Overview of Splenectomy

A splenectomy is a type of surgery where the spleen is removed. The spleen is an organ on the upper left side of your belly. Even though some people used to think it served no real purpose, we now know that it has important jobs in protecting the body. These include helping to get rid of germs in your blood, removing old or damaged blood cells, and helping to make antibodies (proteins that help fight infection).

A spleen might need to be removed for a number of different reasons. These can be because of certain diseases, if it’s affected by cancer, if it’s causing other problems because of its size or shape, or if it’s been hurt in an accident.

The way the spleen is removed depends on what the problem is and the patient’s health. Splenectomy can be done using three main methods: an open surgery where a large cut is made, a laparoscopic surgery which uses smaller cuts and special tools, or with robotic tools controlled by the surgeon. Each method has its pros and cons, like how long it takes to recover after surgery, how much pain you might have, and the risks of complications.

In places where there are more medical resources, doctors usually prefer doing a laparoscopic surgery. However, in places where resources are more limited, open surgery is more common.

Removing your spleen can increase your chances of getting infections and having other complications, so it’s usually recommended to have regular doctor visits after the surgery. This lets the doctor check on how you’re doing and deal with any problems that might come up.

Anatomy and Physiology of Splenectomy

The spleen is an important organ located on the left side of the body, right under the 9th to 11th ribs. Its surrounding organs include the stomach, pancreas, large intestine, and left kidney. Despite some differences in size among individuals, an adult’s spleen is typically about 12 cm long, 7 cm wide, and 3 cm thick, and it usually weighs around 150 grams.

There are certain ligaments that keep the spleen anchored to the nearby organs. These include the gastrosplenic ligament, which stretches from the stomach to the spleen and contains arteries that supply the stomach; and the splenorenal ligament, which extends from the left kidney to the spleen and holds the arteries that supply the spleen. These ligaments not only keep the spleen in place but also allow blood to circulate properly to and from the spleen.

The splenic artery, which arises from the major blood vessel called the celiac trunk, is what primarily supplies blood to the spleen. This artery takes a path over the body and tail of the pancreas before reaching the spleen. The splenic artery then splits into smaller arteries, which supply blood to the spleen and parts of the stomach. The spleen’s waste blood gets drained through veins that eventually form the splenic vein. This vein then merges with another vein, forming the portal vein, which is situated behind the ‘neck’ of the pancreas. The lymph fluid from the spleen gets drained into specially designated lymph nodes near the pancreas and spleen.

Some people, about 10% to 30%, have what’s known as an accessory spleen – extra spleen tissue. Most of the time, these are located near the spleen itself, but they can also be found near the tail end of the pancreas, or the ligaments connecting the spleen to other organs. Very rarely, an accessory spleen is found in a completely different spot, lower down in the abdomen.

Why do People Need Splenectomy

Surgery to remove the spleen, known as splenectomy, is usually done for various reasons. Here are some common causes:

There are certain medical conditions that are present at birth that may require a splenectomy. These include:

  • Hereditary spherocytosis: a condition that causes a breakdown of red blood cells.
  • Hereditary elliptocytosis: a disease that also affects red blood cells, making them oval-shaped.
  • Pyruvate kinase deficiency: this disorder affects red blood cells, leading to a low amount of blood cells.
  • Sickle cell disease: a condition that makes red blood cells become rigid and shaped like c-shaped farm tools, known as sickles.
  • Thalassemia: a blood disorder involving lesser than normal amounts of an oxygen-carrying protein.

The spleen can also be removed due to acquired (not present at birth) immune disorders such as:

  • Immune thrombocytopenic purpura: a disorder that can lead to easy or excessive bruising and bleeding.
  • Autoimmune hemolytic anemia: a condition where the body’s immune system mistakenly destroys its own red blood cells.

Certain kinds of cancers and blood disorders also may necessitate the removal of the spleen. These include:

  • Different forms of leukemia: cancer of the body’s blood-forming tissues, including bone marrow.
  • Lymphoma: a cancer of the lymphatic system, which includes the spleen.
  • Polycythemia vera: a slow-growing blood cancer where your bone marrow produces too many red blood cells.
  • Myelofibrosis: a serious bone marrow disorder that disrupts your body’s normal production of blood cells.

