Laparoscopic Splenectomy

Overview 

The spleen is a blood-filled organ found in the upper left abdomen. It is a red blood cell storage organ that also includes numerous specialized white blood cells called "macrophages" (disease fighting cells) that filter blood. The spleen is a component of the immune system that also eliminates old and damaged blood particles from the body. The spleen aids the body in identifying and killing germs. The spleen can influence platelet count, red blood cell count, and even white blood cell count.

The gold standard approach for removing the spleen in elective patients is laparoscopic splenectomy (LS), however it is still a highly difficult treatment due to the fragility of the spleen's parenchyma and capsule, as well as its intimate linkages with the stomach, pancreas, and colon. Indications for LS have quickly risen, and it is now regarded the standard technique for practically all illnesses requiring splenectomy, including benign and malignant hematologic disorders and non-hematologic malignancies, as well as spleen damage, which is being handled laparoscopically.

 

What is the Spleen?

The spleen is a tiny organ located right above your stomach within your left rib cage. The spleen is around the size of an avocado in adults. The spleen is a component of the lymphatic system (which is part of your immune system). It serves various key functions in keeping your body healthy.

Many different conditions, diseases, syndromes, and accidents have an impact on how your spleen functions. Providers frequently address the ailment or sickness that is producing spleen difficulties. If required, your spleen might be removed during an operation known as a splenectomy.

 

What Does the Spleen Do?

Your spleen:

• Stores blood.
• Filters blood by removing cellular waste and getting rid of old or damaged blood cells.
• Makes white blood cells and antibodies that help you fight infection.
• Maintains the levels of fluid in your body.
• Produces antibodies that protect you against infection.

 

What are the Parts of the Spleen?

The spleen is divided into two sections. They all have various responsibilities. The spleen contains the following types of tissue:

1. White pulp: The white pulp generates white blood cells as part of the immune system. Antibodies are produced by these blood cells. Antibodies help to fight infection.
2. Red pulp: The red pulp serves as a filter. It eliminates waste from the blood as well as old or damaged blood cells. Bacteria and viruses are also destroyed by red pulp.

 

What Conditions Causes Spleen Dysfucntion?

Many disorders, conditions, injuries and diseases can cause problems in the spleen. These problems include:

• Spleen enlargement (splenomegaly): Several disorders can cause the spleen to grow and become overly large. Even if you haven't eaten much, an enlarged spleen can induce pain and an uneasy sensation of fullness. Splenomegaly is a potentially fatal disorder in which the spleen ruptures (tears) or bleeds. The spleen can swell as a result of:

1. Cancers of the blood, such as leukemia and Hodgkin's lymphoma, as well as cancers from other parts of the body that metastasize (spread) to the spleen.
2. Clots of blood in the spleen or liver.
3. Anemias of several forms, including hemolytic anemia.
4. Cystic fibrosis(CF).
5. Infections such as mononucleosis (mono), syphilis, malaria, and endocarditis (infection of the lining of the heart).
6. Cirrhosis and other liver issues.
7. Gaucher disease and other inherited metabolic diseases
8. Inflammatory diseases, including sarcoidosis.
9. Protein disorders like amyloidosis.

 

• Functional asplenia: This condition occurs when your spleen does not function properly. It has the potential to overreact (hypersplenism) and destroy healthy red blood cells. Too many blood cells destroyed can raise the risk of infection and cause bruising and bleeding. Functional asplenia can be caused by:

1. An accident or trauma that damages the spleen.
2. Celiac disease.
3. Sickle cell disease.

 

• Damaged or ruptured spleen: Injuries and trauma can cause your spleen to burst (rip). Spleen injury is commonly caused by car accidents and strikes to the abdomen (belly). This potentially fatal injury can result in extensive internal bleeding. Symptoms of a ruptured spleen include:

1. A quick heartbeat.
2. Nausea.
3. Dizziness.
4. Pain under the ribs on the left side.

 

How Do I Know If I My Spleen Should Be Removed?

There are various reasons why a spleen may need to be removed, and the list below, while not inclusive, contains the most prevalent ones.

1. ITP (auto-immune thrombocytopenia purpura): This is the most prevalent explanation. A patient's platelet count is low with this condition because the body produces antibodies against platelets, causing them to be destroyed in the spleen. Patients are at danger of bleeding because platelets are blood cells that help in blood coagulation. Medical therapy is the primary line of treatment, but when that fails, removing the spleen (splenectomy) can be curative or greatly increase platelet count in the vast majority of patients.
2. Hemolytic anemia: Hemolytic anemia occurs when the body produces antibodies against red blood cells, which are then destroyed in the spleen. When medical therapy fails, some individuals seek splenectomy to avoid or reduce the need for blood transfusions.
3. Hereditary illnesses: Hereditary (genetic) illnesses that influence the morphology of red blood cells include spherocytosis, sickle cell disease, and thalassemia. In some individuals, the spleen detects the red cells as aberrant and may suppress them, perhaps necessitating splenectomy to alleviate symptoms.
4. Malignancy: Rarely, patients with cancers of the cells which fight infection, known as lymphoma or certain types of leukemia, require spleen removal. When the spleen gets enlarged, it sometimes removes too many platelets from your blood and has to be removed. Sometimes the spleen is removed to diagnose or treat a tumor.
5. Other reasons: Sometimes the blood supply to the spleen becomes blocked (infarct) or the artery abnormally expands (aneurysm) and the spleen needs to be removed. Rarely, the spleen can become infected and is best treated with removal.

