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Splenectomy
Splenectomy CORNELIUS E. SEDGWICK
THE indications for splenectomy may be conveniently divided into two groups. The first group is directly related to the spleen itself, the indications are clear-cut and concern only the surgeon. The second group of indications for splenectomy involves altered functions of the spleen, altered physiology and pathology of the blood forming organs and is the concern of the hematologist (Table 1). Table I INDICATIONS FOR SPLENECTOMY
Group 1. 2. 3.
1 Splenic tumors Wandering spleen Ruptured spleen
Group 1. 2. 3. 4.
2 Familial hemolytic anemia Thrombocytopenic purpura Acquired hemolytic anemia Splenomegaly with hypersplenism
SURGICAL INDICATIONS
Benign splenic tumors are usually cysts. Large retention cysts may produce pressure symptoms on adjacent organs and require splenectomy. Hydatid cysts of the spleen do not present a problem in this country. Primary malignant tumors of the spleen, lymphosarcoma or Hodgkin's disease confined to the spleen should be removed. The wandering spleen is rare and becomes a problem only if there is torsion and pressure. Of those indications directly related to the spleen itself, ruptured spleen is by far the commonest indication for splenectomy. Even in this category the spleen is frequently abnormally enlarged, such as that found secondary to malaria. Ruptured spleen may be caused by direct external violence, by a stab or gunshot wound. The diagnosis of ruptured spleen is usually apparent if there is a history of trauma and there are signs and , 725
Cornelius E. Sedgwick
726
symptoms of blood loss, such as shock. The amount of blood loss is not necessarily reflected by the hematocrit reading. Vasoco"nstriction may compensate for blood loss and the hematocrit may vary little from normal. A better laboratory diagnostic aid is a rapidly rising white blood cell count to 40,000 or 50,000 in a matter of a few hours, stimulated by peritoneal irritation. Pain, tenderness, and spasm in the left side of the abdomen are common, as well as pain in the left shoulder from subdiaphragmatic irritation. One should be aware that rupture l'll:ay be intracapsular rather than into the free abdominal cavity. The patient may weather the initial injury and show little evidence clinically of severe trauma while an intracapsular hematoma of the spleen develops. This may rupture at a later date into the free abdominal cavity, producing all the si gns and symptoms of perforation and hemorrhage. All patients with the slightest suspicion of splenic rupture should be hospitalized and carefully followed. Immediate blood replacement and surgery should be available at a moment's notice. HEMATOLOGICAL INDICATIONS
The second group of indications for splenectomy (Table 1) involves careful blood studies and evaluation by a competent hematologist. Only the occasional surgeon who has confined his interests to the hematological problems associated with splenic disease will be competent to decide when splenectomy is indicated. It is a complex problem with changing opinions even among those best informed and it is wise for the general surgeon to be guided by his medical confreres when there is a question of the advisability of removing the spleen of a patient with a particular blood dyscrasia. It is generally agreed that splenectomy is indicated in the familial type of hemolytic anemia, but even with this blood dyscrasia a cure can be expected only if the proper preoperative diagnosis has been made. It should be emphasized that the other indications for splenectomy are not definite. Diagnosis is difficult and the results following splenectomy sometimes are beneficial and at other times seem to have little or no effect on the progress of the disease. Until we have more definite information relative to the function of the spleen and other hemopoietic organs and until more definite criteria are established regarding the indications for splenectomy, most surgeons should seek the help of competent hematologists before advising surgical treatment. CONTRAINDICATIONS
Competent hematologic study will reveal those diseases in which splenectomy is not indicated. The spleen should never be removed in any patient with agnogenic myeloid hyperplasia, for in this disease the spleen has taken over the hemopoietic function of the bone marrow. Splenec-
Splenectomy
727
tomy should be avoided when leukemia, Hodgkin's disease, pernicious anemia or polycythemia vera is present. Splenectomy is of no value in Mediterranean and sickle cell anemias. TECHNIQUE