Hypersplenism, a condition where the spleen is overactive and can cause reduction of blood cells and platelets, could be another reason for a splenectomy. This can be caused by different underlying diseases or conditions including:

  • Metabolic storage disorders such as Gaucher or Niemann-Pick disease.
  • Several infectious diseases.
  • Inflammatory disorders.
  • Disorders of the spleen itself.
  • Congestive disorders affecting the blood supply to the spleen.

At times, the spleen may need to be removed due to its location near other organs. For example, if diseases are affecting the pancreas or the stomach and surgical treatment is needed, the spleen may also have to be removed.

Lastly, accidental trauma or injury to the spleen could lead to its removal. The spleen is commonly affected in blunt abdominal trauma; it can happen because of physical sports, car accidents, falls, etc. It’s also reported that ruptures can occur spontaneously or as a rare complication of a colonoscopy (a test allowing the doctor to look at the inner lining of your large intestine).

When a Person Should Avoid Splenectomy

There are no strict rules saying you can’t have a splenectomy, which is a surgery to remove the spleen. However, in some situations, the doctors need to be extra careful. For example, if the patient’s spleen is bigger than usual or if they have a condition known as portal hypertension, meaning high blood pressure in the vein leading to the liver.

When a spleen weighs between 1000g to 2000g, doing a laparoscopic spleen removal, which is done through tiny cuts instead of a large one, can be tricky. This is because the large size of the spleen can make it difficult to operate in the limited space and to remove the spleen. Studies have shown that people with a large spleen may spend more time in surgery, lose more blood, and have a higher chance of needing open surgery.

If there is enough time before surgery, the doctors might use a technique called splenic artery embolization. This is a procedure that helps to reduce the size of the spleen, making laparoscopic surgery easier.

In the same way, for patients with portal hypertension, the surgery can be more challenging because they are more likely to bleed excessively due to weakened veins in the stomach and throat (esophagogastric varices), and lower numbers of blood platelets which are cells that help to stop bleeding (thrombocytopenia). These patients might also experience longer surgery times, higher blood loss, and an increased chance of needing open surgery.

Equipment used for Splenectomy

A splenectomy, or the removal of the spleen, can be performed using different surgical methods: an open surgery, a laparoscopic procedure, or a robotic-assisted procedure. Depending on the chosen technique, the surgeon will need a variety of tools and equipment.

In an open splenectomy, the surgeon will typically use a variety of standard surgical tools such as a scalpel for cutting, an electrocautery device to stop bleeding from small blood vessels, retractors to keep the surgical site open and accessible, and sutures to close the wound afterwards. They will also require ligature clips to control bleeding from larger vessels, a suction irrigation system to keep the area clean, a surgical stapler or ligature device for closing surgical wound, and sterile drapes, gowns, and gloves to maintain a clean and safe surgical environment.

If the surgeon performs a laparoscopic splenectomy, they’ll use a thin tube with a camera (a laparoscope) to visualize the inside of the body on a monitor. This procedure also requires different types of surgical tools, or trocars, which are inserted through small incisions in the body. These can include a scalpel, specialized laparoscopic instruments like graspers, scissors, and tissue dissectors, and devices that emit energy to cut or coagulate tissue. They will also have an insufflation system to inflate the abdomen with CO2 gas and create a working space during the surgery. Additionally, they’ll need an endoscopic clips or ligating devices to control bleeding, a specimen bag to collect tissue samples, and sutures to close the wounds. Also, just in case the laparoscopic approach needs to be switched to an open surgery, a major abdominal surgery tray will be kept on hand.

For a robotic-assisted splenectomy, the surgeon will control a sophisticated robotic system from a console. This system includes robotic arms equipped with specialized tools, and a high-definition three-dimensional camera system. Similarly to the laparoscopic procedure, this approach uses monitors, trocars, a scalpel, energy devices integrated into the robotic instruments for cutting and coagulation, endoscopic clips or ligating devices for vessel control, and sutures. The abdomen will also be inflated using a pneumoperitoneum insufflation system and CO2 gas insufflator. Lastly, a set of tools for open surgery (a laparotomy tray) will be in the room, just in case.