 

How You Detect Spleen Abnormalities Need Laparoscopic Splenectomy?

A complete blood count (CBC) is often performed as part of an examination to determine the number, size, and shape of the cells in your blood. It is sometimes necessary to get a sample of bone marrow. The bone marrow is where red cells and other blood components are produced, and it can be highly useful in determining the cause of the issues. 

Finally, nearly no one has their spleen surgically removed without some imaging. Ultrasound, computed tomography (CAT scan), or magnetic resonance imaging are some examples (MRI). Understanding the size and structure of the spleen is essential for determining the origin of the disease and planning surgical procedures. Furthermore, a nuclear scan of the spleen can be useful at times, especially if accessory spleens or "splenules" of the spleen are detected. 

 

Advantages of Laparoscopic Splenectomy

Individual results may vary depending on your overall condition and health but the usual advantages are:

• Less postoperative pain.
• Shorter hospital stay.
• Faster return to a regular, solid food diet.
• Quicker return to normal activities.
• Better cosmetic results.
• Fewer incisional hernias.

 

Am I A Candidate For Laparoscopic Spleen Removal?

The majority of patients are candidates for laparoscopic splenectomy. Though the surgeon's experience is the most essential component in determining whether the spleen can be removed laparoscopically, the size of the spleen is the most crucial variable in determining whether the spleen can be removed laparoscopically. The laparoscopic procedure is difficult to use when the spleen is exceedingly big. Sometimes, utilizing advanced X-ray equipment to stop the artery to the spleen shortly before surgery might decrease the spleen enough to allow the laparoscopic method. To determine whether this approach is right for you, you should have a complete assessment by a surgeon trained in laparoscopic spleen removal, as well as consultation with your other specialists.

 

What Preparations Are Required?

1. You will be required to obtain written consent for surgery once your surgeon has discussed the possible risks and advantages of the procedure with you.
2. Depending on your age and medical condition, preoperative preparation may involve blood testing, a medical examination, a chest x-ray, and an EKG.
3. If feasible, vaccination with a vaccine to help prevent bacterial infections after the spleen is removed should be given two weeks before surgery.
4. Depending on your health, a blood transfusion and/or blood products such as platelets may be required.
5. It is advised that you shower the night before or the morning of the procedure.
6. You should not eat or drink anything after midnight the night before the procedure, save drugs that your surgeon has informed you are okay to take with a sip of water the morning before surgery.
7. Aspirin, blood thinners, anti-inflammatory drugs (arthritis meds), and Vitamin E may need to be temporarily discontinued for several days to a week before surgery.
8. Weight loss pills or St. John's Wort should be avoided for two weeks before surgery.
9. Quit smoking and make arrangements for any home assistance you may require.

 

Laparoscopic Splenectomy Procedure

The abdomen is examined, and any accessory spleens found are recognized. The omentum is initially moved aside, and the splenocolic and phrenocolic ligaments are exposed and separated using an energy instrument, preferably radiofrequency, and the laparoscopic LigaSure® vascular sealing system is used. This phase allows for additional mobilization and inferior retraction of the colon's splenic flexure.

The splenorenal ligament is subsequently dissected, allowing access to the splenic hilum. The gastrosplenic ligament and short gastric vessels are closed and split along the greater gastric curvature using a radiofrequency instrument. The stomach can be retracted to the right when the dissection is completed up to the level of the left crus.

The pancreatic body-tail, which runs along the top margin of the splenic artery, is exposed when the stomach is moved to the right. A careful but decisive dissection permits the splenic artery to be isolated in its free portion as soon as it exits the pancreatic tail, roughly 2-3 cm before its forking at the hilum. A hem-o-lok seals it, making the subsequent dissection safer and reducing the bulk of the spleen.

If a slight violation of the parenchyma is found, the bleeding is solely venous from this point forward. The splenic vessels are bare and straight once the spleno-diaphragmatic ligament has been completely detached.

At this stage, the hilum is removed with a single firing of an endoscopic stapler filled with a 60-mm vascular cartridge, as long as the pancreas tail is protected and all hilar structures may be included within the jaws of the stapler, which we term the "stapling method."

