Acs0525 splenectomy-2005

© 2005 WebMD, Inc. All rights reserved.5 Gastrointestinal Tract and Abdomen

ACS Surgery: Principles and Practice25 Splenectomy — 1

Medicine is not an exact science, and nowhere is this observation moreappropriate than in the operating room when a spleen is beingremoved.1

The first reported splenectomy in the Western world was per-formed by Zacarello in 1549, though the veracity of his operativedescription has been questioned. Between this initial report andthe 1800s, very few cases were recorded. The first reportedsplenectomy in North America was performed by O’Brien in1816. The patient was in the act of committing a rape when hisvictim plunged a large knife into his left side. As in this case, mostearly splenectomies were done in patients who had undergonepenetrating trauma; often, the spleen was protruding from thewound and the surgeon proceeded with en masse ligation. Thefirst elective splenectomy was performed by Quittenbaum in 1826for sequelae of portal hypertension, and soon afterward,Wells per-formed one of the first splenectomies using general anesthesia;both patients died. In 1866, Bryant was the first to attemptsplenectomy in a patient with leukemia. Over the following 15years, 14 splenectomies were attempted as therapy for leukemia;none of the patients survived. In a 1908 review of 49 similar cases,Johnston reported a mortality of 87.7%.2 These dismal results ledto the abandonment of splenectomy for leukemia. In 1916,Kaznelson, of Prague, was the first to report good results fromsplenectomy in patients with thrombocytopenic purpura.

As the 20th century progressed, splenectomy became morecommon in direct proportion to the increase in the use of theautomobile.The eventual recognition of the syndrome known asoverwhelming postsplenectomy infection (OPSI) made splenicconservation an important consideration. Partial splenectomy hadinitially been described by the French surgeon Péan in the 19thcentury. This procedure received little further study until almost100 years later, when the Brazilian surgeon Campos Cristo reeval-uated Péan’s technique in his report of eight trauma patients treat-ed with partial splenectomy.3 Simpson’s report on 16 childrenadmitted for splenic trauma to the Hospital for Sick Children inToronto between 1948 and 1955 was instrumental in establishingthe validity of nonoperative treatment of splenic trauma [see 7:7Injuries to the Liver, Biliary Tract, Spleen, and Diaphragm].4

In late 1991 and early 1992, four groups working indepen-dently—Delaître in Paris, Carroll in Los Angeles, Cushieri in theUnited Kingdom, and our group in Canada—published the firstreports of laparoscopic splenectomy in patients with hematologicdisorders.5-7 Since then, the development of operative techniquesfor partial laparoscopic splenectomy has tested the limits of mini-mally invasive surgery and encouraged clinical research into meth-ods of simplifying the execution of the operation.8,9 The adoptionof laparoscopic splenectomy has led to a gradual decrease in theindications for open splenectomy; however, both procedures arestill essential components of spleen surgery.

Anatomic Considerations

Most anatomy texts suggest that the splenic artery is constantin its course and branches; however, as the classic essay by

Michels made clear, each spleen has its own peculiar pattern ofterminal artery branches.10

SPLENIC ARTERY

The celiac axis is the largest but shortest branch of the abdom-inal aorta: it is only 15 to 20 mm long.The celiac axis arises abovethe body of the pancreas and, in 82% of specimens, divides intothree primary branches: the left gastric artery, which is the firstbranch, and the hepatic and splenic arteries, which derive from acommon stem. In rare instances, the splenic artery originatesdirectly from the aorta; even less often, a second splenic arteryarises from the celiac axis.There are numerous other possible vari-ations, in which the splenic artery may originate from the aorta,the superior mesenteric artery, the middle colic artery, the left gas-tric artery, the left hepatic artery, or the accessory right hepaticartery. As a rule, however, the splenic artery arises from the celiacaxis to the right of the midline, which means that the aorta mustbe crossed to reach the spleen and that selective angiography islikely to be difficult at times.The splenic artery can take a very tor-tuous course, particularly in patients who are elderly or who havea longer artery.

In his study of 100 cadaver spleens,10 Michels divided splenicarterial geography into two types, distributed and magistral (orbundled) [see Figure 1]. In the distributed type, found in 70% ofdissections, the splenic trunk is short, and six to 12 long branch-es enter the spleen over approximately 75% of its medial surface.The branches originate between 3 and 13 cm from the hilum [seeFigure 1a]. In the bundled type, found in the remaining 30% ofdissections, there is a long main splenic artery that divides nearthe hilum into three or four large, short terminal branches thatenter the spleen over only 25% to 35% of its medial surface.Theseshort splenic branches originate, on average, 3.5 cm from thespleen, and they reach the center of the organ as a compact bun-dle [see Figure 1b]. Early identification of the type of splenic bloodsupply present can help the surgeon estimate how difficult a par-ticular splenectomy is likely to be. Operation on a spleen with adistributed vascular anatomy usually involves dissection of moreblood vessels; however, the vessels, being spread over a wider areaof the splenic hilum, are relatively easy to deal with. Operation ona spleen with a bundled-type blood supply typically involves dis-section of fewer vessels; however, because the hilum is narrowerand more compact, dissection and separation of the vessels aremore difficult.

BRANCHES OF SPLENIC ARTERY

The splenic branches vary so markedly in length, size, and ori-gin that no two spleens have the same anatomy. Outside thespleen, the arteries also frequently form transverse anastomoseswith each other that, like most collaterals, arise at a 90º angle tothe vessels involved [see Figure 1].11 As a consequence, attempts toocclude a branch of the splenic artery by means of clips orembolization, if carried out proximal to such an anastomosis, mayfail to devascularize the corresponding splenic segment. Beforethe splenic trunk divides, it usually gives off a few slender branch-

25 SPLENECTOMYEric C.Poulin,M.D.,M.Sc.,F.A.C.S.,F.R.C.S.C.,Christopher M.Schlachta,M.D., F.A.C.S.,and Joseph Mamazza,M.D.,F.R.C.S.C.



es to the tail of the pancreas.The most important of these is calledthe pancreatica magna (a vessel familiar to vascular radiologists);occlusion of this branch with embolic material has been reportedto result in pancreatitis. Next, the splenic artery divides into twoto six first and second terminal branches, and these branchesundergo two further levels of division into two to 12 penultimateand ultimate branches. Segmental and subsegmental division canoccur either outside or inside the spleen. The number of arteriesentering the spleen ranges from six to 36. The size of the spleendoes not determine the number of arteries entering it; however,the presence of notches and tubercles usually correlates well witha higher number of entering arteries.

A reasonable general scheme of splenic artery branches mightinclude as many as seven principal branches at various divisionlevels and in various anatomic arrangements: (1) the superior

terminal artery, (2) the inferior terminal artery, (3) the medialterminal artery, (4) the short gastric arteries, (5) the left gas-troepiploic artery, (6) the inferior polar artery, and (7) the supe-rior polar artery [see Figure 2]. Veins are usually located behindthe corresponding arteries, except at the ultimate level of divi-sion, where they may be either anterior or posterior.

First Terminal Division Branches

A classic study from 1917 found that 72% of specimens hadthree terminal branches (superior polar, superior terminal, andinferior terminal) and 28% had two12; the medial terminal arterywas observed in only 20% of cases. When the superior terminalartery is excessively large, the inferior terminal is rudimentary,with an added blood supply often coming from the left gastroepi-ploic and polar vessels.

a

b

Aorta

Left GastricArtery

LeftGastroepiploicArtery

HepaticArtery

Inferior PolarArteries

Inferior PolarArteries

PancreaticaMagna

InferiorTerminalArtery

InferiorTerminalArtery

Superior PolarArtery


TransverseAnastomosis

TransverseAnastomosis

Short GastricArteries

Superior TerminalArtery


Ultimate Branch

Ultimate Branch

Penultimate Branch

PenultimateBranch

Short GastricArteries

Figure 1 Shown are (a) the distrib-uted type and (b) the magistral (bun-dled) type of splenic vascularization.