Who is needed to perform Splenectomy?

A splenectomy, or the removal of the spleen, needs a team of medical professionals to perform it. It’s similar to having many hands on deck for a big task. The team includes the following:

The first and most crucial person is the operating surgeon. This is a doctor who’s specially trained to perform operations, including removing the spleen. They’re the ones in charge of the surgery and ensure everything happens correctly and safely.

The next person is the first assistant. They’re there to aid the operating surgeon during the surgery, kind of like a helpful teammate.

There’s also the surgical technician or operating room nurse. They help by prepping the operating room for surgery, handling the surgical instruments, and assisting the surgeon and first assistant.

The circulating or operating room nurse is responsible for maintaining a safe and efficient environment in the operating room. Think of them as a coordinator who keeps everything running smoothly.

Finally, there’s the anesthesia provider. Their job is to help patients sleep during surgery or to numb the area where surgery will take place. They make sure patients don’t feel any pain during the operation.

All these people work together to make sure your spleen removal goes smoothly and successfully, and that you’re comfortable and safe throughout the process.

Preparing for Splenectomy

Before a planned surgery to remove the spleen (laparoscopic splenectomy), doctors use an ultrasound to check the size and volume of the spleen. This helps them decide on the best surgical method and find out if there are any other health issues that need to be looked at during surgery, such as gallstones in patients who have a genetic red blood cell disorder known as hereditary spherocytosis.

Additionally, patients who have conditions like immune thrombocytopenic purpura (a condition where the immune system mistakenly attacks healthy blood cells) or various types of cancers should have a detailed scan of the abdomen. This scan can help identify if there are any additional smaller spleens present, which can help in preparing a comprehensive surgical plan and ensure the best patient care.

Patients who are having their spleen removed also need to be vaccinated against certain bacteria. In particular, they need protection from Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae, as these are the bacteria most often associated with severe infections after spleen removal. About 5% of people who have this surgery could potentially develop severe infections, and these infections can have a very high mortality rate. To ensure an adequate immune response, vaccinations should be given about 2 weeks before a planned surgery. If the spleen removal is unplanned or the result of an injury, the patient should be vaccinated about 2 weeks after surgery. Often, these vaccinations are given before the patient leaves the hospital.

Furthermore, patients with the condition known as autoimmune thrombocytopenia (where the body’s immune system destroys its own platelets, a type of blood cell that helps with clotting) and who have a very low platelet count should be treated with specific drugs to reduce the loss of blood during surgery. In some cases, patients with disorders like myelofibrosis (a serious bone marrow disorder) or chronic granulocytic leukemia (a type of blood and bone marrow cancer) may need blood platelets transfusion, even if the normal platelet counts are present, as their platelets may not function well. Other health issues like unmanaged chronic diseases, nutritional deficits, anemia, increased platelet count, and clotting or bleeding disorders should also be checked and managed appropriately on an individual basis.

How is Splenectomy performed

A splenectomy is a process where the spleen is surgically removed, and it can be done in several ways including open surgery, laparoscopic technique (utilizing a small camera and small incisions), and robotic-assisted procedures. Most doctors will opt for laparoscopic or robotic-assisted surgeries, due to their benefits like precision and less complications. With laparoscopic and robotic techniques, there’s less moving of the stomach organs involved, and therefore a lesser risk of complications after the surgery.

As for how the patient is positioned during surgery, it’s pretty straightforward for an open splenectomy; they lie down flat on their back. For laparoscopic splenectomy, it’s a bit more undecided. Surgeons use two common approaches, one where the patient lies flat on their back (medial or anterior position) and another where they lie on their side (lateral position). Both positions have their pros and cons, and the surgeon will decide the best technique to use based on the specifics of the surgery.

An open splenectomy procedure starts with the patient lying flat, after which anaesthesia is administered. The surgical team then confirms that everything is in order through a time-out. The surgeon will make a large cut from the chest bone down to the public bone, or a smaller one a bit lower in the left rib cage. The cut will be deepened until the surgeon can go inside the stomach. They will inspect everything inside before starting the surgery, and a medical device called a retractor will be used if needed for viewing.