The spleen is put in a retrieval bag with a 15-mm opening. In the case of benign illness, the spleen can be morcellated and extracted in fragments from the location of the periumbilical trocar, avoiding the need for an additional abdominal incision. If a splenectomy is performed to treat cancer, the spleen is taken intact via a Pfannenstiel incision or by widening the 10 mm left trocar site.

Following extraction, the splenic bed, hilum, and greater curvature of the stomach should be extensively examined to confirm haemostasis. This can be accomplished by lowering the pneumoperitoneum to 9-10 mmHg. At this time, a drain is inserted via the 10 mm trocar site and kept in the splenic bed for two days.

 

Postoperative Management

At the completion of the surgery, the Foley's catheter and orogastric or nasogastric tube are withdrawn. For the first 48 postoperative hours, pain is controlled with parenteral paracetamol 1 g twice a day, followed by oral medicine if necessary. On the first postoperative day, all patients are urged to ambulate and are given an unlimited meal.

The drain is removed on the second postoperative day, and the majority of patients are released on that day. In the early postoperative phase, patients are watched for bleeding, atelectasis, and infection. When platelet counts reach 1 million, antiplatelet medication is advised as a treatment for thrombotic problems or as a preventative measure.

Because portal vein or mesenteric vein thrombosis can be a significant consequence of splenectomy, patients might be kept on low-molecular-weight heparin preventive dosages for 4 weeks after surgery. Infectious problems are uncommon. The risk of overwhelming post-splenectomy infection (OPSI) is greatest in children under the age of five, as well as in patients who have previously had immunosuppressive medication. Antibiotic prophylaxis is performed in accordance with the Guidelines for Overwhelming Post-Splenectomy Infection Prophylaxis, and the drug of preference is penicillin; if penicillin allergies exist, trimethoprim-sulfamethoxazole or erythromycin should be administered.

 

What Can I Expect After Surgery?

You should be allowed to return home as soon as you can resume oral intake, pee, and care for your basic requirements. When it is safe to return home, your surgeon will notify you.

Generally, once you've returned home, you can perform the following things, although each scenario is different, and "at home" activities should be reviewed with your doctor.

• Activity: You may walk and climb stairs as an activity. You can shower, but most doctors advise against taking a bath for at least a week after surgery. When you feel stronger, discuss more demanding activities with your surgeon.
• Driving: Consult your surgeon. Most people can drive again 5 to 7 days following surgery. You should not drive while taking pain medication.
• Diet: Unless you have unique dietary demands, such as diabetes, you can consume a typical diet at home.
• Bowel function: Constipation is typical after surgery, especially if you are using pain medication. It is critical to drink enough of water and consume adequate fiber in your diet. Your surgeon may advise you on how to improve your gut function after surgery. Before taking a cathartic, see your surgeon.

 

Complications & Risks

Complications from laparoscopic splenectomy are uncommon, but you should consult your doctor about the possibility of complications in your specific case. Cannula site infections, pneumonia, internal bleeding, or infection inside the abdomen at the site where the spleen used to be are all possible complications, though they are uncommon. Following surgery, the pancreas may become inflamed (pancreatitis) or leak fluid. Hernias at the cannula sites or an overwhelming infection throughout the body can arise months or years later. This complication is also uncommon.

OPSI, or Overwhelming Post-Splenectomy Illness, refers to an infection that arises following a splenectomy. OPSI is caused by a lack of a spleen, which is required to combat certain bacterial infections. Immunization is typically administered prior to spleen removal and is one means of assisting the body in fighting and preventing infection. If an infection develops, medications such as penicillin can be used because the bacteria that frequently cause this kind of illness are antibiotic-resistant. It is critical that you inform your doctor or any doctor who is covering for you that you had your spleen removed.

 

When To Call Your Doctor?

Be sure to call your physician or surgeon if you develop any of the following:

• Persistent fever over 101 degrees F (39 C).
• Bleeding.
• Increasing abdominal swelling.
• Pain that is not relieved by your medications.
• Persistent nausea or vomiting.
• Chills.
• Persistent cough or shortness of breath.
• Purulent drainage (pus) from any incision.
• Redness surrounding any of your incisions that is worsening or getting bigger.
• You are unable to eat or drink liquids.

 

Summary

 

Splenectomy is the surgical removal of the spleen. The spleen is an organ located on the upper left side of your abdomen, beneath your rib cage. It aids in the battle against infection by filtering unwanted material from your blood, such as old or broken blood cells.

Splenectomy is most commonly performed to repair a burst spleen, which is generally caused by an abdominal injury. Splenectomy may also be done to treat various problems such as a painfully enlarged spleen (splenomegaly), some blood abnormalities, some malignancies, infection, and noncancerous cysts or tumors.

Splenectomy is most commonly performed using a tiny video camera and special surgical tools (laparoscopic splenectomy). With this type of surgery, you may be able to leave the hospital the same day and recover fully in two weeks.