic fossa and adjacent area are irrigated with warm
saline and inspected for hemostasis. The accessory spleen is
inspected again. A drainage tube is not routinely placed
unless there is suspicion of a pancreatic injury. Wound is
closed in the surgeon’s preferring manner.
46.5 Splenectomy for Trauma
46.5.1 Indication
Hemodynamically unstable cases even with initial fluid re-
suscitation should undergo an immediate operation [4]. The
patients who do not respond to the nonoperative manage-
ment also require surgical intervention.
46.5.2 Total Splenectomy vs Partial
Splenectomy
Total splenectomy is indicated for patients with unstable
circulation intraoperatively, coagulopathy, or multiple
organ injury. Partial splenectomy or splenic repair is other-
wise considered for the preservation of the immunological
function of the spleen.
46.5.3 Total Splenectomy
In contrast to the elective splenectomy, total splenectomy for
trauma needs rapid hemostasis. After entering the abdominal
cavity, anteromedial traction of the spleen by the surgeon’s
T. Ishii and T. Yonekura
Fig. 46.7 Partial splenectomy for splenic trauma, ligation of lobar/
segmental vessel corresponding to the injury area
non-dominant hand is applied. Wrapping the damaged
spleen with gauze may help to control the bleeding. The
posterolateral attachment is dissected sharply or bluntly, so
that the spleen is mobilized out of the abdominal cavity. This
dissection is continued underneath the pancreas. After tem-
poral hemostasis is achieved by occluding the splenic hilar
vessels by the surgeon’s fingers, the extent of the injury is
assessed. Application of temporal hilar occlusion with a
vascular clamp may also be helpful. If total splenectomy is
indicated, hilar vessels are ligated and divided from the
posterior aspect of the hilum. Care should be taken to
avoid the injury of the pancreatic tail. Hilar division is
followed by the dissection of the gastrosplenic ligament.
Accessory spleen should be in situ for possible preservation
of the immunological function.
46.5.4 Partial Splenectomy and Splenic Repair
Partial splenectomy for trauma is indicated for deep splenic
injury without the involvement of the hilar vessels. After
the adequate mobilization, the extent and localization
of the injury are assessed. Lobar or segmental vessels
corresponding to the injury area will be tied and divided,
followed by the splenic parenchymal resection along to the
vascular demarcating line (Fig. 46.7). Bleeding from the cut
46 Splenectomy
Fig. 46.8 Hemostasis from the cut surface with vertical mattress
sutures over pledgets
surface is controlled by suture ligations and vertical mattress
sutures over pledgets (Fig. 46.8). Superficial injury can be
repaired by the direct suture of the parenchyma. Topical
application of the hemostatic sheet may also be helpful.
46.6 Postoperative Complications
Postoperative complications after splenectomy include
intraperitoneal hemorrhage, pancreatitis, infection, pleural
effusion, venous thrombosis, and splenosis. Postoperative
293
hemorrhage is rare and avoidable by ensuring the hemostasis
before abdominal closure. Postoperative temporary eleva-
tion of serum amylase could occur due to the intraoperative
manipulation of the pancreas; however, continuing elevation
of serum amylase as well as abdominal pain and paralytic
ileus raises the suspicion of pancreatitis or pancreatic injury.
Acute infectious complications include intra-abdominal
abscess, wound infection, and pulmonary infection related
to atelectasis. If the pleural effusion, particularly on the left
side develops, intra-abdominal or left subphrenic infectious
complication should be suspected. Late infectious compli-
cations, mostly the OPSI, are prone to occur in pediatric
patients. Preoperative vaccination is recommended to mini-
mize the risk of OPSI, but long-term postoperative antibiotic
prophylaxis is still controversial. Portal vein thrombosis
has been documented to be rare but may be more common
complication than it clinically detected. Splenosis can occur
in trauma cases or in case of intraoperative splenic injury.
Some hematologic disorder could recur due to the splenosis.
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