Second Terminal Division Branches

Superior polar artery The superior polar artery is presentin 65% of patients. It usually arises from the main splenic trunk(75% of cases) or the superior terminal artery (20% of cases), buton occasion, it may originate from the inferior terminal artery orseparately from the celiac axis (thus providing the spleen with adouble splenic artery). In most instances, the superior polar arterygives rise to one or two short gastric branches; rarely, it gives riseto the left inferior phrenic and pancreatic rami.The presence andsize of this artery appear to be correlated with tubercle formation,in that it is more prominent in spleens with large tubercles. Thesuperior polar artery is frequently very long and slender and thuseasily torn during splenectomy; accordingly, it was suggested in1928 that ligation of splenic branches be started from the inferiorpole of the spleen.13

Inferior polar artery The inferior polar artery is present in82% of cases. As many as five collateral branches may arise fromthe splenic trunk, the inferior terminal artery, or, as noted, the leftgastroepiploic artery. Inferior polar branches may have multipleorigins, and they tend to be of smaller caliber than the superiorpolar artery.

Left gastroepiploic artery The left gastroepiploic artery, themost varied of the splenic branches, courses along the left side ofthe greater curvature in the anterior layer of the greater omentum.In 72% of cases, it arises from the splenic trunk several centimetersfrom its primary terminal division, and in 22% of cases, it origi-nates from the inferior terminal artery or its branches; however, itmay also originate from the middle of the splenic trunk or from thesuperior terminal artery. Characteristically, the left gastroepiploicartery gives off inferior polar arteries, which vary in number (rang-ing from one to five), size, and length.Typically, these branches areaddressed first during laparoscopic splenectomy. When they aresmall, they can usually be controlled with the electrocautery.

Collaterals

Short gastric arteries As many as six short gastric arteriesmay arise from the fundus of the stomach, but as a rule, only theone to three that open into the superior polar artery must be li-gated during laparoscopic splenectomy [see Figure 1].

SUSPENSORY LIGAMENTS OF SPLEEN AND TAIL OF PANCREAS

Duplications of the peritoneum form the many suspensory lig-aments of the spleen [see Figure 3]. Medially and posteriorly, thesplenorenal ligament contains the tail of the pancreas and thesplenic vessels. Anteriorly, the gastrosplenic ligament contains theshort gastric and gastroepiploic arteries. In the lateral approach tolaparoscopic splenectomy [see Operative Technique, below], thesplenorenal and gastrosplenic ligaments are easily distinguished,and dissection of the anatomic structures they contain is relative-ly simple. In the anterior approach, these two ligaments lie on topof each other, and to separate them correctly and safely requiresconsiderable experience with splenic anatomy.

The phrenicocolic ligament courses laterally from thediaphragm to the splenic flexure of the colon; its upper portion iscalled the phrenicosplenic ligament.The attachment of the lowerpole on the internal side is called the splenocolic ligament.Between these two structures, a horizontal shelf of areolar tissue,known as the sustentaculum lienis, is formed on which the inferi-or pole of the spleen rests.The sustentaculum lienis is often mold-ed into a sac that opens cephalad and acts as a support for thelower pole. This structure, often overlooked during open proce-dures, is readily visible through a laparoscope. The phrenicocolicligament, the splenocolic ligament, and the sustentaculum lienisare usually avascular, except in patients who have portal hyper-tension or myeloid metaplasia.

A 1937 study found that the tail of the pancreas was in directcontact with the spleen in 30% of cadavers.14 A subsequent reportconfirmed this finding and added that in 73% of patients, the dis-tance between the two structures was no more than 1 cm.15 Caremust be exercised to avoid damage with the electrocautery during

FIRST TERMINALDIVISION

THIRD TERMINALDIVISION

FOURTH TERMINALDIVISION

SECOND TERMINALDIVISION

COLLATERALS

Splenic Artery


Short Gastric Vessels (1– 3)

Left GastroepiploicArtery

Inferior PolarArtery

Penultimate Branches (2–12)

Ultimate Branches (within Spleen) (2–12)


Inferior TerminalArtery

Medial TerminalArtery

Figure 2 Outlined is a general scheme of the levels of division of the splenic artery branches.



dissection as well as damage with the linear stapler in the courseof en masse ligation of the splenic hilum (a maneuver more easilyperformed via the lateral approach to laparoscopic splenectomy).

Laparoscopic Splenectomy

PREOPERATIVE EVALUATION

Currently, we consider all patients evaluated for electivesplenectomy to be potential candidates for laparoscopic splenec-tomy. Contraindications to a laparoscopic approach include severeportal hypertension, uncorrectable coagulopathy, severe ascites,and most traumatic injuries to the spleen. Extreme splenomegalyremains a relative contraindication as well. Because most patientsscheduled for laparoscopic splenectomy have hematologic disor-ders, they undergo the same hematologic preparation that patientsscheduled for open surgery do—namely, steroids and γ-globulins(when required). Ultrasonography is performed to determine the

size of the spleen. Spleen size is expressed in terms of the maxi-mum interpole length (i.e., the length of the line joining the twoorgan poles) and is generally classified into three categories: (1)normal spleen size (< 11 cm), (2) moderate splenomegaly (11 to20 cm), and (3) severe splenomegaly (> 20 cm).16 Becauseextremely large spleens present special technical problems that testthe current limits of laparoscopic surgery, we make use of a fourthcategory for spleens longer than 30 cm or heavier than 3 kg, whichwe call megaspleens [see Table 1]. The ultrasonographer is alsoasked to try to identify any accessory spleens that may be present.Computed tomography is done when there is doubt about theexactness of the ultrasonographic measurement; such measure-ment is sometimes inaccurate at the upper pole and with spleenslonger than 16 cm.

Patients receive thorough counseling about the consequences ofthe asplenic state. Polyvalent pneumococcal vaccine is adminis-tered at least 2 weeks before operation in all cases; preoperative vac-cination against Haemophilus influenzae and meningococci is also

Cardia

Short GastricVessels

GastrosplenicLigament

SplenorenalLigament

SplenicVessels

GastroepiploicArtery

PhrenicocolicLigament

SplenocolicLigament

GastrocolicLigament

Lesser Sac

GreaterOmentum

SustentaculumLienis

Figure 3 Depicted are the suspensoryligaments of the spleen.



advisable. Heparin prophylaxis for thrombophlebitis is administeredaccording to standard guidelines, provided that there is no hema-tologic contraindication [see 6:6 Venous Thromboembolism]. Nonsteroidalanti-inflammatory drugs (NSAIDs) are often given orally beforeoperation to minimize postoperative pain; however, on empiricalgrounds, NSAIDs are not used when heparin prophylaxis is em-ployed. Platelets are rarely, if ever, required when laparoscopicsplenectomy is performed for idiopathic (immune) thrombocy-topenic purpura (ITP).

OPERATIVE PLANNING

Laparoscopic splenectomy presents special problems, such asthe necessity of dealing with a fragile and richly vascularized organthat is situated close to the stomach, the colon, and the pancreasand the difficulty of devising an extraction strategy that is compat-ible with proper histologic confirmation of the pathologic processwhile maintaining the advantages of minimal access surgery. Forsuccessful performance of laparoscopic splenectomy, a detailedknowledge of both splenic anatomy and potential complications isessential. The operative strategy is largely determined by theanatomic features, which, as noted [see Anatomic Considerations,above], may vary considerably from patient to patient.17

OPERATIVE TECHNIQUE

Lateral Approach

This approach was first described in connection with laparoscop-ic adrenalectomy and is currently used for most laparoscopic splen-ectomies.18 At present, the only indication for the anterior approachto laparoscopic splenectomy is the presence of massive splenomegalyor a megaspleen.Typically, this alternative approach is taken whena spleen reaches or exceeds 23 cm in length or 3 kg in weight.

Step 1: placement of trocars The patient is placed in theright lateral decubitus position, much as he or she would be for

a left-side posterolateral thoracotomy. The operating table isflexed and the kidney bolster raised to increase the distancebetween the lower rib and the iliac crest. Usually, four 12 mmtrocars are used around the costal margin so that the camera, theclip applier, and the linear stapler can be interchanged with max-imum flexibility [see Figure 4]. The trocars must be far enoughapart to permit good working angles. Some advantage may begained from tilting the patient slightly backward; this step givesthe operating team more freedom in moving the instrumentsplaced along the left costal margins, especially during liftingmovements, when it is easy for instrument handles to touch theoperating table. For the same reason, it is also advisable to placethe anterior or abdominal side of the patient closer to the edgeof the operating table.

