Evidence - Open splenectomy

• If possible, no splenectomy before age 6 years.
• In principle, if splenectomy is not indicated for other reasons, preserve the spleen in part or in toto.
• Vaccinate the patient (pneumococci/haemophilus vaccine) as soon as the indication for splenectomy is discussed, at least 2 weeks prior to the procedure. If the splenectomy is performed without prior vaccination, maintain a vaccine interval of at least 10-14 days post-splenectomy. In children aged 2 years and older, meningococcal vaccination is also recommended. In children aged 10 years and younger, penicillin prophylaxis for at least 2 years should also be considered.
• Continue low-molecular-weight heparin therapy until full ambulation, for at least four weeks after splenectomy, to prevent portal vein thrombosis.
• Since the prognosis in portal vein thromboses is improved by immediate heparin therapy and later with oral anticoagulants, monitoring of at-risk patients in the first year after splenectomy by diagnostic Doppler ultrasonography and D-dimer testing should be considered.
• Portal vein thrombosis is more common in patients with a very large spleen, and according to a study listed below (20) in thrombocytosis of >600-1000 103/μl, and diathetic thrombophilia. Some reviews recommend post-splenectomy treatment with ASA 100 mg/day for one year (level of recommendation: C, 8, 20), but this has not been justified by the data available thus far.
• If thrombocytopenia is the underlying disease, preoperative administration of platelet products is not advised, as they will be metabolized shortly thereafter.
• In patients with elective splenectomy and a small spleen (<500 g), consider laparoscopic splenectomy.
• Laparoscopic splenectomy is contraindicated in hepatic cirrhosis with portal hypertension.
• In case of fever and suspected infection after splenectomy initiate treatment immediately.
• In patients with abdominal trauma of unknown origin, perform the splenectomy via a midline incision.
• Elective splenectomy via a subcostal/transverse left upper quadrant incision.
• Accessory spleens (which may occur in 20% of all cases) are always found in the left hemiabdomen. The accessory spleens must only be removed when performing a splenectomy in patients with underlying hematological disorders. Accessory spleens are visualized preoperatively by scintiscanning with Tc99m-labeled RBCs.
• In multivisceral tumor operations without signs of tumor infiltration sparing the spleen is always justified. If the spleen has to be removed in these procedures, a markedly increased rate of complications and infections should be expected.
• At present, autotransplantation of splenic tissue (e.g., into the greater omentum) has been completely discontinued.
• Hanging spleen technique Positioning in laparoscopic splenectomy: 60-degree right lateral recumbent position with elevated left flank. Anti-Trendelenburg position. Optical trocar in the umbilical region and three more working trocars along the costal arch. Option: Technique in the lithotomy position.
• Both laparoscopic splenectomy techniques do not differ significantly with regard to the duration of surgery, blood loss and perioperative complications.  In patients undergoing surgery with the hanging spleen technique there is only somewhat less use of material and a reduction in the number of incisions. Further prospective trials must be conducted to decide whether the hanging-spleen technique is the method of choice.

The Effect of Laparoscopic Splenectomy on the Immune Function for Cirrhosis Patients

Overwhelming Post-Splenectomy Infections (OPSI) After Cytoreductive Surgery and Hyperthemic Intraperitoneal Chemotherapy: a Prospective Observational Study

Comparison of Laparoscopic Splenectomy in Supine Position with Hanging-Spleen Technique in Idiopathic Thrombocytopenic Purpura Zentralbl Chir 2011; 136(2): 159-163

Laparoscopic splenectomy for immune thrombocytopenia (ITP) patients with platelet counts lower than 1 × 109/L. Wu Z, Zhou J, Pankaj P, Peng B. Int J Hematol. 2011 Dec;94(6):533-8. Epub 2011 Nov 5.

A new technique for partial splenectomy with radiofrequency technology. Karadayi K, Turan M, Sen M.Surg Laparosc Endosc Percutan Tech. 2011 Oct;21(5):358-61.

Reappraisal of anterior approach to laparoscopic splenectomy: technical feasibility and its clinical application. Choi SH, Kang CM, Hwang HK, Lee WJ.Surg Laparosc Endosc Percutan Tech. 2011 Oct;21(5):353-7.

Splenic trauma – our experience at a level I Trauma Center. Saurabh G, Kumar S, Gupta A, Mishra B, Sagar S, Singhal M, Khan RN, Misra MC. Ulus Travma Acil Cerrahi Derg. 2011 May;17(3):238-42.

Laparoscopic splenectomy: consensus and debatable points. Bani Hani MN, Qasaimeh GR, Bani-Hani KE, Alwaqfi NR, Al Manasra AR, Matani YS, El-Radaideh KM.S Afr J Surg. 2010 Jul 13;48(3):81-4.

