Surgical Procedures: Spleen

  • What is splenectomy?

    Splenectomy means removal of the spleen. The spleen is a solid organ situated in the left upper recess of the abdominal cavity. It has functions related to immunity and also is involved in the removal of damaged blood cells from the system.

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  • Why remove the spleen?

    Occasionally it is necessary to remove the spleen as an emergency when it is damaged through trauma; it is a very vascular structure and, when damaged, it can haemorrhage, resulting in life-threatening blood loss. Splenectomy in this circumstance always requires an “open” surgical approach. Laparoscopic splenectomy is an option for non-emergency, or elective, removal of the spleen. This is not a common surgical requirement, but there are certain medical conditions where it may need to be considered. The most common of these is in the treatment of idiopathic thrombocytopaenic purpura (ITP), where the spleen removes excessive amounts of platelets from the bloodstream. Platelets are an important part of the mechanism involved in stopping bleeding and if there are insufficient platelets in the system, easy bruising and spontaneous haemorrhage can occur.

    Often ITP can be managed without surgery, but sometimes removal of the spleen is the best option. Hereditary spherocytosis is a rare condition where red blood cells are abnormally shaped and are destroyed by the spleen, resulting in anaemia, jaundice and increased formation of gallstones. Splenectomy is the treatment of choice. Occasionally it is necessary to remove a spleen that is massively enlarged due to involvement with a myeloproliferative disorder (malignancy of the blood and lymph systems). There are other rare indications for elective splenectomy, such as thrombotic thrombocytopaenic purpura (TTP), thalassaemia major, hairy cell, occasionally splenic abcesses, cysts or tumours, but they will not be discussed further here.

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  • Open vs. Laparoscopic Splenectomy

    Removal of the spleen through an “open” approach requires a large muscle-cutting incision in the upper abdomen, significant post-operative discomfort and, typically, about 5 days hospitalisation. Heavy lifting needs to be avoided for the next month until the muscle wound gains strength. Fortunately it is now possible to do the operation laparoscopically, even for massively enlarged spleens. With laparoscopic technology, the muscle is not cut to gain access and there is a dramatic reduction in postoperative discomfort, even though the procedure performed inside the abdomen is essentially the same.

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  • How is laparoscopic splenectomy done?

    A laparoscope and long narrow instruments are introduced to the abdominal cavity through a series of 5-15mm muscle splitting incisions. The image captured by the laparoscope is relayed to a video monitor so that, by viewing progress on the monitor, it is possible to free up the spleen. It is then manoeuvred into a plastic bag within the abdomen. The neck of the bag is brought out through one of the 10mm incisions and the spleen retrieved from the bag bit by bit until the bag is empty. The bag is then withdrawn as well. The patient should be able to go home the next day.

    With larger spleens, sometimes an appendicectomy-sized incision is required to facilitate removal of the spleen. Another innovation is the “hand port”, a special valve which allows the hand to be introduced to the abdominal cavity to help manoeuvre a very large spleen. The hand port access site can then be used for the removal of the spleen.

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  • What are the effects of splenectomy?

    Patients who have had their spleens removed have increased susceptibility to so-called encapsulated organisms which are usually filtered out of the bloodstream and destroyed by the spleen. For this reason it is desirable to vaccinate patients against pneumococcus and meningococcus preoperatively whenever possible. If patients have been treated with high dose steroids prior to splenectomy (for example, as treatment for ITP), immunisation is delayed until after surgery, when the patient has been weaned off the immunosuppressive medication. Splenectomised patients have susceptibility to a condition called “overwhelming sepsis”, which can be rapidly fatal unless effective antibiotic therapy is instituted immediately. This always needs to be born in mind when such individuals develop an unexplained fever.

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  • Who should perform laparoscopic splenectomies?

    Laparoscopic splenectomy is a technically very demanding laparoscopic procedure, particularly when the spleen is significantly enlarged. There is considerable room for downside, dramatic haemorrhage being the main concern. For this reason in particular, permission is always obtained from the patient prior to surgery to convert to the open approach should circumstances dictate. Surgeons looking to do this operation laparoscopically should have a particular interest in laparoscopic surgical procedures and an ability to perform complex laparoscopic procedures competently.

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  • Andrew Bowker’s experience of splenectomy

    Andrew Bowker’s experience of splenectomy includes laparoscopic removal of 5 massively enlarged spleens (weights 1000-2000gms). He has a 0% conversion-to-open rate for this operation.

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