A local anesthetic is infiltrated into the skin at the midpoint ofthe anterior costal margin, and a 12 mm incision is made.The firsttrocar is inserted under direct vision, and a symmetrical 15 mmHg pneumoperitoneum is created.The locations of the remainingtrocars are determined by considering the anatomic configurationin relation to the size of the spleen to be excised. In most cases, thefourth posterior trocar cannot be inserted until the splenic flexureof the colon has been mobilized. Accordingly, the procedure isusually started with three trocars in place.

12 mm

12 mm

1

23

4

UsualExtractionSite

Figure 4 Laparoscopic splenectomy: lateralapproach. Shown is standard trocar placement. Fourtrocars are used. In most cases, the procedure isbegun without the posterior trocar in place.

Table 1 Classification of Spleens According to Spleen Length*

Spleen Class

Normal-size spleenModerate splenomegalyMassive splenomegalyMegaspleen

Spleen Length

7–11 cm12–20 cm21–30 cm

> 30 cm

*Spleen length is defined as interpole length, measured along a straight line connectingthe two poles.



Troubleshooting. After years of using the Veress needle, we nowprefer the open method of inserting the first trocar. It is true thatuse of the Veress needle is for the most part safe; however, the smallnumber of catastrophic complications that occur with blind meth-ods of first trocar insertion are more and more difficult to justify.Admittedly, these complications are infrequent, and thus, it isunlikely that even a large randomized trial would be able to showany significant differences between various methods of first trocarinsertion. Nevertheless, even though complications occur with theopen method of first trocar insertion as well, they are very uncom-mon and tend to be limited to trauma to the intestine or the omen-tal blood vessels; they do not have the same serious consequencesas the major vessel injury that may arise from blind trocar insertion.

Trocar placements differing from the ones we describe may beconsidered. More experienced surgeons (or those simply wishingto make the procedure easier) may choose to replace one or two12 mm trocars with 5 mm trocars [see Figure 5a].The procedurecan also be performed with only three trocars. In leaner patients,one of the trocars can be inserted into the umbilicus to gain a cos-metic advantage.The advent of needlescopic techniques has madeit possible to replace some of the 5 and 12 mm trocars with 3 mmtrocars. The ultimate (i.e., least invasive) technique, usuallyreserved for lean patients with ITP and normal-size spleens,involves one 12 mm trocar placed in the umbilicus and two 3 mmtrocars placed subcostally [see Figure 5b]. This approach requirestwo different camera-laparoscope setups, so that a 3 mm laparo-scope can be interchanged with a 10 mm laparoscope as necessaryto permit application of clips or staplers through the umbilicalincision once the dissection is completed. The specimen is thenretrieved through the umbilicus. Because the use of 3 mm laparo-scopes is accompanied by a decrease in available intra-abdominallight and focal width, a meticulously bloodless field and sophisti-cated surgical judgment are critical for successful performance ofneedlescopic splenectomy.

Step 2: search for and retrieval of accessory spleens Thecamera is inserted, and the stomach is retracted medially to exposethe spleen. Then a fairly standard sequence is followed. A thor-ough search is then made for accessory spleens. To maximizeretrieval, all known locations of accessory spleens should be care-

fully explored [see Figure 6]. Any accessory spleens found shouldbe removed immediately; they are considerably harder to locateonce the spleen is removed and the field is stained with blood.

Troubleshooting. It is especially important to retrieve accessoryspleens from patients with ITP, in whom the presence of overlookedaccessory spleens has been associated with recurrence of the disease.Remedial operation for excision of missed accessory spleens hasbeen reported to bring remission of recurrent disease; such operationcan be performed laparoscopically.The overall retrieval rate for ac-cessory spleens should fall between 15% and 30%.

Splenic activity has been demonstrated after open and laparo-scopic splenectomy for trauma and hematologic disorders19,20;accordingly, it is advisable to wash out and recover all splenic frag-ments resulting from intraoperative trauma at the end of the pro-cedure.This step is particularly important for patients with ITP, inwhom intraoperative trauma to the spleen is thought to contributeto postoperative scan-detectable splenic activity. As of this writing,we have recovered accessory spleens in 33% of ITP cases treatedlaparoscopically.

Step 3: control of vessels at lower pole, demonstration of“splenic tent,” and incision of phrenicocolic ligament Thesplenic flexure is partially mobilized by incising the splenocolic lig-ament, the lower part of the phrenicocolic ligament, and the sus-tentaculum lienis.The incision is carried slightly into the left sideof the gastrocolic ligament.This step affords access to the gastro-splenic ligament, which can then be readily separated from thesplenorenal ligament to create what looks like a tent.This maneu-ver cannot be accomplished in all cases, but when it can be done,it simplifies the procedure considerably.The walls of this so-calledsplenic tent are made of the gastrosplenic ligament on the left andthe splenorenal ligament on the right, and the floor is made up ofthe stomach. In fact, this maneuver opens the lesser sac in its lat-eral portion (a point that is better demonstrated with gentleupward retraction of the splenic tip) [see Figure 7].

The branches of the left gastroepiploic artery are controlledwith the electrocautery or with clips, depending on the size of thebranches.The avascular portion of the gastrosplenic ligament, sit-uated between the gastroepiploic artery and the short gastric ves-

Figure 5 Laparoscopic splenectomy: lateral approach. Shown are alternative trocar placements. (a) In some patients (e.g., thin patientswith normal-size spleens), a 12 mm trocar may be placed in the umbilicus to gain a cosmetic advantage, and most of the other trocars maybe downsized to 5 mm. (b) In the needlescopic approach, only three trocars are placed: a 12 mm trocar in the umbilicus and two 3 mm subcostal trocars.Two camera-laparoscope setups (3 and 10 mm) are required.

a b



sels, is then incised sufficiently to expose the hilar structures in thesplenorenal ligament.To accomplish this, the lower pole is gentlyelevated; in this position, the spleen almost retracts itself as it nat-urally falls toward the left lobe of the liver. At this point, the sur-geon can usually assess the geography of the hilum and determinethe degree of difficulty of the operation.The fourth trocar, if need-ed, is then placed posteriorly under direct vision, with care takento avoid the left kidney. Caution must also be exercised in placingthe trocars situated immediately anterior and posterior to the iliaccrest. The iliac crest can impede movement and hinder upwardmobilization of structures if the trocars are placed over it ratherthan in front of or behind it [see Figure 8].

Finally, the phrenicocolic ligament is incised all the way to theleft crus of the diaphragm, either with a monopolar electrocauterywith an L hook or with scissors. A small portion of the ligament isleft to keep the spleen suspended and facilitate subsequent bag-ging.The phrenicocolic ligament is avascular except in patients withportal hypertension or myeloproliferative disorders (e.g., myeloidmetaplasia). Leaving 1 to 2 cm of ligament all along the spleen sidefacilitates retraction and handling of the spleen with instruments.

Troubleshooting. Remarkably few instruments are needed forlaparoscopic splenectomy: most of the operation is done withthree reusable instruments. A dolphin-nose 5 mm atraumaticgrasper is used to elevate and hold the spleen. It is also used to sep-arate tissue planes and vessels with blunt dissection because itsatraumatic tip is easily insinuated between tissue planes. A gentlycurved 5 mm fine-tip dissector (Crile or Maryland) and a 10 mm90º right-angle dissector are the only other tools required for cost-efficient dissection.

When a powered instrument is called for, we use a monopolarelectrocautery with an L hook or a gently curved scissors.Alternatively, an ultrasonic dissector or a tissue-welding devicemay be used, albeit at a much higher cost.

Step 4: dealing with splenic hilum and tailoring operativestrategy to anatomy It is advisable to base one’s operativestrategy on the specific splenic anatomy. If a distributed anatomy

a

Greater Omentum(12%)

Mesentery(0.5%)

Left Ovary(0.5%)

Hilar Region (54%)

Pedicle (25%)

Tail of Pancreas (6%)

Splenocolic Ligament (2%)

Figure 6 Laparoscopic splenectomy: lateral approach.(a) Accessory spleens are known to occur at specificsites. (b) Shown is an accessory spleen.

b

Figure 7 Laparoscopic splenectomy: lateral approach. The so-called splenic tent is formed by the gastrosplenic and splenorenalligaments laterally and the stomach below.



is present, the splenic branches are usually dissected and clipped.This is not only the least costly approach but also the simplest, inthat the vessels are spread over a wider area of the splenic hilumand are easier to dissect and separate [see Figure 9].

