Perioperative management - Open splenectomy

• Hematological disorders, e.g., spherocytosis
• Autoimmune cytopenia, e.g., warm antibodies
• Storage disorder, e.g., Gaucher disease
• Thrombocytopenia, e.g., Werlhof disease
• Cysts, e.g., echinococcus
• Hemangioma
• Metastasis
• Abscess
• Primary splenic tumor
• Multivisceral resections
• Trauma
• Delayed splenic rupture
• Spontaneous rupture
• Splenic artery aneurysm
• Splenic vein thrombosis

Children ideally no younger than 15 years of age
Relevant comorbidity

Planned splenectomy always mandates a strict indication!

Splenectomy is indicated based on the patient’s underlying disease. Due of the multitude of possible pathologies, a focused diagnostic work-up by hematologists and internists is required.

Surgeons are especially interested in the morphology and vascular supply of the organ as well as the general operability and prognosis of the patient.

• Lab panels: Complete blood count, electrolytes, creatinine, coagulation, blood type
• Ultrasonography
• Abdominal CT and/or MRI
• If necessary, isotope scintigraphy to check for any accessory spleens
• ECG
• Chest radiographs
• If necessary, pulmonary function testing and BGA

• If possible, the patient should be vaccinated against pneumococci, meningococci and Hib at least two weeks prior to surgery
• Ready 2-4 units of packed  RBCs
• In large spleens, the organ may be downsized by embolizing the splenic artery
• Since gastric decompression facilitates the procedure, place a gastric tube when inducing anesthesia

• General complications Thrombosis, embolism, pneumonia, wound infection, incisional hernia, hemorrhage, keloid formation, cutaneous nerve injury.
• Specific complications: Injury to abdominal organs such as the intestines, stomach and pancreas; pancreatic fistula; gastric wall necrosis; thrombophilia; susceptibility to infection; perisplenic/splenorenal abscess formation; pleural effusion; splenic and portal vein thrombosis; OPSI syndrome.

As in all other major abdominal operations, splenectomy is performed  under general anesthesia, with an epidural catheter if possible.

Also see:
Intubationsnarkose
Thorakale Periduralanästhesie bei viszeralchirugischen Eingriffen

With the patient in standard recumbent position, support the left flank with a cushion to expand the thoracic aperture for better exposure of the spleen. Depending on surgeon preference, the arms may abducted or adducted.

The surgeon stands to the right of the patient, the assistant to the left, and the scrub nurse at the feet. A second assistant may facilitate the procedure.

• Standard abdominal tray with long abdominal retractors
• Retractor systems such as (thoracic) Mercedes retractor or self-retaining systems such as Omnitract
• Electrocautery, bipolar scissors are helpful
• Standard sutures and ligatures, with fine vascular sutures in readiness
• Suction
• Cellsaver, if necessary

• Analgesia with central and peripheral analgesics
  Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management)
  Follow this link to the current German guideline [MM1]Behandlung akuter perioperativer und posttraumatischer Schmerzen [Treatment of acute perioperative and posttraumatic pain].[MM2]

• Unrestricted ambulation and return to normal diet

• Bowel movement: Cathartics, if necessary

• Thrombosis prophylaxis depending on the underlying disease, procedure with intermediate to high risk of thrombosis
  Follow this link to the current German guideline [MM3]Leitlinie Prophylaxe der venösen Thromboembolie [Guideline on prophylaxis in venous thromboembolism].[MM4]
  Note: Renal function, HIT II (history, platelet check)

• Close monitoring of the platelet count (antiplatelet agent if thrombocytosis exceeds 800,000/µl). In 80% of patients, the platelet count will normalize after a few weeks

• Pneumonia prophylaxis

• Regular wound inspection

• Suture removal 10-12 days after surgery

• Length of stay in hospital about 8-10 days

• Work disability about 3 weeks

• If not done preoperatively, vaccinate the patient 2-4 weeks after surgery