- If possible, no splenectomy before age 6 years.
- In principle, if splenectomy is not indicated for other reasons, preserve the spleen in part or in toto.
- Vaccinate the patient (pneumococci/haemophilus vaccine) as soon as the indication for splenectomy is discussed, at least 2 weeks prior to the procedure. If the splenectomy is performed without prior vaccination, maintain a vaccine interval of at least 10-14 days post-splenectomy. In children aged 2 years and older, meningococcal vaccination is also recommended. In children aged 10 years and younger, penicillin prophylaxis for at least 2 years should also be considered.
- Continue low-molecular-weight heparin therapy until full ambulation, for at least four weeks after splenectomy, to prevent portal vein thrombosis.
- Since the prognosis in portal vein thromboses is improved by immediate heparin therapy and later with oral anticoagulants, monitoring of at-risk patients in the first year after splenectomy by diagnostic Doppler ultrasonography and D-dimer testing should be considered.
- Portal vein thrombosis is more common in patients with a very large spleen, and according to a study listed below (20) in thrombocytosis of >600-1000 103/μl, and diathetic thrombophilia. Some reviews recommend post-splenectomy treatment with ASA 100 mg/day for one year (level of recommendation: C, 8, 20), but this has not been justified by the data available thus far.
- If thrombocytopenia is the underlying disease, preoperative administration of platelet products is not advised, as they will be metabolized shortly thereafter.
- In patients with elective splenectomy and a small spleen (<500 g), consider laparoscopic splenectomy.
- Laparoscopic splenectomy is contraindicated in hepatic cirrhosis with portal hypertension.
- In case of fever and suspected infection after splenectomy initiate treatment immediately.
- In patients with abdominal trauma of unknown origin, perform the splenectomy via a midline incision.
- Elective splenectomy via a subcostal/transverse left upper quadrant incision.
- Accessory spleens (which may occur in 20% of all cases) are always found in the left hemiabdomen. The accessory spleens must only be removed when performing a splenectomy in patients with underlying hematological disorders. Accessory spleens are visualized preoperatively by scintiscanning with Tc99m-labeled RBCs.
- In multivisceral tumor operations without signs of tumor infiltration sparing the spleen is always justified. If the spleen has to be removed in these procedures, a markedly increased rate of complications and infections should be expected.
- At present, autotransplantation of splenic tissue (e.g., into the greater omentum) has been completely discontinued.
- Hanging spleen technique Positioning in laparoscopic splenectomy: 60-degree right lateral recumbent position with elevated left flank. Anti-Trendelenburg position. Optical trocar in the umbilical region and three more working trocars along the costal arch. Option: Technique in the lithotomy position.
- Both laparoscopic splenectomy techniques do not differ significantly with regard to the duration of surgery, blood loss and perioperative complications. In patients undergoing surgery with the hanging spleen technique there is only somewhat less use of material and a reduction in the number of incisions. Further prospective trials must be conducted to decide whether the hanging-spleen technique is the method of choice.
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Literature summary
Ongoing trials on this topic
The Effect of Laparoscopic Splenectomy on the Immune Function for Cirrhosis PatientsOverwhelming Po
The Effect of Laparoscopic Splenectomy on the Immune Function for Cirrhosis PatientsOverwhelming Po
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