The spleen will then be separated from the organs it’s attached to, and it will be shifted to medially that exposes the backside of the spleen. The organ will then be removed, ensuring that there is no bleeding left. If there are injuries to the pancreatic tail, a drain might be placed. The surgeon will check for any extra spleens, remove them if needed and then sew up the opened skin.

A laparoscopic splenectomy involves the much same process, but with a few minor differences. The surgeon will make a few small cuts in the stomach. They will introduce a laparoscope, a thin tube with a camera in one of the small cuts, for visualization, and special tools are used to remove the spleen. The cuts will be sewed up after the spleen is removed. This kind of spleen removal is often preferred because it usually means less pain, a quicker recovery, and less noticeable scars compared to an open splenectomy.

There is also an option called Hand-Assisted Laparoscopic Splenectomy (HALS) that combines the benefits of open and laparoscopic surgery, making it a good option for cases of enlarged spleens. In this technique, the surgeon uses one hand to perform the surgery while maintaining air pressure in the stomach cavity.

A new approach that’s being used is the Single-Incision Laparoscopic Splenectomy. As the name suggests, it only requires one small cut which can lead to faster recovery times and reduced scarring. As with all surgeries, the best method will depend on an individual’s specific needs and circumstances.

Possible Complications of Splenectomy

Having your spleen taken out, also known as a splenectomy, can lead to issues during and after surgery. Some problems might only show up in the first three months after surgery, while others might develop later.

During the surgery, a few complications can come up:

1) Bleeding: The spleen or nearby blood vessels might get accidentally cut during surgery. If the doctors can’t stop the bleeding quickly, they may need to open up your abdomen to get a better look and control the situation.

2) Injuries to nearby organs: The stomach, colon, and pancreas are close to the spleen, so they might accidently get hurt during the surgery. An injury to the pancreas can cause inflammation known as pancreatitis, a buildup of pancreatic fluid, and potential formation of a pancreatic fistula, a type of abnormal connection between the pancreas and another organ or the skin. In about 15% of spleen removal surgeries, the pancreas gets injured. If this happens, doctors will typically place a drain to remove any extra fluid.

3) Leaving behind spleen tissue: Sometimes, small bits of spleen might be missed during surgery.

4) Splenic rupture and splenosis: The process where the spleen breaks and spleen tissue starts to grow in other areas of the body.

After surgery, in the following three months, you might face a few issues:

1) OPSI: Overwhelming post-splenectomy infection (OPSI) is a severe and quick whole-body infection that can happen after spleen removal. Symptoms may include high fever, headache, chills, yellowing of skin and eyes (a condition called jaundice), decrease in urine output (anuria), severe infection leading to organ failure (septic shock), difficulty in breathing, and multiple organ failure. OPSI is a serious condition and can lead to coma and death.

2) Bleeding

3) Abdominal abscess: This is basically a buildup of pus in your abdomen, usually below the diaphragm or due to blood clot infection or injury to the digestive tract. Doctors typically treat this with drainage and antibiotics.

4) Venous thromboembolism (VTE): After a spleen removal, about 6% to 11% of patients experience a blood clot in their veins.

Other late complications can include infections, hernias in your abdomen, or even an increased risk of cancer. Patients without a spleen are much more likely to die from severe blood infection, or septicemia, compared to those with a normal spleen, because the spleen plays an important role in fighting off infections. In addition, patients who’ve had their spleen removed also have a higher risk of other bacterial and viral infections due to suppression of their immune system. Patients may also face an increased risk of cancer and cancer-related death, which is the greatest in the first 2 to 5 years after surgery but can persist even 10 years and beyond.

What Else Should I Know About Splenectomy?

Splenectomy, the medical term for surgery to remove the spleen, plays a pivotal role in treating various health issues. It also has long-term effects on a person’s health. Doctors may recommend spleen removal for several reasons, including blood disorders, spleen injuries, spleen cysts, and specific types of cancer. While the surgery can improve symptoms, prevent other health complications, and boost the overall well-being of a patient, it’s not without potential risks.