The incision for splenectomy depends somewhat upon the pathologic process involving the spleen and the surrounding organs and the habitus of the patient. If the indication for splenectomy is perforation or rupture, a high, long, left rectus muscle-splitting incision is usually adequate not only for splenectomy but also for further abdominal exploration and possible surgery. If this incision for ruptured spleen is inadequate, as soon as the peritoneum is opened and the diagnosis confirmed, a transverse extension to the left should be made, which allows better access to the spleen. For elective splenectomy with a moderately enlarged spleen, such as that found in hemolytic anemia or thrombocytopenic purpura in an average patient with narrow or average costal angle, a long left rectus muscle-splitting incision is satisfactory. In a patient with a wide costal margin, however, or in a patient with congestive splenomegaly in which there is a possibility of perisplenitis with a tremendously enlarged spleen adherent to the diaphragm or when there is suspected bleeding from portal hypertension, a long transverse or subcostal incision extending from the midline well back to the lumbar muscles will be of greater technical assistance. If the spleen is extremely large and a splenorenal shunt for portal hypertension is to follow splenectomy, an abdominothoracic incision, extending the abdominal incision through the eighth interspace, gives adequate exposure and facilitates the operation. There are two types of splenectomy which depend upon the indications-an emergency splenectomy or an elective splenectomy. An emergency splenectomy is performed for a ruptured or perforated spleen. In such a case other abdominal organs frequently are injured. When the abdominal cavity is opened, the peritoneal cavity is frequently found to be filled with blood, and gastric and intestinal contents. The incision must be large enough to enable rapid exploration of the abdomen and all of the trauma quickly noted and evaluated. If splenectomy is indicated the technique is different from that employed in elective splenectomy. It is too time-consuming and difficult in the presence of massive hemorrhage to open the lesser sac, locate and ligate the splenic artery at its origin. It should be remembered that the splenic vessels are much more accessible from behind. With the operator on the right side, the left hand is quickly introduced over the spleen and the spleen retracted downward and to the right (Fig. 230). The peritoneal folds of the lateral gutter are divided, the splenorenal ligament is incised and the spleen retracted anteriorly. Bleeding often occurs from the vessels between the spleen and the diaphragm. A packing in the form of a long leg roll is placed beneath the
728
Cornelius E. Sedgwick
diaphragm. As this packing is inserted the spleen is gradually displaced downward and anteriorly, and the vessels entering the spleen from behind are easily visualized, ligated and divided. Care should be taken not to injure the stomach. The hemorrhage is controlled, the attachments to the stomach and colon can be divided more leisurely and the spleen
Fig. 230. Emergency splenectomy. Note posterior attachments are divided, packing (leg roll) is placed beneath diaphragm, and vessels are isolated and ligated from behind.
removed. The packing is then removed from beneath the diaphragm and any persistent bleeding is controlled. The technique for elective splenectomy is somewhat different. The gastrocolic omentum is divided and the lesser sac entered (Fig. 231). The stomach is mobilized along the entire greater curvature. With the stomach retracted upward and the large bowel downward, the
Splenectomy
729
body of the pancreas and spleen are well visualized. The splenic artery is then ligated near its origin. The spleen is approached from behind, dividing the posterior parietal peritoneum which allows the spleen to be brought anteriorly. Any remaining vasa brevia which are attached to the stomach are divided and the spleen is mobilized together with the tail of the pancreas. The vessels are ligated individually at the hilus of
Fig. 231. Elective splenectomy. Lesser sac is entered; attachments to stomach and bowel are divided, and splenic artery is ligated. Vessels are then isolated from behind as in emergency splenectomy (see Fig. 230). (From SURGICAL CLINICS of NORTH AMERICA 35: 675 [June] 1953.)
the spleen, taking care not to damage any of the pancreatic tissue. Hemostasis is assured. Careful exploration is made for accessory spleens. A drain is placed in the left upper quadrant and brought out through the incision, and the abdomen is closed. POSTOPERATIVE COMPLICATIONS
The complications following a carefully performed splenectomy should be relatively infrequent. There is always the problem of postoperative
730
Cornelius E. Sedgwick
hemorrhage but this should not occur if sufficient care is taken to assure hemostasis during the procedure. Following splenectomy the chance of a thrombosis and particularly pyelophlebitis which is exceedingly rare must be kept in mind. Such complications occur more frequently after splenectomy than after other abdominal operations because of the excessive rise in platelets that takes place immediately after splenectomy. On occasion it may be necessary to institute anticoagulation therapy. Infection may follow splenectomy particularly if the pancreas has been damaged. Subdiaphragmatic abscesses are more frequent after splenectomy than other abdominal procedures. This can be prevented by taking care not to injure pancreatic tissue and by instituting drainage through a stab wound in the flank in all cases of splenectomy. SUMMARY
Certain definite indications for splenectomy are directly related to the spleen itself, the most common of which is the ruptured spleen. The other indications for splenectomy require study and evaluation by the hematologist. In properly selected cases splenectomy may be expected to be of real value. The technique of splenectomy as described is dependent upon whether the operation is an emergency procedure or an elective procedure.
