Splenectomy

Christopher T. Siegel and Raymond Onders

Introduction

Nontraumatic splenectomy is usually indicated for patients with benign or malignant hematologic disorders who are not responding to medical therapy. Indications include idiopathic thrombocytopenic purpura (ITP) or other hematologic disorders that lead to splenic sequestration of platelets and red blood cells; patients with thrombotic thrombocytopenic purpura (TTP), hereditary spherocytosis, autoimmune hemolytic anemia, or symptomatic thalassemias may also respond to splenectomy. Splenectomy may also be a treatment option for malignancies such as primary lymphoma or metastatic disease to the spleen.

The key to safe splenectomy is understanding the anatomy surrounding the spleen (Fig. 17-1). The spleen must be safely mobilized from all the surrounding structures to prevent common perioperative complications related to the splenic anatomy, including gastric injury or leak during division of short gastric vessels; pancreatitis or pancreatic fistula from the pancreatic tail during mobilization of the splenic hilum; colon injury during division splenic flexure; left pleural effusion or left pulmonary atelectasis from excessive diaphragm manipulation; and bleeding from short gastric vessels, splenic artery, or splenic vein.

FIGURE 17–1 Spleen and surrounding structures.

During the postoperative period, splenic vein thrombosis can lead to inferior mesenteric vein or portal vein thrombosis, with serious consequences (Fig. 17-2, A). The most serious long-term complication of splenectomy is sepsis, which can be decreased with preoperative immunization for the common encapsulated organisms, including meningococcal, pneumococcal, and Haemophilus influenzae type B infections, either 2 weeks before or on the last day of admission after surgery.