A bundled anatomy lends itself more to a single use of the lin-ear stapler, provided that the tail of the pancreas is identified anddissected away when required.When possible, a window is creat-ed above the hilar pedicle in the splenorenal ligament so that allstructures can be included within the markings of the linear sta-pler under direct vision [see Figure 10].The angles provided by thevarious trocars make this maneuver much easier via the lateralapproach than via the anterior approach. Dissection continueswith individual dissection and clipping of the short gastric vessels;occasionally, these vessels can also be taken en masse with the lin-ear stapler. So far, we have not used sutures in this setting, exceptonce to control a short gastric vessel that was too short to beclipped safely.This portion of the operation is performed while thespleen is hanging from the upper portion of the phrenicocolic lig-ament, which has not yet been entirely cut.

Troubleshooting. It is at this point in the procedure that experi-ence in designing the operative strategy pays off in reduced oper-ating time. Because of the many variations in size, shape, vascularpatterns, and relations to adjacent organs, spleens are almost asindividual as fingerprints. Accordingly, an experienced spleen sur-geon learns to keep an open mind with regard to operative strate-gy and must be able to call on a wide range of skills to facilitate theprocedure.

The surgeon should start by looking at the internal surface ofthe spleen. If the splenic vessels cover more than 75% of the inter-nal surface (as is the case in 70% of patients), a distributed anato-my is present. With a distributed vascular anatomy, the vesselstend to be easier to dissect and isolate and thus can be readily (andcost-effectively) controlled with clips. On the other hand, if thesplenic vessels entering the spleen cover only 25% to 35% of theinner surface of the hilum (30% of patients), the pattern is bun-dled. With a bundled vascular anatomy, the vessels, being fewerand closer together, can usually be controlled with a single appli-cation of the vascular stapler across the hilum, provided that thetail of the pancreas can be protected.

Step 5: extraction of spleen A medium-size or large heavy-duty plastic freezer bag, of the sort commercially available in gro-cery stores, is used to bag the spleen. This bag is sterilized andfolded, then introduced into the abdominal cavity through one ofthe 12 mm trocars [see Figure 11]. The bag is unfolded and thespleen slipped inside to prevent splenosis during the subsequentmanipulations. Grasping forceps are used to hold the two rigidedges of the bag and to effect partial closure. Bagging is facilitat-ed by preserving the upper portion of the phrenicocolic ligament.After final section of the phrenicocolic ligament and any diaphrag-matic adhesions present, extraction is performed through one ofthe anterior port sites. Extraction through a posterior site is moredifficult because of the thickness of the muscle mass; usually, theincision must be opened, and more muscle must be fulguratedthan is desirable.

The subcostal or umbilical incision through which extraction isto take place is extended slightly. A grasping forceps is insertedthrough the extraction incision to hold the edges of the bag insidethe abdomen. Gentle traction on the bag from outside brings thespleen close to the peritoneal surface of the umbilical incision andthen out of the wound [see Figure 12]. Specimen retrieval bags

Rib Margin

Iliac Crest

Figure 8 Laparoscopic splenectomy: lateral approach. Shown isthe recommended trocar placement around the iliac crest.

a b

Figure 9 Laparoscopic splenectomy: lateral approach. (a, b) Clipping is well suited to controlling shortgastric or gastroepiploic vessels. It is also appropriate for distributed-type splenic vasculatures, in whichmore splenic vessels are spread over a wider area of the hilum.



have been developed that can accommodate a normal-size spleenand thus make bagging much easier, but they are costly.

A biopsy specimen of a size suitable for pathologic identificationis obtained by incising the splenic tip. The spleen is then frag-mented with finger fracture, and the resulting blood is suctioned.The remaining stromal tissue of the spleen is then extractedthrough the small incision, hemostasis is again verified, and all tro-cars are removed. No drains are used. The incisions are closedwith absorbable sutures and paper strips.

Troubleshooting. The freezer bags can be more easily intro-duced into the abdomen if they are pulled in rather than pushedin [see Figure 11].This may be accomplished by bringing out a 5mm toothed grasper through the introduction trocar from anoth-er properly angled trocar, grasping the specimen bag, and pullingthe bag back down through the trocar.A laparoscopic hernia meshintroducer may also be used.

Slipping the spleen into a freezer bag is also an acquired skillthat takes some time to master. It is an important skill that is use-ful in many other instances where specimen retrieval is needed(e.g., in procedures involving the gallbladder, the appendix, theadrenal glands, or the colon). In addition, it is highly cost-effective,in that these commercially available bags cost only a few centseach. Admittedly, laparoscopic retrieval bags are easier to use, buttheir substantially higher cost can become a factor in a busy min-

a

b

c

Figure 10 Laparoscopic splenectomy: lateral approach. (a through c)Stapling is particularly well suited to the compact hilum found in themagistral-type distribution of splenic vessels. As shown, all of the vas-cular structures are within the stapler markers, and the tail of thepancreas is well protected.

Figure 11 Laparoscopic splenectomy: lateral approach.Illustrated is the introduction of a sterile freezer bag for specimenextraction via the pull method. A toothed grasper is passed acrossthe abdomen between two trocars and brought out through the 12mm umbilical trocar site. This grasper is used to pull the extrac-tion bag back into the abdomen.

Figure 12 Laparoscopic splenectomy: lateral approach. Shown isthe position of the specimen bag before finger fragmentation orpulp suction.



imally invasive surgery unit. We use a powerful suction machine(–70 mm Hg) and a custom-made sharp beveled 10 mm cannulato suction splenic tissue from the plastic retrieval bag.

Anterior Approach

The anterior approach is seldom used nowadays; however, itremains the preferable approach in some patients with massivesplenomegaly (21 to 30 cm long) and all patients with mega-spleens (> 30 cm or > 3 kg) with the aid of hand-assisted devices[see Special Considerations, Hand-Assisted LaparoscopicSplenectomy, below]. Very large spleens are extremely heavy anddifficult to manipulate with laparoscopic instruments, and it iscomplicated to lift them so as to gain access to the phrenicocolicligament posteriorly.The anterior approach can also be consideredif another procedure (e.g., cholecystectomy) is being contemplat-ed; alternatively, in this situation, the lateral approach can be used,and the patient can be repositioned for the secondary procedure.

Step 1: placement of trocars Under general anesthesia, thepatient is placed in a modified lithotomy position to allow the sur-geon to operate between the patient’s legs and to allow the assis-tants to stand on each side of the patient. The procedure is per-formed through five trocars in the upper abdomen [see Figure 13],with the patient in a steep Fowler position with left-side elevation.A 12 mm trocar is introduced through an umbilical incision, anda 10 mm laparoscope (0° or 30°) is connected to a video system.A 12 mm trocar is placed in each upper quadrant, and two 5 mmtrocars are inserted close to the rib margin on the left and rightsides of the abdomen. Alternatively, trocars can be deployed in asemicircle away from the left upper quadrant.Trocar sites are care-fully selected to optimize working angles. The 12 mm ports areused to allow introduction of clip appliers, staplers, or the laparo-scope from a variety of angles as needed.

Troubleshooting. With increasing experience, we find that weprefer to do as many laparoscopic splenectomies as possible via

the lateral approach because it is so much easier, even with spleensthat are longer than 20 cm and are readily palpable.The decisionis arbitrarily made on the basis of estimated available workingspace. If the spleen comes too close to the iliac crest or the mid-line, the anterior approach should be taken instead.

Step 2: isolation of lower pole and control of blood supply The left hepatic lobe is retracted, and the stomach isretracted medially to expose the spleen. Accessory spleens aresearched for, and the phrenicocolic ligament, the splenocolic lig-ament, and the sustentaculum lienis are incised near the lowerpole with an electrocautery and a hook probe or with scissors.Vascular adhesions—frequently found on the medial side of thespleen—are cauterized.The gastrocolic ligament is carefully dis-sected close to the spleen, and the left gastroepiploic vessels areligated one by one with metallic clips or, if small, simply cauter-ized. The upper and lower poles of the spleen are gently liftedwith one or both palpators (placed through the 5 mm ports) toexpose the splenic hilum and the tail of the pancreas within thesplenorenal ligament, thereby facilitating individual dissectionand clipping of all the branches of the splenic artery and veinclose to the spleen. The short gastric vessels are then identifiedand ligated with clips or, occasionally, with staples. No suturesare used. Alternatively, the splenic artery itself can be isolatedand clipped within the lesser sac before extensive dissection ofthe lower pole and suspensory ligaments.