THE indications for splenectomy may be conveniently divided into two groups. The first group is directly related to the spleen itself, the indications are clear-cut and concern only the surgeon. The second group of indications for splenectomy involves altered functions of the spleen, altered physiology and pathology of the blood forming organs and is the concern of the hematologist (Table 1). Table I INDICATIONS FOR SPLENECTOMY
Group 1. 2. 3.
1 Splenic tumors Wandering spleen Ruptured spleen
Group 1. 2. 3. 4.
2 Familial hemolytic anemia Thrombocytopenic purpura Acquired hemolytic anemia Splenomegaly with hypersplenism
SURGICAL INDICATIONS
Benign splenic tumors are usually cysts. Large retention cysts may produce pressure symptoms on adjacent organs and require splenectomy. Hydatid cysts of the spleen do not present a problem in this country. Primary malignant tumors of the spleen, lymphosarcoma or Hodgkin's disease confined to the spleen should be removed. The wandering spleen is rare and becomes a problem only if there is torsion and pressure. Of those indications directly related to the spleen itself, ruptured spleen is by far the commonest indication for splenectomy. Even in this category the spleen is frequently abnormally enlarged, such as that found secondary to malaria. Ruptured spleen may be caused by direct external violence, by a stab or gunshot wound. The diagnosis of ruptured spleen is usually apparent if there is a history of trauma and there are signs and , 725
Cornelius E. Sedgwick
726
symptoms of blood loss, such as shock. The amount of blood loss is not necessarily reflected by the hematocrit reading. Vasoco"nstriction may compensate for blood loss and the hematocrit may vary little from normal. A better laboratory diagnostic aid is a rapidly rising white blood cell count to 40,000 or 50,000 in a matter of a few hours, stimulated by peritoneal irritation. Pain, tenderness, and spasm in the left side of the abdomen are common, as well as pain in the left shoulder from subdiaphragmatic irritation. One should be aware that rupture l'll:ay be intracapsular rather than into the free abdominal cavity. The patient may weather the initial injury and show little evidence clinically of severe trauma while an intracapsular hematoma of the spleen develops. This may rupture at a later date into the free abdominal cavity, producing all the si gns and symptoms of perforation and hemorrhage. All patients with the slightest suspicion of splenic rupture should be hospitalized and carefully followed. Immediate blood replacement and surgery should be available at a moment's notice. HEMATOLOGICAL INDICATIONS
The second group of indications for splenectomy (Table 1) involves careful blood studies and evaluation by a competent hematologist. Only the occasional surgeon who has confined his interests to the hematological problems associated with splenic disease will be competent to decide when splenectomy is indicated. It is a complex problem with changing opinions even among those best informed and it is wise for the general surgeon to be guided by his medical confreres when there is a question of the advisability of removing the spleen of a patient with a particular blood dyscrasia. It is generally agreed that splenectomy is indicated in the familial type of hemolytic anemia, but even with this blood dyscrasia a cure can be expected only if the proper preoperative diagnosis has been made. It should be emphasized that the other indications for splenectomy are not definite. Diagnosis is difficult and the results following splenectomy sometimes are beneficial and at other times seem to have little or no effect on the progress of the disease. Until we have more definite information relative to the function of the spleen and other hemopoietic organs and until more definite criteria are established regarding the indications for splenectomy, most surgeons should seek the help of competent hematologists before advising surgical treatment. CONTRAINDICATIONS
Competent hematologic study will reveal those diseases in which splenectomy is not indicated. The spleen should never be removed in any patient with agnogenic myeloid hyperplasia, for in this disease the spleen has taken over the hemopoietic function of the bone marrow. Splenec-
Splenectomy
727
tomy should be avoided when leukemia, Hodgkin's disease, pernicious anemia or polycythemia vera is present. Splenectomy is of no value in Mediterranean and sickle cell anemias. TECHNIQUE
The incision for splenectomy depends somewhat upon the pathologic process involving the spleen and the surrounding organs and the habitus of the patient. If the indication for splenectomy is perforation or rupture, a high, long, left rectus muscle-splitting incision is usually adequate not only for splenectomy but also for further abdominal exploration and possible surgery. If this incision for ruptured spleen is inadequate, as soon as the peritoneum is opened and the diagnosis confirmed, a transverse extension to the left should be made, which allows better access to the spleen. For elective splenectomy with a moderately enlarged spleen, such as that found in hemolytic anemia or thrombocytopenic purpura in an average patient with narrow or average costal angle, a long left rectus muscle-splitting incision is