Procedure: Splenectomy

Surgery

February 16, 2023

≈16 min

Introduction

The spleen is an encapsulated, immunologic, solid organ located in the posterolateral left upper quadrant immediately beneath the diaphragm and lateral to the greater curve of the stomach and the tail of the pancreas. Its primary function is hematologic filtration and immunologic protection – particularly against encapsulated bacteria^[1]. In the trauma setting, the spleen and liver are the most commonly injured intra-abdominal organs following blunt trauma and the spleen is at risk for injury in penetrating trauma of the thoracoabdominal and abdominal regions^[2].

Initial evaluation of the spleen in the trauma setting can occur at bedside via the Focused Assessment with Sonography in Trauma (FAST) which can demonstrate a hypoechoic or black rim around the spleen in the left upper quadrant view or intra-abdominal free fluid in any view. For the hemodynamically unstable patient with concern for intra-abdominal injuries, splenic injury may be diagnosed on FAST exam or ultimately in the operating room. For the hemodynamically stable trauma patient, the imaging modality of choice is a computed tomography (CT) scan with intravenous contrast which can demonstrate hemoperitoneum, parenchymal hypodensities, intraparenchymal hematoma, subcapsular hematoma, or contrast “blush” or extravasation. The American Association for the Surgery of Trauma has developed a scale for grading splenic injury^[3], which is summarized in Table 1.

While splenic injury grading can be useful to evaluate the severity of injury, with Grade V injuries being associated with up to a 22% mortality^{[3, 4]}, it does not necessarily predict the need for surgical exploration. This chapter will provide an overview of the indications, operative planning, procedural steps, and complications of urgent/emergent splenectomy in the trauma setting^[5].

Table 1 – The American Association for the Surgery of Trauma Spleen Injury Scale*

Grade	Computed Tomography Findings	Intraoperative Findings
I	• Subcapsular hematoma <10% surface area • Parenchymal laceration <1 cm depth • Capsular tear	• Subcapsular hematoma <10% surface area • Parenchymal laceration <1 cm depth • Capsular tear
II	• Subcapsular hematoma 10-50% surface area • Intraparenchymal hematoma <5 cm • Parenchymal laceration 1-3 cm depth	• Subcapsular hematoma 10-50% surface area • Intraparenchymal hematoma <5 cm • Parenchymal laceration 1-3 cm depth
III	• Subcapsular hematoma >50% surface area • Ruptured subcapsular or intraparenchymal hematoma ≥5 cm • Parenchymal laceration >3 cm depth	• Subcapsular hematoma >50% surface area or expanding • Ruptured subcapsular or intraparenchymal hematoma ≥5 cm • Parenchymal laceration >3 cm depth
IV	• Any injury in the presence of a splenic vascular injury or active bleeding confined within splenic capsule • Parenchymal laceration involving segmental or hilar vessels producing >25% devascularization	• Parenchymal laceration involving segmental or hilar vessels producing >25% devascularization
V	• Any injury in the presence of splenic vascular injury with active bleeding extending beyond the spleen into the peritoneum • Shattered spleen	• Hilar vascular injury that devascularizes the spleen • Shattered spleen

*Adapted from Tinkoff et al^[3]. If findings from multiple grades present the final grade is highest grade present.

Indications/Contraindications

In the trauma setting the decision to proceed to the operating room will be determined by the patient’s hemodynamic status, physical exam, and grade of injury. Indication to immediately proceed to the operating room for laparotomy and splenectomy is hemodynamic instability and splenic trauma. Peritonitis and other intraabdominal injuries are indications for immediate laparotomy in the settings of operating room^[1].

Option for Trial of Non-Operative Management: Stable Patients in Facilities With Adequate Resources

Patient Requirements:

Hemodynamically stable
No evidence of peritonitis
No other indications for operating room
No evidence of ongoing blood loss

Facility Requirements:

Staff that can perform serial abdominal exams every 2-3 hours
Continuous hemodynamic monitoring
Ability to perform serial hematocrit labs every 4-6 hours
Optional but strongly encouraged: interventional radiologists or another physician equipped to perform angioembolization. Angioembolization should be considered in patients that have Grade 3 or higher splenic injuries, contrast extravasation on CT scan, moderate hemoperitoneum, or evidence of ongoing bleeding as suggested by decreasing hematocrit^[5].

Patients who qualify for non-operative management should be continuously monitored for the development of indications to pursue operative interventions including hemodynamic instability, development of peritoneal signs, decreasing hematocrit, or hypotension or persistent tachycardia despite adequate fluid resuscitation^[1].

When in doubt, the safest course of action is to proceed to the operating room and perform splenectomy if the spleen is injured and contributing to hemorrhage. Additionally, if practicing in a situation with limited resources (limited blood product, access to laboratory, intensive care unit monitoring) the safest course of action is to proceed with splenectomy.

Equipment

Major abdominal exploratory laparotomy tray
Self-retaining retractor (e.g. Bookwalter)
Bipolar cautery
Suction – 1 is sufficient but 2 is ideal
Ligasure, harmonic scalpel, or other similar instrument for hemostasis
Anticipate needing >20-30 laparotomy pads
2-0 Silk Ties [2-0 or 0 silk or vicryl ties ok, but we prefer silk]
2-0 or larger sutures for suture ligation
Drain available

Preparation

The preparation for splenectomy in the trauma patient is often limited due to the urgent/emergent nature of the procedure. In addition to the below operative preparations, the surgeon should consider the postoperative needs of the patient including the need for intensive care unit monitoring or if additional imaging or procedures are needed depending on injury burden.

Operative Preparation

Ensure all necessary equipment is available and in-room.
Try to have at least 4 units of packed red blood cells or other blood product equivalent available within the room prior to incision. If the patient is unstable then it is appropriate to activate the institution’s massive transfusion protocol.
The most important preparation is to have at least two large bore (18 gauge or larger) peripheral intravenous lines in place.
If time allows, a short debrief of the operative plan with all surgical, anesthesia, and nursing staff can be particularly useful in the trauma laparotomy to give ample warning of when significant changes in hemodynamics are expected.
The planning of preoperative antibiotics should be based on the patient’s overall expected injury burden. While standard preoperative antibiosis such as a 1^st generation cephalosporin (e.g., cephazolin) is appropriate for isolated splenectomy, the addition of a second antibiotic such as metronidazole should be considered if concerned for enteric contamination.
Place foley
Only after ensuring adequate intravenous access, have anesthesia place nasogastric or orogastric tube to decompress stomach.

Postoperative Preparation

Begin planning for a safe postoperative disposition for the patient early including the consideration of intensive care unit monitoring, serial laboratory monitoring, and further imaging or interventions based on the injury burden.
The spleen plays a vital role in the defense against encapsulated organisms and as a result patients that undergo splenectomy are at risk for overwhelming sepsis and require additional immunizations (see “Splenectomy Specific Complications” below).

Steps for Trauma Exploratory Laparotomy with Splenectomy

1. Prep and drape patient for standard trauma exploratory laparotomy (supine position with arms lateral, sterile preparation from neck to mid-thighs, keep patient normothermic by warming the operating room and using a Bair hugger if available).

2. Make a large midline incision from sub-xiphoid to pelvis through fascia but stop prior to entering peritoneum.
We prefer to utilize electrocautery for incision over a scalpel because it is significantly more hemostatic and cosmesis is not critical in the trauma situation. At this point warn anesthesia and nursing staff that you are about to make entry into the abdomen and that large hemodynamic changes may take place due to the release of the intra-abdominal tamponade effect. Ensure you have blood products in the room, suction available, and ample laparotomy pads for intra-abdominal packing. The goal should be to get into the abdomen as quickly as possible.

3. Perform exploratory laparotomy for trauma (discussed separately)

When you first enter the abdomen the primary goal should be to evacuate the clot and blood as quickly as possible – scooping out clot with your hands and then using laparotomy pads to quickly absorb and remove blood are the fastest and most effective methods. Suction is less effective and should be used last, or for smaller amounts. Then proceed with intraabdominal packing of all 4 quadrants with laparotomy pads beginning with the area with the highest suspicion of injury or active bleeding.
Packing of the left upper quadrant is achieved by retracting the abdominal wall superiorly and placing laparotomy pads between the diaphragm and spleen, lateral wall and bleed, splenic flexure of the colon and spleen, and anterior to the spleen creating a snug, sandwich-like effect.
After all 4 quadrants have been packed, do a quick scan of the other 3 quadrants for any life-threatening injuries and then turn your attention to the quadrant with the most severe injuries.
The spleen can remain packed while dealing with other more urgent injuries such as massive bleeding or GI contamination. If the spleen is the most urgent injury, then proceed with hemorrhage control and splenectomy first.