Because of the segmental and terminal distribution of splenicarteries, it is easy to determine the devascularized portions of thespleen: these segments exhibit a characteristic grayish color,whereas the vascularized segments retain a pinkish hue.When theorgan is completely isolated, it is left in its natural cavity, and hemo-stasis is verified.

Troubleshooting. If one elects first to clip the splenic artery withinthe lesser sac, there are a few precautions that must be taken. First,the clipping must be done distal to the pancreatica magna to prevent

5 mm

5 mm

12 mm

12 mm

12 mm

Usual Extraction Site

AlternateSurgical Extraction

Figure 13 Laparoscopic splenectomy: anterior approach. Shown isstandard trocar placement. The umbilical site is used for the camera.The remaining trocars are placed in the left and right upper quadrants,the epigastrium, and the right subcostal region. Depending on the size ofthe spleen, the trocars can also be disposed in a semicircle away from theleft upper quadrant.



pancreatic injury. Second, one must make sure that the splenicartery proper is clipped, not one of its branches (e.g., the superiorterminal branch).This is an easy mistake to commit with the distrib-uted type of splenic vasculature [see Figure 1] because the splenicartery itself is short and the branches can take off very early.Third,one must always keep in mind the possibility of an anastomoticbranch between the major splenic branches, as described by Tes-tut.11 Should a major terminal branch be clipped rather than thesplenic artery proper, there will be no spleen ischemia if such ananastomosis is present [see Figure 1].

Yet another challenge posed by the anterior approach is that ifbleeding occurs, the blood tends to pool in the area of the hilumand obscure vision even more, whereas in the lateral approach, theblood tends to flow away from the operative field. One quicklylearns that there is a steep price to pay for cutting corners duringthe dissection. The dissection must be meticulous, especiallybehind branches of the splenic vein.

Step 3: extraction of spleen Given that the anteriorapproach is now used only in cases of massive splenomegaly ormegaspleen, bagging can be problematic.The largest commercial-ly available freezer bag we have seen measures 27 by 28 cm, andthe largest spleen we have been able to bag in one of them was 24cm long. Furthermore, an accessory extraction incision is oftenrequired; a Pfannenstiel incision gives better cosmetic results, buta left lower quadrant incision can also be used. Hand-assisteddevices are used with increasing frequency in laparoscopicremoval of large spleens [see Special Considerations, Hand-Assist-ed Laparoscopic Splenectomy, below].

If the spleen cannot be bagged, it may be fragmented in thepelvis before extraction, provided that the abdomen is copiouslywashed and cleaned of any residual spleen fragments before clo-sure to prevent splenosis. Most patients with large spleens havehematologic malignancies; thus, residual splenic activity is not ascrucial an issue in these patients as it would be in others.

Laparoscopic Partial Splenectomy

Concern regarding the risk of OPSI has encouraged the prac-tice of preserving splenic tissue and function whenever possible.For this reason, partial splenectomy has occasionally been indi-cated for treatment of benign tumors of the spleen and for exci-sion of cystic lesions.21 Its use has been described in connectionwith the management of type I Gaucher disease, cholesterylester storage disease, chronic myelogenous leukemia, and tha-lassemia major, as well as with the staging of Hodgkin dis-ease.22,23 Partial splenectomy has also been an option in themanagement of splenic trauma when the patient’s condition isstable enough to permit the meticulous dissection required forthe operation.24,25

Like standard laparoscopic splenectomy, laparoscopic partialsplenectomy is performed with the patient in the right lateral decu-bitus position.Trocar placement is similar as well.The splenocolicligament and the lower part of the phrenicocolic ligament areincised to permit mobilization of the lower pole of the spleen. If thelower portion of the spleen is to be excised, branches of the gas-troepiploic vessels supplying the lower pole are dissected andclipped close to the parenchyma.An appropriate number of penul-timate branches of the inferior polar artery are then taken in sucha way as to create a clear line of demarcation between normalspleen and devascularized spleen. This process is continued untilthe desired number of splenic segments are devascularized.

Next, a standard monopolar electrocautery is used to score the

splenic capsule circumferentially, with care taken to ensure that a5 mm rim of devascularized splenic tissue remains in situ; this isthe most important technical point for this procedure [see Figure14].The incision is then carried into the splenic pulp. Atraumaticintestinal graspers are also used to fracture the splenic pulp in abloodless fashion. The laparoscopic L hook and scissors provideexcellent hemostatic control.

Once the spleen has been allowed to demarcate, resection isremarkably bloodless, provided that the 5 mm rim of ischemic tis-sue is left in place. Complete control of the splenic artery is notrequired before splenic separation, because division occurs in anischemic segment of spleen.9 The feasibility of leaving portions ofischemic spleen in situ has been demonstrated in a large prospec-tive, randomized trial involving partial splenic embolization as pri-mary treatment of hematologic disorders.26

If the superior pole is to be removed, the phrenicocolic ligamentmust be incised almost entirely so that the spleen can be easilymobilized and the proper exposure achieved. The short gastricbranches are taken first, along with the desired number of superi-or polar artery branches.

Laparoscopic partial splenectomy can be performed either withor without the aid of selective preoperative arterial embolization(see below). Radiologists are capable of cannulating the desiredsegmental splenic arterial branch and embolizing the segment thatis to be resected.We have removed the superior pole in a patientwith a class IV isolated splenic injury sustained while skiing8;laparoscopic partial splenectomy was made possible largely by theaccuracy of selective arterial embolization, which permitted con-trol of the bleeding and allowed laparoscopy to be performed inunhurried conditions.27

Preoperative Splenic Artery Embolization

Preoperative splenic artery embolization is used as an adjuvantin a few patients to make laparoscopic splenectomy possible andto reduce blood loss. Although it is now infrequently used, itremains a useful tool in the armamentarium of spleen surgeons.

Generally speaking, the technique involves embolization of thespleen with coils placed proximally in the splenic artery andabsorbable gelatin sponges and small coils placed distally in eachsplenic arterial branch (the double embolization technique), withcare taken to spare vessels supplying the tail of the pancreas [seeFigure 15].

The procedure is ended when it is estimated radiologically that80% or more of the splenic tissue has been successfully embolized.In most cases, successful embolization is achieved with both prox-imal and distal emboli; in a minority of cases, it is achieved withproximal emboli alone or with distal emboli alone.28

Troubleshooting Preoperative splenic artery embolization issafe, provided that two main principles are adhered to. First,embolization must be done distal to the pancreatica magna toavoid damaging the pancreas. Second, neither microspheres norabsorbable gelatin powder should be used, because particles ofthis small size may migrate to unintended target organ capillariesand cause tissue necrosis; only coils and absorbable gelatin spongefragments should be used.

POSTOPERATIVE CARE

Postoperative care for patients who have undergone laparo-scopic splenectomy is usually simple.The nasogastric tube insert-ed after induction of general anesthesia is removed either in therecovery room, once stomach emptying has been verified, or the



next morning, depending on the duration and the degree of tech-nical difficulty of the procedure. The urinary catheter is usuallyremoved before the patient leaves the recovery room.The patientis allowed to drink clear fluids on the morning after the operation;when clear fluids are well tolerated, the patient is allowed to pro-ceed to a diet of his or her choice.

If the patient has no history of ulcer or dyspepsia, one naprox-en sodium tablet (500 mg) is given with sips of water on the morn-ing before operation. Meperidine injections (1 mg/kg) are admin-istered during the first night, followed by oral acetaminophen (1 gevery 6 hours). If pain is not well controlled, coanalgesia with anNSAID is added; this combination produces the best results.Because of its side effects (i.e., nausea, vomiting, abdominal full-ness, and constipation), codeine is currently avoided if at all possi-ble.When naproxen sodium is used, prophylactic doses of subcu-taneous heparin are avoided on empirical grounds, especially if theplatelet count is low or platelet function is abnormal.