satisfactory. In a patient with a wide costal margin, however, or in a patient with congestive splenomegaly in which there is a possibility of perisplenitis with a tremendously enlarged spleen adherent to the diaphragm or when there is suspected bleeding from portal hypertension, a long transverse or subcostal incision extending from the midline well back to the lumbar muscles will be of greater technical assistance. If the spleen is extremely large and a splenorenal shunt for portal hypertension is to follow splenectomy, an abdominothoracic incision, extending the abdominal incision through the eighth interspace, gives adequate exposure and facilitates the operation. There are two types of splenectomy which depend upon the indications-an emergency splenectomy or an elective splenectomy. An emergency splenectomy is performed for a ruptured or perforated spleen. In such a case other abdominal organs frequently are injured. When the abdominal cavity is opened, the peritoneal cavity is frequently found to be filled with blood, and gastric and intestinal contents. The incision must be large enough to enable rapid exploration of the abdomen and all of the trauma quickly noted and evaluated. If splenectomy is indicated the technique is different from that employed in elective splenectomy. It is too time-consuming and difficult in the presence of massive hemorrhage to open the lesser sac, locate and ligate the splenic artery at its origin. It should be remembered that the splenic vessels are much more accessible from behind. With the operator on the right side, the left hand is quickly introduced over the spleen and the spleen retracted downward and to the right (Fig. 230). The peritoneal folds of the lateral gutter are divided, the splenorenal ligament is incised and the spleen retracted anteriorly. Bleeding often occurs from the vessels between the spleen and the diaphragm. A packing in the form of a long leg roll is placed beneath the
728
Cornelius E. Sedgwick
diaphragm. As this packing is inserted the spleen is gradually displaced downward and anteriorly, and the vessels entering the spleen from behind are easily visualized, ligated and divided. Care should be taken not to injure the stomach. The hemorrhage is controlled, the attachments to the stomach and colon can be divided more leisurely and the spleen
Fig. 230. Emergency splenectomy. Note posterior attachments are divided, packing (leg roll) is placed beneath diaphragm, and vessels are isolated and ligated from behind.
removed. The packing is then removed from beneath the diaphragm and any persistent bleeding is controlled. The technique for elective splenectomy is somewhat different. The gastrocolic omentum is divided and the lesser sac entered (Fig. 231). The stomach is mobilized along the entire greater curvature. With the stomach retracted upward and the large bowel downward, the
Splenectomy
729
body of the pancreas and spleen are well visualized. The splenic artery is then ligated near its origin. The spleen is approached from behind, dividing the posterior parietal peritoneum which allows the spleen to be brought anteriorly. Any remaining vasa brevia which are attached to the stomach are divided and the spleen is mobilized together with the tail of the pancreas. The vessels are ligated individually at the hilus of
Fig. 231. Elective splenectomy. Lesser sac is entered; attachments to stomach and bowel are divided, and splenic artery is ligated. Vessels are then isolated from behind as in emergency splenectomy (see Fig. 230). (From SURGICAL CLINICS of NORTH AMERICA 35: 675 [June] 1953.)
the spleen, taking care not to damage any of the pancreatic tissue. Hemostasis is assured. Careful exploration is made for accessory spleens. A drain is placed in the left upper quadrant and brought out through the incision, and the abdomen is closed. POSTOPERATIVE COMPLICATIONS
The complications following a carefully performed splenectomy should be relatively infrequent. There is always the problem of postoperative
730
Cornelius E. Sedgwick
hemorrhage but this should not occur if sufficient care is taken to assure hemostasis during the procedure. Following splenectomy the chance of a thrombosis and particularly pyelophlebitis which is exceedingly rare must be kept in mind. Such complications occur more frequently after splenectomy than after other abdominal operations because of the excessive rise in platelets that takes place immediately after splenectomy. On occasion it may be necessary to institute anticoagulation therapy. Infection may follow splenectomy particularly if the pancreas has been damaged. Subdiaphragmatic abscesses are more frequent after splenectomy than other abdominal procedures. This can be prevented by taking care not to injure pancreatic tissue and by instituting drainage through a stab wound in the flank in all cases of splenectomy. SUMMARY
Certain definite indications for splenectomy are directly related to the spleen itself, the most common of which is the ruptured spleen. The other indications for splenectomy require study and evaluation by the hematologist. In properly selected cases splenectomy may be expected to be of real value. The technique of splenectomy as described is dependent upon whether the operation is an emergency procedure or an elective procedure.