Indications for Splenectomy
Traumatic injury to the spleen is no longer an immediate or mandatory indication for operation or splenectomy. Computed tomography (CT) scanning or ultrasound can accurately characterize splenic injury in patients with blunt trauma. Non-operative 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 hemodynamic instability, bleeding >1,000 mL, transfusion of more than 2 units of blood, or other evidence of ongoing blood loss. In children under 14 years old, more aggressive non-operative support is justified. When operative intervention is necessary, preservation of the spleen should be considered if bleeding can be controlled quickly and when there are no other life-threatening intra-abdominal injuries. 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 of no proven value.
Iatrogenic (Intraoperative) Splenic Injury
The spleen may be injured 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 by traction on capsular adhesions leading to persistent bleeding. To avoid splenectomy, hemostasis should be attempted using suture plication, topical hemostatic agents (including absorbable mesh), electrocautery, or argon beam coagulation. However, if secure hemostasis is not possible before blood loss is sufficient to require blood transfusion, the patient is better managed by splenectomy than by repeated attempts at splenic salvage.
Hematologic Diseases
Indications for splenectomy should be determined with the close cooperation of a hematologist/oncologist. Common indications include immune thrombocytopenic purpura (ITP), hereditary spherocytosis, thalassemia major, and certain forms of autoimmune hemolytic anemia unresponsive to medical management. Thrombotic thrombocytopenic purpura (TTP) and hairy-cell leukemia unresponsive to other treatment strategies are occasional indications for splenectomy.
Myeloproliferative disorders may lead to massive splenomegaly. Related symptoms may be best relieved by splenectomy although it does not usually alter overall survival. This information should be clearly discussed with the patient prior to operation, and they should be aware of the frequent requirement for blood or blood products when splenectomy is carried out for very large spleens. Massive splenomegaly may preclude a laparoscopic approach. In these circumstances an open or "hand-assisted" laparoscopic technique may be used. The operative morbidity and mortality rates are higher in these patients due to the hematologic comorbidity.
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 neoplasm. Splenectomy is occasionally included in en bloc resection for malignancy in an adjacent organ. Distal pancreatectomy usually includes splenectomy if preservation of the splenic artery and vein is either contraindicated (malignancy) or technically impossible.
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 benefit of prophylactic penicillin is less clear in children over 5 years old and in adults. All patients who have undergone non-elective splenectomy should be immunized with Pneumovax (a non-viable pneumococcal vaccine). When planning elective splenectomy, patients should be immunized with Pneumovax, and against Haemophilus influenza and meningococcus, preferably two or more weeks before operation.
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.