Patients receiving I.V. cortisone are given oral steroids onpostoperative day 1 after an overlap I.V. injection; thereafter,steroids are gradually tapered. Patients are allowed to shower 12hours after surgery and are advised to keep the paper strips cov-ering the trocar incisions in place for 7 to 10 days. No drains areused. No limitations are imposed on physical activity, andpatients are allowed to tailor their activities to their degree ofasthenia or discomfort.

COMPLICATIONS

Postoperative complications directly related to splenectomyinclude intraoperative and postoperative hemorrhage; left lowerlobe atelectasis and pneumonia; left pleural effusion; subphrenic

a b

c d

Figure 14 Laparoscopic splenectomy: partial splenectomy. (a, b) The splenic capsule is scored withthe monopolar cautery, and a 5 mm margin of devitalized tissue is left. (c) The splenic pulp is frac-tured with an atraumatic grasper. The electrocautery with the L hook is also used to controlparenchymal bleeding. (d) Shown is the cut surface of the spleen after transection. The operative fieldremains remarkably dry.

Figure 15 Laparoscopic splenectomy: splenic artery emboliza-tion. Shown are splenic angiograms of a patient with thromboticthrombocytopenic purpura before (left) and after (right) splenicartery embolization with 3, 5, and 7 cm coils and absorbablegelatin sponge fragments.



collection; iatrogenic pancreatic, gastric, and colonic injury; andvenous thrombosis.24-31

Successful laparoscopic splenectomy depends to a large extenton proper preparation. Recognition of anatomic elements andtheir arrangement is paramount. As with other laparoscopic pro-cedures, the keys are avoiding complications and minimizing tech-nical misadventures.Vascular structures should be cleanly isolatedand dissected from surrounding fat; they then can usually be con-trolled with two clips proximally and distally. Staplers should beused with care and should not be applied blindly. The stapler tipshould be clearly seen to be free of tissue before it is closed; oth-erwise, hemorrhage from partial section of a major splenic branchmight occur after the instrument is released. Blind application ofthe stapler may also result in damage to the tail of the pancreas,which often lies in close proximity to the inner surface of thespleen. If both clips and a linear stapler are used, it is vital to pre-vent interposition of clips in the staple line, which will cause thestapler to misfire and possibly to jam.

Improper use of the electrocautery during the procedure cancause iatrogenic injury to the stomach, the colon, or the pancreas.In a smoke-filled environment, where controlling vessels is difficultand time consuming, blind fulguration of fat in the hilum can leadto bleeding. Structures close to the lower pole in the gastrocolicligament can be approached more aggressively, but not those inthe hilum.To prevent arcing and spot necrosis, which may resultin delayed perforation and sepsis, the instrument should be acti-vated only in proximity to the target organ.

The assistants also play an important role in preventing com-plications. All instruments, including those handled by assistants,should be moved under direct vision. Especially in the anteriorapproach, retraction of the liver and stomach and elevation of thespleen require constant concentration if lacerations and subse-quent hemorrhage or perforation are to be avoided.

SPECIAL CONSIDERATIONS

Extraction of Specimens

Spleens removed via the anterior approach are extractedthrough the umbilical trocar site after finger fragmentation in aplastic bag. It is rarely necessary to enlarge the umbilical incisionto more than 2 or 3 cm.When the lateral approach is used, extrac-tion is more easily performed through one of the ports situatedanteriorly. This extraction site also requires little or no enlarge-ment. On occasion, for a spleen longer than 20 cm, a 7.5 to 10 cmPfannenstiel incision is made, and the operator’s forearm is intro-duced into the abdomen to deliver the spleen into the pelvis forextraction in large fragments under direct vision.32 The abdomenis copiously irrigated before closure.

Special mention should be made of extraction of the splenicspecimen from patients with malignant disease. If lymphoma orHodgkin disease is suspected, neither preoperative splenic arteryembolization nor finger fragmentation in a plastic bag should beperformed, for fear of making the histologic diagnosis difficult.Extraction of intact spleens through a small left subcostal or medi-an incision has also been employed when preservation of tissuearchitecture is required. Alternatively, a port site may be slightlyenlarged, and a knife or a Mayo scissors may be used to furnishthe pathologist with intact specimen pieces of various sizes. Thevarious techniques of fragmentation and extraction of splenic tis-sue during laparoscopic splenectomy should be discussed andagreed on with the pathologist ahead of time to ensure that prop-er pathologic diagnoses are not compromised by either necrotic

tissue (in the case of preoperative splenic artery embolization) oraltered tissue architecture (in the case of finger fragmentation),especially if malignancy is suspected but not proved. In practice,however, we have found that the diagnosis is made preoperativelyin more than 90% of patients with benign and malignant hemato-logic disease; hence, the issue rarely arises.

Hand-Assisted Laparoscopic Splenectomy

The term hand-assisted laparoscopic surgery refers to laparo-scopic procedures performed with the aid of a plastic deviceinserted in a 7.5 to 10 cm wound.This plastic hand port consistsof a sealed cuff that enables a hand to be inserted into and with-drawn from the abdomen without loss of pneumoperitoneum dur-ing the operation; in this way, the surgeon regains some of the tac-tile feedback lost in conventional laparoscopic surgery [see Figure16]. A number of different models have been developed, some ofthem quite expensive. Most use either an inflatable sleeve clippedto an O-ring, a spiral inflatable valve, or a flap valve to maintainpneumoperitoneum.

The optimal placement of the incision for a hand-assistedlaparoscopic splenectomy remains a subject of debate: recom-mended locations have included the upper midline, the rightupper quadrant, the left iliac fossa, and, for very large spleens, thePfannenstiel position.Whether the surgeon is left-handed or right-handed plays a role; most surgeons agree that the nondominanthand should be used in the device.

There are obvious advantages and drawbacks to hand-assistedlaparoscopic splenectomy.The most apparent disadvantage is thecosmetic cost of a longer abdominal incision (except when aPfannenstiel incision is employed). More generally, the use of alonger incision would seem to be at odds with the current trendtoward developing surgical techniques that reduce surgical traumaas much as possible. Nevertheless, comparative studies of splenec-tomy in patients with large spleens (> 700 g) seem to indicate thatfor the most part, the hand-assisted approach yields outcomessimilar to those of conventional laparoscopic splenectomy.33

Although the precise role of hand-assisted laparoscopic splenec-tomy remains to be defined, it is likely that this technique will finda place in the surgical management of patients with large spleens.In addition, the hand-assisted approach may be a valuable aid for

Figure 16 Laparoscopic splenectomy: hand-assisted. Shown isthe use of a hand port in the left lower quadrant to facilitatelaparoscopic splenectomy in a patient with a large spleen.



surgeons who have not yet completed the learning curve for con-ventional laparoscopic splenectomy. Finally, this technique mayrender preoperative splenic embolization unnecessary for mostvery large spleens.

OUTCOME EVALUATION

No randomized, prospective trials comparing open splenectomywith laparoscopic splenectomy have yet been conducted. At pres-ent, such trials are unlikely to be held, for a variety of reasons. Forone thing, randomization is difficult with procedures that are still inevolution.At one end of the spectrum, laparoscopic splenectomy isdone for patients with ITP, who usually are relatively healthy andhave normal-size spleens. In many of these patients, needlescopicinstruments (< 3 mm) can be used in conjunction with a single 12mm port site in the umbilicus.This approach permits hospital dis-charge within 24 hours of operation in a significant number ofcases. At the other end of the spectrum, laparoscopic splenectomyis done for patients with myeloid metaplasia and spleens longerthan 30 cm. In this setting, a laparoscopic approach poses formi-dable challenges, and the optimal technique and its justificationremain to be determined.The window of opportunity for random-ized comparative trials may have been lost.

Large case series and nonrandomized comparative trials, how-ever, have consistently reported better outcomes from laparoscop-ic splenectomy than from open splenectomy.34-41 For example, inone set of 528 patients [see Table 2],36-39 the rate of postoperativepneumonia was 1.1% (6/528), and no subphrenic abscesses oc-curred as postoperative complications. Many surgeons who havecompleted the learning curve associated with the procedure feelthat there is still room for improvement regarding complicationrates and length of stay for patients with ITP and other relativelybenign conditions necessitating laparoscopic splenectomy. Themore serious conditions and the mortality seen in conjunctionwith the procedure tend to occur in patients with advanced hema-tologic malignancies or megaspleens. In such cases, most of theadverse results are related to the disease state rather than to theoperation, and it remains to be seen whether laparoscopic splenec-tomy will have a positive effect on outcome.

