Splenectomy

A splenectomy is the total or partial surgical removal of the spleen,

an organ that is part of the lymphatic system.

The human spleen is a dark purple bean-shaped organ located in the

upper left side of the abdomen just behind the bottom of the rib cage.
In adults, the spleen is about 4.8 X 2.8 X 1.6 in (12 X 7 X 4 cm) in
size, and weighs about 4–5 oz (113–14 g). The spleen plays a role in
the immune system of the body. It also filters foreign substances from
the blood and removes worn-out blood cells. The spleen regulates blood
flow to the liver and sometimes stores blood cells—a function known as
sequestration. In healthy adults, about 30% of blood platelets are
sequestered in the spleen.

Splenectomies are performed for a variety of different reasons and with

different degrees of urgency. Most splenectomies are done after a
patient has been diagnosed with hypersplenism. Hypersplenism is not a
specific disease but a syndrome (group or cluster of symptoms) that may
be associated with different disorders. Hypersplenism is characterized
by enlargement of the spleen (splenomegaly), defects in the blood
cells, and an abnormally high turnover of blood cells. It is almost
always associated with such specific disorders as cirrhosis of the
liver or certain cancers. The decision to perform a splenectomy depends
on the severity and prognosis of the disease that is causing the
hypersplenism.
 There are two options for accessing the
spleen for a splenectomy (A, 1 and
2). After the abdomen is entered,
the spleen is located, and the
artery leading to it is tied off
(B). The ligament connecting the
stomach and spleen is cut (C), as
is the ligament connecting the
spleen and colon (D). This frees
the spleen for removal (E).

Splenectomy always required

There are two diseases for which a splenectomy is the only treatment—
primary cancers of the spleen and a blood disorder called hereditary
spherocytosis (HS). In HS, the absence of a specific protein in the red
blood cell membrane leads to the formation of relatively fragile cells
that are easily damaged when they pass through the spleen. The cell
destruction does not occur elsewhere in the body and ends when the
spleen is removed. HS can appear at any age, even in newborns, although
doctors prefer to put off removing the spleen until the child is five
to six years old.

Splenectomy usually required

There are some disorders for which a splenectomy is usually

recommended. They include:
 • Immune (idiopathic) thrombocytopenic purpura (ITP). ITP is a
disease in which platelets are destroyed by antibodies in the
body's immune system. A splenectomy is the definitive treatment
for this disease and is effective in about 70% of cases of
chronic ITP.
• Trauma. The spleen can be ruptured by blunt as well as
penetrating injuries to the chest or abdomen. Car accidents are
the most common cause of blunt traumatic injury to the spleen.
• Abscesses. Abscesses of the spleen are relatively uncommon but
have a high mortality rate.
• Rupture of the splenic artery. This artery sometimes ruptures as
a complication of pregnancy.
• Hereditary elliptocytosis. This is a relatively rare disorder. It
is similar to HS in that it is characterized by red blood cells
with defective membranes that are destroyed by the spleen.

Splenectomy sometimes required

Other disorders may or may not necessitate a splenectomy. These include:

• Hodgkin's disease, a serious form of cancer that causes the lymph

nodes to enlarge. A splenectomy is often performed in order to
find out how far the disease has progressed.
• Autoimmune hemolytic disorders. These disorders may appear in
patients of any age but are most common in adults over 50. The
red blood cells are destroyed by antibodies produced by the
patient's own body (autoantibodies).
• Myelofibrosis. Myelofibrosis is a disorder in which bone marrow
is replaced by fibrous tissue. It produces severe and painful
splenomegaly. A splenectomy does not cure myelofibrosis but may
be performed to relieve pain caused by the swelling of the spleen.
• Thalassemia. Thalassemia is a hereditary form of anemia that is
most common in people of Mediterranean origin. A splenectomy is
 sometimes performed if the patient's spleen has become painfully
enlarged.