The spleen plays a crucial role in fighting infections, particularly certain bacteria that have a protective casing around themselves. Because of this, people who have had their spleen removed have a higher risk of getting infections. As such, they often need lifelong check-ups to make sure they stay healthy. This includes getting certain vaccines and possibly taking antibiotics to lessen the risk of infection. Also, removing the spleen can influence the number of different kinds of cells in the blood and could raise the chance of blood clots.

In conclusion, while spleen removal surgery can offer benefits by alleviating certain health conditions, it does come with some potential risks. It’s critical that doctors carefully evaluate these against the benefits and guide their patients on how to best take care of themselves after the operation, so as to help them stay healthy and avoid complications.

Frequently asked questions

1. What are the potential risks and complications associated with a splenectomy? 2. How will my immune system be affected after the spleen is removed, and what steps should I take to prevent infections? 3. Will I need any vaccinations before or after the surgery, and how long should I wait to receive them? 4. What is the recommended method of splenectomy for my specific condition, and why? 5. How long is the typical recovery period after a splenectomy, and what can I expect in terms of pain management and activity restrictions during this time?

Splenectomy, the surgical removal of the spleen, can have various effects on the body. Without a spleen, individuals may be more susceptible to certain infections, particularly those caused by encapsulated bacteria. Additionally, the absence of a spleen can affect the body's ability to filter and remove old or damaged red blood cells, potentially leading to anemia or other blood disorders. It is important for individuals who have undergone splenectomy to take certain precautions, such as receiving vaccinations and taking antibiotics, to help prevent infections.

You may need a splenectomy if your spleen is larger than usual or if you have a condition called portal hypertension, which is high blood pressure in the vein leading to the liver. In these situations, the surgery may be more challenging and there is a higher risk of complications such as excessive bleeding. However, there are no strict rules against having a splenectomy and each case is evaluated individually by doctors.

A person should not get a splenectomy if their spleen is larger than usual or if they have portal hypertension, as these conditions can make the surgery more difficult and increase the risk of complications such as excessive bleeding and the need for open surgery.

The recovery time for a splenectomy can vary depending on the surgical method used and the individual patient. Generally, it takes about 4-6 weeks to fully recover from a splenectomy. However, some patients may experience a longer recovery period if they have complications or underlying health conditions. It is important for patients to have regular doctor visits after the surgery to monitor their progress and address any potential issues.

To prepare for a splenectomy, the patient should undergo an ultrasound to check the size and volume of the spleen. This helps determine the best surgical method and identify any additional health issues. Patients should also be vaccinated against certain bacteria, such as Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae, to protect against severe infections after spleen removal. Additionally, patients with certain conditions may require specific treatments or blood transfusions to manage their health before surgery.

The complications of splenectomy include bleeding during surgery, injuries to nearby organs such as the stomach, colon, and pancreas, leaving behind spleen tissue, splenic rupture and splenosis (where the spleen breaks and tissue grows in other areas of the body), overwhelming post-splenectomy infection (OPSI), abdominal abscess, venous thromboembolism (VTE), increased risk of infections, hernias in the abdomen, and an increased risk of cancer and cancer-related death.

The text does not provide information about the symptoms that require splenectomy.

The safety of splenectomy in pregnancy depends on several factors, including the specific reason for the splenectomy and the stage of pregnancy. In general, splenectomy is considered safe during pregnancy if it is necessary to treat a life-threatening condition or if conservative management options have been exhausted. However, splenectomy during pregnancy is associated with certain risks and considerations. These include the potential for increased bleeding during surgery, the risk of infection after surgery, and the potential impact on the immune system. Additionally, the removal of the spleen can increase the risk of certain infections, such as those caused by Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Therefore, it is important for pregnant individuals who undergo splenectomy to receive appropriate vaccinations to protect against these infections. The decision to perform a splenectomy during pregnancy should be made on a case-by-case basis, taking into account the specific medical condition, the risks and benefits of the procedure, and the overall health of the pregnant individual and fetus. It is important for pregnant individuals considering splenectomy to consult with their healthcare provider to discuss the potential risks and benefits and to receive appropriate prenatal care and monitoring.

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