Splenectomy is a surgery done to remove the spleen for the treatment of various conditions. It can be performed as an open surgery through a large abdominal incision, or with the help of a telescopic instrument called a laparoscope, or through robotic surgery.
The spleen is a small organ located in the upper left abdomen behind the lower ribs and just below the diaphragm. Blood vessels and nerves supplying the spleen enter and exit the spleen via its hilum. The spleen is connected by connective tissue ligaments to the stomach and the left kidney.
Though the spleen may not be as well-known as its neighbors, the stomach, liver, left kidney and colon, it has important functions – it produces blood cells, helps to develop immunity to fight infections, and removes dead or damaged cells from the circulation.
Depending on the operative procedure adopted, splenectomy can be classified as:
Depending on the amount of spleen removed, the splenectomy may be partial or complete.
Splenectomy may be performed for the following conditions:
Blood disorders which may include:
Enlarged spleen, where the spleen sequestrates excess blood cells and destroys them. The spleen may be enlarged in the following conditions:
Rupture of the spleen, which may occur due to:
Patients with rupture of the spleen with low blood pressure require emergency surgery.
Splenic vein thrombosis, where the drainage of blood from the spleen is obstructed by a clot in the splenic vein
Aneurysm of the splenic artery. An aneurysm is a localized ballooning of an artery which can burst at any time resulting in instant death
Large cysts of the spleen, which may be due to:
Cancers of the spleen, which include:
Abscess of the spleen
It must however be remembered that splenectomy is not done for all patients with the above conditions, but is only done when it is really required and the benefit of removing it far outweighs the disadvantages of not having a spleen.
Before splenectomy, tests are done to confirm the need for the splenectomy. These include:
Routine tests: Routine tests which are done before any surgery include:
In older patients, a detailed assessment of the heart may be required to make sure that they are fit for surgery.
Type of Anesthesia: Splenectomy is done under general anesthesia. You will be asleep during the procedure and will not be aware of what is going on.
Pre-operative Check-up: Routine tests as indicated above are ordered a few days before the surgery. Since your immunity will be affected following the splenectomy, vaccination against pneumococcal, meningococcal and Hemophilus influenzae infections will be given 3 weeks prior to surgery. Medications like aspirin should be stopped around a week prior to the procedure. Admission is required a day before the surgery. Informed consent is obtained. These preparations can be skipped for individuals undergoing emergency splenectomy.
The Day before Surgery: An enema is administered the previous afternoon or evening before the surgery along with gut-sensitive antibiotics.
Fasting before Surgery: Overnight fasting is required and occasionally intravenous fluid maybe required to keep you well hydrated. Sedation is sometimes required for good overnight sleep before the surgery.
Shift from the Ward or Room to the Waiting area in the Operating room: An hour or two before the surgery, you will be shifted to the operating room waiting area on a trolley. Once the surgical room is ready, you will be shifted to the operating room.
Anesthesia before Surgery: In the operating room, the anesthetist will inject drugs through an intravenous line and make you inhale some gases through a mask that will put you in deep sleep.
During the procedure:
For the laparoscopic procedure, four to five small incisions will be made and ports will be introduced into the abdomen so that the laparoscope and the instruments can be introduced through them. Carbon dioxide will be insufflated to increase the visibility inside the abdomen.
The connective tissue attachments of the spleen to the neighboring organs in the abdomen will then be cut, along with coagulation or ligation of blood vessels that could cause bleeding.
The spleen that is freed from all its attachments will then be removed through a larger incision on the abdomen, or through a port with the help of a puncture-resistant bag. The spleen will be fragmented inside the bag before being brought out through one of the ports.
The abdomen will also be examined for any accessory spleens, which should be removed during the same sitting to prevent recurrence of the primary disorder for which the procedure was carried out.
If gallstones are also present, you will be turned on your back, and the gallbladder will be removed during the same surgery.
Once confirmed that there are no bleeding spots, the instruments will be removed, the abdomen deflated, the ports withdrawn, a drainage tube inserted, and the incisions will be closed with stitches. Platelet transfusion will be administered if necessary.
If the procedure cannot be completed through laparoscopy, it may be converted to open surgery.
For the open procedure, the surgeon will make a large incision on the abdomen and insert her/his hand along the convex surface of the spleen. The ligaments that attach the spleen to the surroundings will be cauterized or tied if they contain blood vessels and cut. The separated spleen will then be delivered through the wound. The abdomen will also be checked for accessory spleens or bleeding spots, and if all appears fine, it will be closed in layers.
Robotic surgery is similar to laparoscopic surgery. During robotic surgery, the surgeon will sit at a console and guide robotic arms to perform the surgery with utmost precision. The procedure, however, is not as widely available as laparoscopy, and requires an expensive set-up and surgeons trained in the procedure.
After the Procedure:
Waking up from General Anesthesia: Once the surgery is over you may wake up feeling a bit groggy due to anesthetic effect. Once fully awake, you will be shifted on the trolley and taken to the recovery room.
Recovery room: In the recovery room, a nurse will monitor your vitals and observe you for an hour or two before shifting you to the room or a ward.
Post-operative recovery: You will remain in the hospital for a few days following the procedure. You will receive intravenous fluids and will be allowed to take in liquids once your bowel sounds return. You will be slowly shifted to semi-solid foods and later to solid foods. Chest physiotherapy may be started after 24 hours to prevent chest infection. The abdominal drain will be removed once the drainage is minimal. Blood counts will be measured on the next day following the surgery. If you were taking steroids before the surgery, they will be reduced following the surgery. Antibiotics will be prescribed to prevent infection and pain relievers to reduce pain.
Early movement of your legs and some mobilization will be encouraged to prevent DVT or deep vein thrombosis, where a clot is formed in the deep veins of the legs. The clot can travel up to the lungs and even be fatal. Other measures like special stockings may also be used to prevent DVT.
Discharge from hospital: Once your wounds have healed and you can eat normal food, you will be discharged from the hospital. Restrict activities for six to eight weeks and follow up with your doctor on a regular basis as advised.
Like any other surgical procedure, splenectomy is also associated with complications which may include the following:
