Anatomy of the spleen
The spleen is a blood filled organ located in the upper left abdominal cavity. It is a storage organ for red blood cells and contains many specialized white blood cells called “macrophages” (disease fighting cells) which act to filter blood. The spleen is part of the immune system and also removes old and damaged blood particles from your system. The spleen helps the body identify and kill bacteria. The spleen can affect the platelet count, the red blood cell count and even the white blood count. The spleen is suspended in its anatomical location by way of peritoneal attachments. Adjacent structures include the diaphragm superiorly, the splenic flexure of the colon inferiorly, the tail of the pancreas medially, the left kidney and left adrenal gland, inferoposteriorly, and the stomach anteromedially. The tail of the pancreas is adjacent to the splenic hilum, with the splenic hilum and vein coursing superior along the superior border of the pancreas. The splenic vein lies posterior to the artery, which is described as having serpentine tortuosity. Ten to twenty percent of patients have accessory spleens. It is important to locate an accessory spleen during exploration. The most common location is the splenic hilum, followed by the omentum, mesocolon, and mesentary of the bowel.
Indications for (non-trauma) laparoscopic splenectomy
Relieve symptomatic splenomegaly
Splenic infiltration with neoplasm (ALL, AML, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma)
- infectious mononucleosis
idiopathic thrombocytopenic purpura (ITP)
- hemolytic anemia
- hereditary spherocytosis
Lymphoma (Hodgkin’s, non-Hodgkin’s)
- in hemodynamically stable patients
In some cases, splenic abscesses and splenic cysts are indications for laparoscopic splenectomy.
An evaluation typically includes a complete blood count (CBC), a visual look at the blood cells placed on a glass slide called a ‘smear’, and often a bone marrow examination. Sometimes an ultrasound examination of your spleen, a computerized tomography (CT scan), magnetic resonance imaging (MRI) or nuclear scan is needed.
Advantages of laparoscopic splenectomy
Results may vary depending on your overall condition and health. Usual advantages are: • Less postoperative pain
- Shorter hospital stay
- Faster return to a regular, solid food diet
- Quicker return to normal activities
- Better cosmetic results
Patients undergoing splenectomy should receive vaccinations against encapsulated organisms (haemophilus influenza, pneumococcus, meningococcus species) in order to prevent over-whelming post-splenectomy sepsis (OPSI). Optimally, vacinnations should be administered 2 weeks prior to surgery. However, in emergent cases, vaccinations can be postponed until 1-2 weeks postoperatively.
Patient positioning: right semi-lateral decubitus position *Operating table: flexed at approximatly 30 degrees to increase space between the costal margin and iliac crest, and the patient is pleced in reverse Trendelenberg *Bean bag used to secure patient position and all pressure points padded *The surgeon and camera operator are on the patient’s right, and the assistant on the left *video monitors at the patient’s head bilaterally *When prepping the patient, the patient’s right subcostal margin should be marked in the event of an open conversion; the umbilicus should be left visible often *An open laparotomy tray should be available *Veress needle can be used to obtain insufflation medial to the anterior axillay line and inferior to the left costal margin *The first port is commonly placed in the midclavicular line approximately 6 cm from the costal margin *Exact subsequent ports vary with patient’s body habitus and spleen size *For most patients three 5 mm ports will parallel the costal margin from just left of midline to the midaxillary line *A 12 mm port is placed inferior to the line connecting the first three ports; this is the camera port *The inferior pole of the spleen mobilized by dividing the splenocolic ligament and lateral attachments with sharp scissors or an energy device *Dissection should be carried medial to lateral *The splenorenal ligament should be divided for the length of the spleen, without Gerota’s fasica *The gastrosplenic ligament containing the short gastric vessels are divided with an energy device *If concern for difficult hilar dissection, judiciously clip the splenic artery as its exposed during gastrosplenic ligament dissection *While the assistant elevates and retracts the spleen, the hilum should be distinguished from the tail of the pancreas and an endoscopic linear stapler with vascular load should be used to divide the vessels *Inspect the field for hemostasis *If desiring to use a specimen retrieval bag, a 12 mm port can be replaced with an 18 mm port *The bag should be of adequate strength to prevent rupture *The spleen can be morsalized; alternatively an incision can be extended and the spleen removed intact
What happens if the operation cannot be performed or completed by the laparoscopic method?
In a small number of patients the laparoscopic method cannot be performed. Factors that may increase the possibility of choosing or converting to the “open” procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, inability to visualize organs or bleeding problems during the operation. The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.
What can I expect after surgery?
After surgery you will be given intravenous fluids (IV’s) in your arm. You may have a stomach tube coming up out your nose to prevent vomiting or stomach bleeding because your stomach can fill up with stomach juices and not empty properly after this surgery. Not every surgeon uses this tube. You will be given pain medication to relieve the discomfort you may experience from the small incisions. You will need to let your nurse and surgeon know what your pain medication needs are since everyone has a different pain threshold. As soon as you can resume oral intake, urinate, and care for your basic needs, you will typically be able to go home. Your surgeon will tell you when it is safe to go home. Typically, once you have gone home, you may do the following, but each situation differs and “at home” activities should be discussed with your doctor. • Activity: You can walk and go up stairs. You can shower, but most surgeons prefer that you do not soak in a tub for at least a week or more after surgery. When you feel stronger ask your surgeon about more strenuous activities.
- Driving: Ask your surgeon. Most people can resume driving 5 to 7 days after surgery. You should not be taking pain medication when you drive.
- Diet: Unless you have special dietary needs, such as diabetes, you can eat a normal diet at home.
- Bowel function: It is common to get constipated after surgery, especially when you are taking pain medication. It is important to drink plenty of water and take in enough fiber in your diet. Your surgeon may advise you about means to help your bowel function postoperatively. Ask or call your surgeon before taking a cathartic.
What complications can occur?
Complications following laparoscopic splenectomy are infrequent, but you should consult your doctor regarding possible complications based on your specific case. Possible complications may include cannula site infections, pneumonia, internal bleeding or infection inside the abdomen at the site where the spleen used to be, although these complications are infrequent. The pancreas can become inflamed (pancreatitis). Problems that can occur a few months to years later are hernias at the cannula sites or overwhelming infection throughout the entire body. This complication is also infrequent. Overwhelming infection that occurs after splenectomy is called OPSI or Overwhelming Post-Splenectomy Infection. OPSI is a result of not having a spleen to fight certain bacterial infections. Immunization is usually given before you have your spleen removed and is one method to help the body fight and prevent infection. Antibiotics, like penicillin, can be given if an infection develops because the bacteria that commonly cause this type of infection are very sensitive to antibiotics. It is important that you tell your physician or any physician that is covering for your doctor that you had your spleen removed.
When to call your doctor
Be sure to call your physician or surgeon if you develop any of the following:
- Persistent fever over 101 degrees F (39 C)
- Increasing abdominal swelling
- Pain that is not relieved by your medications
- Persistent nausea or vomiting
- Persistent cough or shortness of breath
- Purulent drainage (pus) from any incision
- Redness surrounding any of your incisions that is worsening or getting bigger
- You are unable to eat or drink liquids