Indications for Splenectomy
Trauma
Traumatic injury to the spleen is no longer an immediate or mandatory indication for operation or splenectomy, either in the adult or child. Computed tomography (CT) scanning or emergent ultrasound can diagnose splenic injury in patients with blunt trauma to the abdomen or lower chest. Nonoperative support with in-hospital observation for up to 5 days is indicated in children and adults with splenic injury and hemodynamic stability provided there is no evidence of other intra-abdominal injuries that might require laparotomy. Accepted indications for operation in adults include the significant accumulation of intraperitoneal blood (over 1,000 ml), the requirement for more than 2 units of blood transfusion, a progressively decreasing hemoglobin concentration, or hemodynamic instability. More aggressive nonoperative support is justified in children under 14 years old. When operative intervention is necessary, preservation of the spleen should be considered if bleeding can be controlled quickly and other life-threatening intra-abdominal injuries are absent. Again, in children under 14 years of age, more aggressive attempts at intraoperative splenic salvage are justified. Splenic autotransplantation with a free-graft for maintenance of specific splenic immunity is still experimental and of unproven efficacy.
Hematologic Diseases
Indications for splenectomy should be determined with the close cooperation of a hematologist/oncologist. Common indications include hereditary spherocytosis, thalassemia major, and certain forms of immune thrombocytopenic purpura (ITP) unresponsive to medical management. Myeloproliferative disorders may lead to massive splenomegaly and can cause symptoms that are best relieved by splenectomy, primarily for symptomatic relief. Splenectomy does not usually alter overall survival, and this information should be clearly discussed with the patient prior to operation, again with a hematologist/oncologist, including the probable requirement for blood or blood products. In the presence of splenomegaly, the procedure is best performed using an open or "hand-assisted" laparoscopic technique. The operative morbidity and mortality rates are higher in these patients due to the hematologic comorbidity. Thrombotic thrombocytopenic purpura (TTP) and hairy-cell leukemia unresponsive to other treatment strategies are occasional indications for splenectomy.
Hodgkin's Disease
Selected patients with clinical Stage I-A or II-A Hodgkin's disease may be candidates for a staging laparotomy or laparoscopy. In the absence of obvious liver or intra-abdominal nodal disease, splenectomy is an integral part of the staging procedure to exclude splenic involvement, which would alter the method of treatment.
Iatrogenic (Intraoperative) Splenic Injury
The spleen may be injured inadvertently during the performance of intraperitoneal procedures, especially those involving the distal esophagus, stomach, distal pancreas, or splenic flexure of the colon. These injuries may occur directly from operative retractors or, more often, secondary to inadvertently avulsed capsular adhesions that can lead to persistent bleeding. Hemostasis should be attempted using suture plication, topical hemostatic agents (including absorbable mesh), electrocautery, or argon beam coagulation so that splenectomy is not required. However, if rapid hemostasis is not possible, hemorrhage severe enough to require blood transfusion is better managed by formal splenectomy than by repeated attempts at splenic salvage, especially in the adult patient.
Other Indications for Splenectomy
Less common indications for splenectomy include splenic abscesses, cysts, sinistral portal hypertension secondary to isolated splenic vein thrombosis or obstruction, or splenic mass presumed to be a primary or undiagnosed neoplasm. Splenectomy is occasionally included in en bloc resection for malignancy in an adjacent organ, such as the stomach, colon, adrenal gland, or pancreas. Distal pancreatectomy usually includes splenectomy if preservation of the splenic artery and vein is either contraindicated (malignancy) or technically impossible.
Prophylaxis Against Post-Splenectomy Sepsis
Most pediatricians believe that children who have undergone splenectomy before the age of 5 years should be treated with a daily dose of penicillin until the age of 10 years. The use of prophylactic penicillin is less defined in children over 5 years old and in adults. All patients who have undergone nonelective splenectomy should be immunized with Pneumovax (a nonviable pneumococcal vaccine containing the more common virulent strains of the pneumococcus family). If elective splenectomy is planned, patients should also be immunized with Pneumovax, preferably two or more weeks before operation. Children less than 10 years old and all patients with immunosuppression or an associated immunodeficiency should be vaccinated against pneumococcus, H. influenza, meningococcus, and Hepatitis B.
Qualifications for Performing Operations on the Spleen
The qualifications of a surgeon performing any operative procedure should be based on training (education), experience, and outcomes. At a minimum, surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform emergency and elective operations on the spleen. For laparoscopic splenic procedures, surgeons should have advanced laparoscopic training and expertise.
