Spleen: Splenectomy

Splenectomy Vaccination

Vaccinations

  • Hemophilus influenzae Type B
    • HiB Single Dose
  • Meningococcus
    • Quadrivalent Conjugate ACWY – 2 Doses ≥ 8 Weeks Apart
    • Monovalent Serogroup B Series – 2 Doses ≥ 4 Weeks Apart
  • Pneumococcus
    • 13-Valent Conjugate (PCV13) – 1 Dose Initially
    • 23-Valent Polysaccharide (PPSV23) – 1 Dose After 8 Weeks

Timing

  • Elective: Finish 2 Weeks Before – Start 10-12 Weeks Prior
  • Emergent: Start 2 Weeks After (Impaired Functional Ab Responses Prior)
    • Give Just Prior to Discharge if Concern for Loss to Follow Up

Boosters Mn

  • HiB: None
  • MCV: Every 5 Years (Quadrivalent Conjugate)
  • PCV: After 5 Years & At Age 65 (PPSV23)
    • Some Recommend Every 5-7 Years

Splenectomy

Basics

  • Preserved Function Requires: 1/3 of Splenic Mass
  • Indications:
    • Trauma (Most Common Cause)
    • ITP (Most Common Elective Cause)
    • Hereditary Spherocytosis
    • Felty Syndrome
    • Splenic Abscess
    • Splenic Cyst (Hydatid Cysts)
    • Splenic Vein Thrombosis
    • Cancer
  • Approach Comparison
    • Laparoscopic
      • Lower Morbidity & Mortality
      • Shorter Hospital Stay & Faster Recovery
      • Higher OR Cost but Lower Total Cost from Decreased Stay
    • Open
      • High Risk for Injury to Pancreas

Elective Splenectomy

  • Approach: Laparoscopic
  • Laparoscopic Approaches:
    • Lateral (Right-Lateral Decubitus)
      • Most Common Approach
    • Anterior
      • Indications:
        • Massive Splenomegaly (> 23 cm of 3 kg)
        • If Another Procedure is Required
      • May Require an Accessory Extraction Incision if Too Large
    • Posterior
      • More Difficult Due to Thick Muscle Mass
  • Procedure:
    • Mobilize Ligaments
      • Divide Splenocolic Ligament
      • Divide Gastrosplenic Ligament & Short Gastrics
        • Ligate Close to Spleen (Avoid Gastric Injury)
      • Divide Splenorenal Ligament & Visualize Splenic Vessels
    • Resect Spleen
      • Divide Splenic Artery & Vein
      • Avoid Injury to Tail of Pancreas
      • Divide Splenophrenic Ligament (Last)
        • Maintains Cephalad/Lateral Retraction
    • Spleen Morcellated & Extracted
  • Ligate Hilar Vessels Before Splenophrenic Division

Traumatic Splenectomy

  • Approach: Open
  • Procedure:
    • Mobilize Spleen & Pancreatic Tail to Midline Together
      • Left Hand Around Spleen & Retract Medially
      • Divide Splenophrenic Ligament
    • Fully Mobilize
      • Divide Gastrosplenic Ligament & Short Gastrics
        • Ligate Close to Spleen (Avoid Gastric Injury)
      • Divide Splenocolic Ligament
    • Ligate Splenic Artery & Then Splenic Vein
      • Avoid Injury to Tail of Pancreas
  • Ligate Hilar Vessels After Complete Mobilization

Post-Splenectomy Hematologic Changes

Laboratory Changes

  • Leukocytosis (WBC)
    • Reliable Markers for Infection After Traumatic Splenectomy:
      • WBC > 15,000 on Postoperative Day #5
      • Platelet/WBC < 20 on Postoperative Day #5
    • Generally Transient Although Lymphocytosis & Monocytosis are More Persistent
  • Polycythemia (RBC)
  • Thrombocytosis (Plt) – Generally Transient

Peripheral Blood Smear Changes

  • Howell-Jolly Bodies (Nuclear Fragments)
  • Poikilocytosis (Abnormally Shaped RBC)
    • Target Cells (Codocyte)
    • Spur Cells (Acanthocytes)
  • Pappenheimer Bodies (Fe Deposits)

Howell-Jolly Bodies 1

Poikilocytosis 2

Pappenheimer Bodies 3

Post-Splenectomy Complications

Postoperative Hemorrhage

  • Most Common Early Complication
  • From Short Gastrics (#1 Most Common) or Splenic Vessels

Overwhelming Post-Splenectomy Infection (OPSI)/Post-Splenectomy Sepsis Syndrome (PSSS)

  • Infection Showing Rapid Progression to Sepsis in Post-Splenectomy Patients
  • High Mortality
  • Cause: Loss of IgM Mediated Immunity to Capsulated Bacteria (HiB, PC & MC)
    • Most Common Organism: Pneumococcus
    • Most Common Infections: PNA, Primary Bacteremia & Meningitis
  • Risk Factors:
    • Peds (Especially Age < 5)
    • If Splenectomy Due to:
      • Malignancy
      • Hemolytic Disorder (Thalassemia Major #1, Sickle Cell #2, Hereditary Spherocytosis, ITP)
  • Tx: Vancomycin & Ceftriaxone

Antibiotic Prophylaxis

  • Possible Indications:
    • First Year Post-Splenectomy
    • Age < 5 Years
    • Immunocompromised
    • History of Sepsis from Encapsulated Organisms
  • Regimen: Penicillin or Amoxicillin
    • If Penicillin Allergy: Cephalosporin

Other Complications

  • Pancreatic Leak
    • Pancreatic Tail Contained in the Splenorenal Ligament
    • May See Postop Fluid Collection in the Lesser Sac
  • Splenosis
  • Venous Thromboembolism
    • Including Portal/Splenic Vein Thrombosis

Mnemonics

Vaccine Booster Frequency After Splenectomy

  • H-“IB” – Initial Bolus
    • Only Need One Initial Dose
  • M-“CV” & P-“CV” – Continued V (5)
    • Require Continued Doses After Five Years

References

  1. Mourao PHO, Haggstrom M. Wikimedia Commons. (License: CC BY-SA-3.0)
  2. Uthman E, Bhimji S, Haggstrom M. Wikimedia Commons. (License: CC BY-4.0)
  3. Mourao PHO. Wikimedia Commons. (License: CC BY-SA-4.0)