4. Splenectomy

Following trauma, the bleeding from the spleen will dissect the retroperitoneal and/or intraperitoneal planes by itself. Usually, once in the operating room the majority of the dissection has been done and the surgeon can complete mobilization bluntly by lifting the spleen anteriorly and medially.
- If the spleen has not auto-dissected, first divide the lateral attachments (splenophrenic and splenorenal ligaments) by elevating the spleen anteriorly and medially and create a dissection plane between the pancreas and kidney using sharp (Metzenbaum scissors or electrocautery) or blunt (using hand) dissection. Then divide the gastrosplenic ligament (using 2 clamps and electrocautery as short gastrics are within this ligament), and finally the splenocolic ligament.
Once the spleen is mobilized anterior and medial, rapid removal can be achieved by clamping and dividing two 2 main blood supplies: the splenic hilum (splenic artery and vein) and the gastrosplenic ligament (short gastric vessels) if not already done. 2 clamps should be placed and division in-between the two clamps can be achieved with bipolar vessel sealing technology, electrocautery, or sharp dissection. The clamps should be placed as close to the spleen as possible, especially when clamping the splenic hilum to avoid injuring the tail of the pancreas. The clamps should remain in place as formal ligation can occur after spleen removal. Take care to keep spleen elevated anteriorly to avoid injuring the gastric wall or pancreas. After clamping and dividing the splenic hilum and gastrosplenic ligament the spleen should be easily removed.
Once the spleen has been removed, now you may return to the location of the intra-abdominal clamps to complete hemostasis. The previous location of the splenic hilum and gastrosplenic ligament should be suture ligated (do not use simple ties) and hemostasis confirmed after removal of the clamp. Take care to not catch any other structures (gastric wall for gastrosplenic; pancreatic tail for splenic hilum) when performing suture ligation.
- If possible, try to individually isolate and ligate the splenic artery and splenic vein separately within the hilum to avoid the development of an arteriovenous fistula postoperatively.

5. Hemostasis and Completion of Exploratory Laparotomy

Examine the splenic bed for bleeding and achieve hemostasis. If bleeding is difficult to identify use a clean laparotomy pad and roll along the splenic bed to identify areas of oozing or occult bleeding. The most common areas for bleeding are the retroperitoneal surface and the ligamentous attachments of the spleen. There are also small veins near the gastroesophageal junction near the short gastric vessels that can be a source of bleeding.
Complete the remainder of the exploratory laparotomy and perform temporary abdominal closure or primary closure of the abdomen depending on the patient’s condition and injury burden.
Immediate postoperative care should be tailored to each patient, but we recommend the placement of a nasogastric tube to prevent gastric distension and potential disruption of the short gastric vessels’ hemostasis; as well as serial hematocrits every 8 hours for the first 24 hours or until stable given the risk of re-bleeding. Drain placement should be considered if there is contamination of the abdomen or concern for pancreatic injury – when in doubt leave a drain! There currently is no recommendation for routine post-operative serial imaging by the Eastern Association for the Surgery of Trauma^[6].

Pitfalls:

Two locations of blood supply need to be controlled: the splenic hilum and the short gastrics at the superomedial aspect of spleen
- Splenic Artery – the predominant perfusion of the spleen. After it branches from the celiac trunk it can take a tortuous route along the superior edge of the pancreas until it enters the spleen at the hilum. The area of division is at the splenic hilum.
- Short Gastric Arteries – contained within the gastrosplenic ligament and a frequent source of postoperative bleeding. Prior to ending the operation carefully inspect the greater curvature of the stomach to ensure adequate hemostasis.
- Splenic Vein – the confluence of typically 6 major veins from the splenic parenchyma conjoin at the hilum to form the splenic vein which then courses posterior to the pancreas and joins the superior mesenteric vein and finally the portal vein. The area of division is at the splenic hilum.
Often exploratory laparotomies for trauma are fast-paced and counting of instruments and laparotomy pads during the operation is not feasible. Prior to closing the abdomen, it can be useful to perform an x-ray series to identify any retained foreign objects such as instruments or laparotomy pads.

Complications

General Postoperative Complications:

Pulmonary complications including atelectasis, pneumonia, and pleural effusions are the most common^[7]. Ensuring adequate pain control to prevent splinting and an incentive spirometry program or chest physical therapy can be helpful postoperatively.
Deep venous thrombosis can develop in up to 10% of patients, and this risk increases if the patient also develops severe thrombocytosis^{[8, 9]}. Chemical prophylaxis for deep venous thrombosis should be started within 24 hours after splenectomy if there is no ongoing bleeding or contraindications due to other injuries^[10].
Postoperative bleeding is a particular concern in the trauma splenectomy patient due to the highly vascular nature of the spleen and the increased coagulopathy following trauma. Tachycardia, decreasing hematocrit, abdominal pain, or fever should prompt further evaluation with CT scan and may require additional intervention such as intra-abdominal drain placement or occasionally angioembolization. Reoperation is relatively rare and has been reported in <2% of patients^[11].
The development of leaks and/or abscesses can occur in trauma splenectomy patients due to the proximity of the spleen to the pancreas and contamination from hollow viscous injury. Increasing left upper quadrant pain, fever, or leukocytosis should prompt ultrasound or CT evaluation to evaluate for fluid collection or abscess formation. Abscess formation can be due to contamination or infected hematomas and will require antibiotics with possible drain placement. Fluid collections may also be due to other damaged structures such as gastric perforation due to injury when taking down the short gastric arteries or a pancreatic leak/fistula.