One of the great attractions of minimally invasive surgery hasbeen the prospect of significant cost reductions. At this point inthe development of laparoscopic splenectomy, however, we arereluctant to place too much trust in premature cost analyses thatdo not take into account the “work in progress” nature of mini-mally invasive surgery. Most surgeons can now perform most

laparoscopic splenectomies with simplified trays of reusable in-struments. Our basic laparoscopic tray contains a few instru-ments and two sizes of reusable clip appliers with inexpensiveclips. As noted [see Operative Technique, above], clips are usedfor distributed-type spleens, and single-use linear staplers aremostly used for magistral-type spleens. To reduce costs, ultra-sonic dissectors are rarely used. In addition, the use of commer-cially available freezer bags instead of laparoscopic retrieval bagsfurther reduces the cost of specimen extraction. Finally, even ifintraoperative costs are higher with laparoscopic splenectomy,our experience is that the increase is offset by reductions in post-operative stay.

We, like most authorities, believe that as a surgeon gains expe-rience with laparoscopic splenectomy, operating time tends to falluntil it approaches that of open splenectomy.We also concur withthe numerous authors who have suggested that once laparoscopicsplenectomy is mastered, use of blood products tends to decreasesubstantially.

Open Splenectomy

PREOPERATIVE EVALUATION

With the growing acceptance of laparoscopic splenectomy, theindications for open splenectomy have essentially been reducedto (1) elective removal of megaspleens and (2) treatment ofsplenic trauma when conservative treatment either is not indi-cated or has failed. In rare cases, open splenectomy may be donefor iatrogenic injuries incurred during left upper quadrant surgi-cal procedures.

Preoperative evaluation for elective open splenectomy is similarto that for laparoscopic splenectomy [see LaparoscopicSplenectomy, Preoperative Evaluation, above]. Preoperative evalu-ation of trauma patients is covered in more detail elsewhere [see7:1 Initial Management of Life-Threatening Trauma]. Essentially, acoagulogram and blood typing and crossmatching are required. Apreoperative CT scan will have established the size of the spleen,the grade of the splenic injury, the presence of other injuries (ifany), and, in elective cases, the location and configuration of anymasses or cysts.

OPERATIVE PLANNING

Most surgeons would agree that the lessons learned from success-ful performance of minimally invasive procedures have had a positive

Table 2 Clinical Results of Laparoscopic Splenectomy

Authors

All diagnosesKatkhouda et al (1998)38

Targarona et al (2000)36

Park et al (2000)37

Poulin et al (2001)39

ITPTrias et al (2000)40

Poulin et al (2001)39

MalignancySchlachta et al (1999)41

Trias et al (2000)40

N

103122203100

4851

1428

ITP/Non-ITP

67/3654/68

129/7450/50

——

——

ConversionRate (%)

3.97.43.08.0

4.23.9

2114*

Length of Stay(days)

2.54.02.73.0

4.02.0

3.05.5

Accessory Spleen Present (%)

16.51212.325

1132

——

Morbidity(%)

6189

15

125.9

1828

Mortality (%)

000.54

N/A0

9N/A

OR Time(min)

161153145180

142160

239171

*71% required accessory incision because of spleen size.



impact on the refinement of the corresponding open procedures.The principles of careful appreciation of fine anatomic details (as de-scribed for laparoscopic splenectomy) and maximal reduction of tis-sue trauma from retractors or excessive tissue handling should be in-corporated into the planning of open splenectomy.

Total versus Partial Splenectomy

As a consequence of the recognition that splenectomy renderspatients susceptible to a lifelong risk of OPSI, it is now routinepractice to attempt splenic conservation. Accordingly, saving nor-mally functioning splenic parenchyma has become the mostimportant goal in the management of splenic injuries. In some50% of adults (and over 80% of children), this goal can beachieved by means of nonoperative treatment. In approximately20% of adults, splenorrhaphy and partial splenectomy are possi-ble; splenectomy is indicated in the remainder. Partial splenecto-my is also favored on occasion when excision of splenic tissue isrequired for the treatment of other elective conditions.

For the sake of brevity, we describe the surgical technique fortotal splenectomy and partial splenectomy concurrently, notingdifferences only where significant.

OPERATIVE TECHNIQUE

Step 1: Incision

The patient is supine, in a reverse Tredelenburg position with a15° tilt to the right. For maximal exposure, a midline incision ismade, starting on the left side of the xiphoid process [see Figure 17].The incision is extended below the umbilicus for a variable distance,depending on circumstances such as the size of the patient, the surgi-cal situation (traumatic versus nontraumatic), the possibility of asso-ciated injury, and the size of the spleen. Occasionally, a left subcostalincision may be used for nontraumatic indications in patients withnormal-size spleens.This incision may be extended onto the rightside to form a chevron incision if necessary; however, this may im-pede the search for accessory spleens. Some surgeons have per-

formed splenectomy via a thoracoabdominal approach, but mosthave abandoned this approach. Appropriate retraction of the leftlobe of the liver and the abdominal wall is achieved with the help ofsurgical assistants placed on each side of the table or the use of self-retaining retractors.

Troubleshooting In trauma cases, the anesthetist shouldalways be informed when the peritoneum is opened; release of atense hemoperitoneum can precipitate hypotension with the lossof tamponade.

Step 2: Evacuation of Blood and Packing of the Abdomen

In trauma cases, gross blood and clots are evacuated manuallywith large laparotomy sponges. All quadrants of the abdomen arethen packed with laparotomy pads. Standard suction equipment isnot very useful for evacuating large quantities of blood from theabdomen.

Step 3: Control of Splenic Artery

Once other major injuries are excluded, the first decision to bemade is whether to control the splenic artery first or to mobilizethe spleen to the midline.This decision is dictated by the urgencyof the clinical situation, the spleen size, and the presence of under-lying disease.

If the decision is made to control the splenic artery first, the mainsplenic trunk is identified above the pancreas via an approach thatleads to the lesser sac either through the gastrocolic ligament orthrough the avascular plane of the greater omentum above the distaltransverse colon. Once dissected, the artery is controlled with a vas-cular loop.The main artery can also be accessed and dissected poste-riorly after the spleen is mobilized [see Figure 18].

Troubleshooting One advantage of dissecting the splenicartery in the lesser sac (as opposed to the hilum) is that the splenicvein is rarely damaged, being located under the pancreas and awayfrom the artery. Good proximal control of the splenic blood sup-ply facilitates the performance of the more complex variations ofpartial splenectomy or total splenectomy for megaspleens.

Step 4: Mobilization of Spleen

If the decision is made to mobilize the spleen first, as in mosttrauma cases, mobilization should be carried out in a carefullyplanned manner; it is all too easy to compound splenic injury withill-advised maneuvers that obligate the surgeon to perform a totalsplenectomy.

Gastric decompression is ensured with a properly placed naso-gastric tube.The spleen is then retracted anteromedially with theleft hand, with care taken to confirm proper retraction of the leftabdominal wall. The phrenicocolic ligament is thereby placed onstretch, and the ligament insertion on the lateral abdominal wallserves as countertraction. The phrenicocolic ligament is thenincised from the bottom up with either long scissors or the 45°-angle tip of a monopolar cautery [see Figure 19]. Efforts should bemade to leave 2 cm of ligament on the spleen side and to avoidcapsular injury. If the surgeon cannot put a finger behind the liga-ment, an assistant should elevate the ligament between the jaws ofa right-angle clamp.The incision of the phrenicocolic ligament isthen extended to the left crus of the diaphragm. Except in patientswith portal hypertension or myeloproliferative disorders, this liga-ment is avascular. The left lateral portion of the gastrocolic liga-ment (the greater omentum) is also dissected away from thesplenic flexure of the colon to facilitate mobilization of the spleen.

Figure 17 Open splenectomy. Shown are midline and left sub-costal incisions.



At this point, the splenocolic ligament and the sustentaculum lienis are left alone.

After complete division of the phrenicocolic ligament, a plane isdeveloped between the pancreas and the retroperitoneal structureswith gentle blunt finger dissection.The spleen can then be deliv-ered to the midline, where the splenectomy can be planned in anunhurried manner [see Figure 20]. Continuing splenic bleedingduring this maneuver can be controlled with manual compressionof the organ. The splenic pedicle may also be gently compressedbetween the thumb and the index finger at this stage. Laparotomysponges are placed in the left subphrenic space.