Laparoscopic splenectomy: comparison between anterior and lateral approaches. Podevin G, Victor A, De Napoli S, Heloury Y, Leclair MD. J Laparoendosc Adv Surg Tech A. 2011 Nov;21(9):865-8. Epub 2011 Aug 19.

Radical gastrectomy with combined splenectomy: unnecessary. Yao XX, Sah BK, Yan M, Chen MM, Zhu ZG. Hepatogastroenterology. 2011 May-Jun;58(107-108):1067-70.

Splenic hilum management during laparoscopic splenectomy. Vecchio R, Marchese S, Swehli E, Intagliata E.J Laparoendosc Adv Surg Tech A. 2011 Oct;21(8):717-20. Epub 2011 Jul 21.

Contemporary pediatric splenectomy: continuing controversies. Wood JH, Partrick DA, Hays T, Sauaia A, Karrer FM, Ziegler MM. Pediatr Surg Int. 2011 Nov;27(11):1165-71. Epub 2011 May 28.

[Elective splenectomy at landspitali university hospital 1993-2004 efficacy and long-term outcome].
Einarsdottir MJ, Bjornsson B, Birgisson G, Haraldsdottir V, Oddsdottir M. Laeknabladid. 2011 May;97(5):297-301. Icelandic.

The best approach for splenectomy in portal hypertension. Andraus W, Pinheiro RS, Haddad LB, Herman P, D’Albuquerque LA. Surgery. 2011 Jun;149(6):853. doi: 10.1016/j.surg.2011.02.014. Epub 2011 Apr 17.

[Living without a spleen]. Lammers AJ. Ned Tijdschr Tandheelkd. 2010 Dec;117(12):611-4. Dutch.

Long-term outcomes of a 5-year follow up of patients with immune thrombocytopenic purpura after splenectomy. Han JJ, Baek SK, Lee JJ, Kim SY, Cho KS, Yoon HJ. Korean J Hematol. 2010 Sep;45(3):197-204. Epub 2010 Sep 30.

Portal vein thrombosis postlaparoscopic splenectomy presenting with infarction of gut: review of risk factors, investigations, postoperative surveillance, and management. Machado NO, Chopra PJ, Sankhla D. Surg Laparosc Endosc Percutan Tech. 2010 Aug;20(4):273-7. Review.

Postsplenectomy infection – strategies for prevention in general practice. Jones P, Leder K, Woolley I, Cameron P, Cheng A, Spelman D. Aust Fam Physician. 2010 Jun;39(6):383-6.

Management of spleen injuries: the current profile. Mikocka-Walus A, Beevor HC, Gabbe B, Gruen RL, Winnett J, Cameron P. ANZ J Surg. 2010 Mar;80(3):157-6

Determinants of splenectomy in splenic injuries following blunt abdominal trauma. Akinkuolie AA, Lawal OO, Arowolo OA, Agbakwuru EA, Adesunkanmi AR. S Afr J Surg. 2010 Feb;48(1):15-9.

Laparoscopic splenectomy: a personal series of 140 consecutive cases. Pattenden CJ, Mann CD, Metcalfe MS, Dyer M, Lloyd DM. Ann R Coll Surg Engl. 2010 Jul;92(5):398-402. Epub 2010 May 19.

[The conservative treatment in the splenic trauma]. Rosito M, Lattarulo S, Pezzolla A, Fabiano G, Palasciano N. Ann Ital Chir. 2009 May-Jun;80(3):231-6. Italian.

Management of post-splenectomy patients in the Netherlands. Lammers AJ, Veninga D, Lombarts MJ, Hoekstra JB, Speelman P. Eur J Clin Microbiol Infect Dis. 2010 Apr;29(4):399-405. Epub 2010 Jan 22.

[Laparoscopic splenectomy: indications, techniques, outcomes]. Borie F, Philippe C. J Chir (Paris). 2009 Aug;146(4):336-46. Epub 2009 Sep 18. Review. French.

Portal and splenic venous thrombosis after splenectomy in patients with hypersplenism. Yoshida M, Watanabe Y, Horiuchi A, Yamamoto Y, Sugishita H, Kawachi K. Hepatogastroenterology. 2009 Mar-Apr;56(90):538-41.

Laparoscopic versus open splenectomy for hypersplenism secondary to liver cirrhosis. Zhu JH, Wang YD, Ye ZY, Zhao T, Zhu YW, Xie ZJ, Liu JM. Surg Laparosc Endosc Percutan Tech. 2009 Jun;19(3):258-62