Splenectomy Specific Complications:

Thrombocytosis occurs in 75-80% of patients and usually peaks between 7-20 days post-splenectomy and usually returns to normal within a few months^[12-14]. Usually, the thrombocytosis does not lead to thrombotic complications, but some patients will develop severe thrombocytosis with platelet counts more than 1,000,000 per microliter. At our institution we will consider starting antiplatelet therapy (aspirin 81 milligrams) in patients whose platelets are >1,000,000/microliter and have no contraindications to aspirin use.
Overwhelming post-splenectomy infection (OPSI) is a rare but deadly complication following splenectomy and patients should be counseled on its warning signs. OPSI is usually due to overwhelming sepsis from encapsulated organisms and can be rapidly fatal^[15]. Patients should be counseled on the importance of adhering to the post-splenectomy vaccination guidelines, should seek immediate evaluation if they develop a fever (especially in children), and should ensure they have a reliable way to identify to future providers that they are asplenic by way of medical identification bracelets or documentation. Our institution has a post-splenectomy vaccine protocol (summarized in Table 2) for patients who undergo unplanned splenectomy to receive their initial vaccine doses at least 14 days post-splenectomy or prior to discharge, whichever comes first.

Table 2 – Brigham and Women’s Hospital Department of Trauma Surgery Post-Splenectomy Vaccine Administration Guidelines

Vaccine	Initial Dose	Repeat Dose	Booster
Haemophilus Influenza Type B [Hib]	Yes	No	No
Meningococcus Men B [Bexsero] Men C/W/Ya [Menveo]	Yes Yes	8 weeks 8 weeks	No Every 5 years
Pneumococcus* PCV13 [Prevnar] PPSV23 [Pneumovax] *If patient already received pneumococcal vaccine when >19 years old, give PPSV23 vaccine at age 65 provided it has been at least 5 years since last PPSV23 vaccine	Yes No	No 8 weeks	No 5 years later
Influenza	Yes (if flu season)	No	Annually

References

L; MAK. Surgical management of splenic injury in the adult trauma patient: UpToDate; 2021 [updated 2/17/2021. Available from: https://www.uptodate.com/contents/surgical-management-of-splenic-injury-in-the-adult-trauma-patient?search=Surgical%20management%20of%20splenic%20injury%20in%20the%20adult%20trauma%20patient&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.
Davis JJ, Cohn I, Jr., Nance FC. Diagnosis and management of blunt abdominal trauma. Ann Surg. 1976;183(6):672-8.
Tinkoff G, Esposito TJ, Reed J, Kilgo P, Fildes J, Pasquale M, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008;207(5):646-55.
Clancy TV, Ramshaw DG, Maxwell JG, Covington DL, Churchill MP, Rutledge R, et al. Management outcomes in splenic injury: a statewide trauma center review. Ann Surg. 1997;226(1):17-24.
Bjerke MWS. Splenic Injury Treasure Island, FL: StatPearls Publishing; [updated January 29, 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441993/.
Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, Guillamondegui OD, et al. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S294-300.
Livingston CD, Sirinek KR, Levine BA, Aust JB. Traumatic splenic injury: its management in a patient population with a high incidence of associated injury. Arch Surg. 1982;117(5):670-4.
Chia TL, Chesney TR, Isa D, Mnatzakanian G, Colak E, Belmont C, et al. Thrombocytosis in splenic trauma: In-hospital course and association with venous thromboembolism. Injury. 2017;48(1):142-7.
Lin JN, Chen HJ, Lin MC, Lai CH, Lin HH, Yang CH, et al. Risk of venous thromboembolism in patients with splenic injury and splenectomy. A nationwide cohort study. Thromb Haemost. 2016;115(1):176-83.
Kwok AM, Davis JW, Dirks RC, Wolfe MM, Kaups KL. Time is now: venous thromboembolism prophylaxis in blunt splenic injury. Am J Surg. 2016;212(6):1231-6.
Shackford SR, Molin M. Management of splenic injuries. Surg Clin North Am. 1990;70(3):595-620.
Valade N, Decailliot F, Rebufat Y, Heurtematte Y, Duvaldestin P, Stephan F. Thrombocytosis after trauma: incidence, aetiology, and clinical significance. Br J Anaesth. 2005;94(1):18-23.
Ahmed R, Isaac AM. Postsplenectomy thrombocytosis and pseudohyperkalemia in trauma: a case report and review of literature. J Trauma. 2009;67(1):E17-9.
Khan PN, Nair RJ, Olivares J, Tingle LE, Li Z. Postsplenectomy reactive thrombocytosis. Proc (Bayl Univ Med Cent). 2009;22(1):9-12.15. Schwartz PE, Sterioff S, Mucha P, Melton LJ, 3rd, Offord KP. Postsplenectomy sepsis and mortality in adults. JAMA. 1982;248(18):2279-83.