Classification

Complete splenectomy

REMOVAL OF ENLARGED SPLEEN. A splenectomy is performed under general

anesthesia. The most common technique is used to remove greatly
enlarged spleens. After the surgeon makes a cut (incision) in the
abdomen, the artery to the spleen is tied to prevent blood loss and
reduce the size of the spleen. Tying the splenic artery also keeps the
spleen from further sequestration of blood cells. The surgeon detaches
the ligaments holding the spleen in place and removes the organ. In
many cases, tissue samples will be sent to a laboratory for analysis.

REMOVAL OF RUPTURED SPLEEN. When the spleen has been ruptured by

trauma, the surgeon approaches the organ from its underside and ties
the splenic artery before removing the ruptured organ.

Partial splenectomy

In some cases, the surgeon removes only part of the spleen. This
procedure is considered by some to be a useful compromise that reduces
pain caused by an enlarged spleen while leaving the patient less
vulnerable to infection.

Laparoscopic splenectomy

Laparoscopic splenectomy, or removal of the spleen through several

small incisions, has been performed more frequently in recent years.
Laparoscopic surgery, which is sometimes called keyhole surgery, is
done with smaller surgical instruments inserted through very short
incisions, with the assistance of a tiny camera and video monitor.
Laparoscopic procedures reduce the length of hospital stay, the level
of postoperative pain, and the risk of infection. They also leave
smaller scars.

As of 2003, however, a laparoscopic procedure is contraindicated if the

patient's spleen is greatly enlarged. Most surgeons will not remove a
spleen longer than 20 cm (as measured by a CT scan) by this method.

Diagnosis/Preparation

The most important part of a medical assessment in disorders of the

spleen is the measurement of splenomegaly. The normal spleen cannot be
felt when the doctor palpates the patient's abdomen. A spleen that is
large enough to be felt indicates splenomegaly. In some cases, the
doctor will hear a dull sound when he or she thumps (percusses) the
patient's abdomen near the ribs on the left side. Imaging studies that
can be used to confirm splenomegaly include ultrasound tests,
technetium-99m sulfur colloid imaging, and CT scans . The rate of
platelet or red blood cell destruction by the spleen can also be
measured by tagging blood cells with radioactive chromium or platelets
with radioactive indium.

Preoperative preparation for a splenectomy procedure usually includes:

• Correction of abnormalities of blood clotting and the number of

red blood cells.
• Treatment of any infections.
• Control of immune reactions. Patients are usually given
protective vaccinations about a month before surgery. The most
common vaccines used are Pneumovax or Pnu-Imune 23 (against
pneumococcal infections) and Menomune-A/C/Y/W-135 (against
meningococcal infections).
Aftercare

Immediately following surgery, patients are given instructions

for incision care and medications intended to prevent infection. Blood
transfusions may be indicated for some patients to replace defective
blood cells. The most important part of aftercare, however, is long-
term caution regarding vulnerability to infection. Patients are asked
to see their doctor at once if they have a fever or any other sign of
infection, and to avoid travel to areas where exposure to malaria or
similar diseases is likely. Children with splenectomies may be kept on
antibiotic therapy until they are 16 years old. All patients can be
given a booster dose of pneumococcal vaccine five to 10 years after
undergoing a splenectomy.

Normal Results

Results depend on the reason for the operation. In blood disorders, the
splenectomy will remove the cause of the blood cell destruction. Normal
results for patients with an enlarged spleen are relief of pain and the
complications of splenomegaly. It is not always possible, however, to
predict which patients will respond well or to what degree.

Recovery from the operation itself is fairly rapid. Hospitalization is

usually less than a week (one to two days for laparoscopic
splenectomy), and complete healing usually occurs within four to six
weeks. Patients are encouraged to return to such normal activities as
showering, driving, climbing stairs, light lifting and work as soon as
they feel comfortable. Some patients may return to work in a few days
while others prefer to rest at home a little longer.
 Readings
about
Splenectomy

Submitted by:
Gundayao, Nessa Joan B.
Group 21
BSN 4 Weidenbach

Submitted to:
Mrs. Candelaria Talabucon, RN MAN
Clinical Instructor