Troubleshooting When performing elective resections ofvery large spleens, experienced spleen surgeons use a few tricks tosimplify the procedure. In most patients with megaspleens, thesuspensory ligaments have been stretched over time, allowing thesurgeon much more leeway in mobilizing or turning the spleen.This greater leeway allows the surgeon to rotate the spleen fromthe lower pole so as to deliver it transversely into the incision.Thus, the presence of a large spleen does not always necessitatethe creation of a long xiphopubic incision, because a transverselyplaced spleen can be extracted into the abdominal wall through ashorter incision.

Step 5a (Total Splenectomy): Planning of Resection

To devise the appropriate operative strategy, the surgeon per-forming open total splenectomy must address the same anatomicissues that he or she would if performing laparoscopic totalsplenectomy—for example, the nature of the splenic blood supply(distributed or bundled) and the distance between the tip of thepancreas and the splenic hilum.The anatomy must be appreciat-ed before the operative strategy can be defined.

Once the spleen has been delivered into the abdominal wall,various techniques may be employed to control the blood supply.The classic approach is to serially clamp, ligate, or suture-ligate the

vessels between curved clamps, starting from the lower pole.Alternatively, the vessels may be controlled with clips.

Troubleshooting We frequently use laparoscopic clip appli-ers to achieve vascular control in open splenectomy. The long,slender design of these devices is particularly useful in obesepatients, in whom it is often difficult to achieve complete mobi-lization of the spleen without causing additional splenic trauma.With laparoscopic clip appliers, vessels can be safely controlledinside the abdomen. Locking plastic clips may also be used.

Spleen

Pancreas

Splenic Artery

Left GastroepiploicArtery

Stomach

Figure 18 Open splenectomy. Thesplenic artery is controlled above thepancreas in the lesser sac. The arterymust be ligated distal to the pancreat-ica magna artery.

Figure 19 Open splenectomy. With the spleen retractedmedially, the phrenicocolic ligament is incised.



Moreover, provided that the same precautions are taken as inlaparoscopic splenectomy, a linear stapler with a vascular cartridgemay be used to control the hilum in one step once the gastroepi-ploic branches have been controlled.

Step 5b (Partial Splenectomy): Planning of Resection

Once the spleen is appropriately placed for full evaluation andadequate hemostasis is ensured, planning for partial splenectomycan start. In trauma cases, such planning is guided by the extentof the injury, and in elective cases, it is guided by the nature of theunderlying pathologic condition [see Table 3].

In most cases, as noted, the spleen can be divided into inde-pendent lobes or segments, each with its own terminal blood sup-ply.The superior pole is supplied by the short gastric vessels, andthe lower pole is supplied by branches of the gastroepiploic artery,which are known to form anastomoses with the inferior polarartery. In addition, most patients, possible variations notwith-standing, have two or three major vessels entering the hilum.Thus,there are usually four or five discrete regions or lobes that may beremoved, individually or in combination, in a partial splenectomy.It should be kept in mind that the vessels supplying the spleen liein different supportive ligaments.The vessels supplying the supe-rior pole (the short gastrics) and the inferior pole (the gastroepi-ploic branches) rest in the gastrosplenic ligament, whereas thesplenic branches proper lie in the splenorenal ligament along withthe tail of the pancreas.

Step 6 (Partial Splenectomy): Exposure of Entire Hilum and Ligation of Appropriate Arteries

The entire hilum of the spleen is then exposed close to theparenchyma.The gastrosplenic ligament and the splenorenal liga-ment must be separated, with care taken to preserve the bloodsupply to both poles of the spleen.There is a fairly avascular area

of the gastrosplenic ligament, between the short gastric vesselssupplying the superior pole and the gastroepiploic branches sup-plying the lower pole, that must be opened; once this is done, acomplete view of the entire splenic blood supply is available.Thesurgeon can then determine whether partial splenectomy is feasi-ble and how many lobes he or she can resect while still leavingenough spleen tissue behind for adequate splenic function. Anynumber of segmental resections are possible. If the surgeon isunsure of the extent of the necessary resection, an accurate assess-ment can be made by temporarily compressing the splenic arteri-al branches.

Selected arterial branches are then carefully dissected as closeto the spleen parenchyma as possible, with the understanding thatthe veins are situated posteriorly in close proximity. The vesselsmay be doubly ligated, transfixed, or clipped. If clips are used, careis taken not to dislodge them with inappropriate manipulations.Once the arterial blood supply is controlled, the affected area ofthe spleen will rapidly become visibly demarcated. If the devital-ized area of the spleen corresponds to the intended resection, asimilar technique is applied to the venous side. Access to thevenous side can also be achieved from the posterior aspect of thespleen.When this approach is followed, it is helpful to identify thetail of the pancreas if possible to avoid inadvertent damage: the tailof the pancreas touches the hilum of the spleen in 30% of casesand lies within 1 cm of the hilum in 70%.

Step 7 (Partial Splenectomy): Incision of Splenic Capsule and Partial Resection of Spleen

The capsule of the spleen is incised circumferentially with ascalpel or a monopolar cautery, and a 5 mm rim of devitalized tis-sue is left in situ.The splenic fragments may be transected with ascalpel, scissors, a monopolar cautery, or a combination thereof.Various techniques have been used to control residual bleeding,including use of a monopolar cautery on spray current; use of acutaneous ultrasonic surgical aspirator; use of an argon beam

Stomach

Liver

Spleen

Figure 20 Open splenectomy. The spleen is delivered to the mid-line by means of blunt and sharp dissection of the areolar planebetween the kidney and the pancreas.

Table 3 Indications and Contraindications for Partial Splenectomy

Indications

Selected grade II–IV splenic injuries with the following:

Hemodynamic stabilityNo evidence of other intra-abdominal organ injuryNo associated head injuryNo coagulopathyCT confirmation of isolated splenic injury

Selective elective indications

Resection of nonparasitic cystsHamartomas and other benign splenic tumors Inflammatory pseudotumor of the spleenType I Gaucher diseaseCholesteryl ester storage diseaseChronic myelogenous leukemiaThalassemia majorSpherocytosisStaging of Hodgkin disease in children

Absolute/relative contraindications in trauma

Inadequate exposureInability to mobilize spleen and tail of pancreas to midlineInability to leave > 25% of splenic mass for complete splenic function



References

coagulator; suture compression, with or without Teflon pledgets;and omental pedicle packing. One low-tech way of dealing withresidual hemostatic requirements is to employ the hollow part ofa Poole suction device to aspirate blood while employing a coagu-lating monopolar current on the suction tip. In some cases, wrap-ping the splenic remnant in an absorbable polyglycolic mesh isuseful. Our experience suggests that when enough residual devi-talized tissue (i.e., at least 5 mm) is left behind circumferentially,good hemostasis is easily achieved, typically requiring nothingmore than simple measures and topical agents. No drains are usedunless the tail of the pancreas has been damaged, in which case aclosed-suction drain is placed.

POSTOPERATIVE CARE

The principles of postoperative care are essentially the same foropen splenectomy as for laparoscopic splenectomy [see Laparo-scopic Splenectomy, Postoperative Care, above], though mostauthors agree that the pace of aftercare is slower with the former.

It should be kept in mind that acute postoperative gastric disten-tion occurs more frequently in children and may necessitate moreprolonged gastric decompression.

COMPLICATIONS

The complications seen after open splenectomy are the same asthose seen after its laparoscopic counterpart [see LaparoscopicSplenectomy, Complications, above]. Hemorrhagic complicationsmay necessitate transfusion, reoperation, or both.

Although the rate of serious postoperative infection aftersplenic surgery is generally considered to be 8%, it is thought tobe lower in patients undergoing splenorrhaphy or partialsplenectomy.The lower rate is probably attributable to the pres-ence of less severe underlying injuries, rather than to the preser-vation of splenic tissue. Infectious complications usually mani-fest themselves between postoperative days 5 and 10 and are typ-ically diagnosed by means of physical examination, chest x-ray,ultrasonography, and CT.

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Acknowledgment

Figures 1, 3, 4, 6a, 13, and 17 through 20 Tom Moore.

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