Open Splenectomy

Description

Open splenectomy is an invasive surgical procedure involving the removal of the spleen. It is used in the treatment of a wide range of haematological disorders, and is preferred over laparoscopic splenectomy in trauma situations and when massive splenomegaly is present.

Provided that the case is not trauma related, there is a significant preoperative protocol that needs to be followed; with particular emphasis on providing immunisations against specific respiratory infections. The surgery is carried out under general anaesthetic and recovery involves pain relief and a gradual easing back into day to day activities. Long term care is required due to the loss of immune function as a result of splenectomy, which most commonly includes the provision of a life-long course of prophylactic antibiotics alongside regular vaccinations.

Complications of the surgery can be severe and include intra-peritoneal haemorrhage alongside infection and sepsis. Severe infection in the form of Overwhelming Postsplenectomy Infection (OPSI) can also occur, which has a rapid onset and requires immediate medical attention. Open Splenectomy also comes with additional risks over laparoscopic splenectomy, such as damage to the pancreatic tail during surgery, resulting in pancreatitis.

What is it?

The spleen is an organ located in the upper left part of the abdomen which performs a number of functions related to the blood including:

1. Removing old red blood cells and recycling their contents.
2. Hosting special immune cells called phagocytes which can engulf and destroy bacteria.

It may be necessary to remove the spleen due to a number of haematological (blood related) disorders and trauma related factors (1). Open splenectomy refers to removal of the spleen after opening up the abdomen and is an invasive procedure unlike its counterpart, laparoscopic splenectomy.

Why is it done?

In general, splenectomies are conducted to treat haematological diseases where the splenic function is disrupted. There is a whole range of both inherited and acquired haematological disorders that involve splenic disease including:

1. Auto-Immune Thrombocytopenic Purpura (ITP) - This is one of the most common reasons necessitating removal of the spleen and involves the body having an abnormal response to platelets in the blood. These platelets help with clotting when there is a bleed, and in ITP this function is disrupted and the platelets are destroyed in the spleen. Hence should medical therapy fail, then splenectomy may be required to restore the ability of the body to clot and stop bleeding (2).
2. Haemolytic Anaemia - This involves a number of different conditions which result in the breakdown of red blood cells in the spleen. Hence removal of the spleen may be required to restore your red blood cell count (3).
3. Hereditary conditions such as spherocytosis and thalassemia - These diseases typically result in abnormal red blood cells, which are then destroyed by the spleen, much like in Haemolytic Anaemia.
4. Haematological cancers such as Lymphomas and Leukaemias (4).
5. If cancer has occurred elsewhere in the body and has spread to the spleen (metastasis), or if there has been a primary spleen cancer (5).

Splenectomies are also indicated in trauma situations where there has been splenic rupture or damage to the splenic tissue necessitating removal.

Anaesthesia

The surgery is usually conducted under general anaesthetic, which means you will be unconscious through the surgery. An endotracheal tube will therefore be required to be placed down your throat to help with breathing during the surgery as shown below.

Will I need to do any preparation?

To reduce the risk of any infections post-splenectomy, your doctor will talk to you about different steps that can be taken. One of the major steps is providing regular immunisations to protect against the most common and serious infections. Ideally, these will be given 2 weeks before the operation is scheduled to take place. Hence these vaccinations will be scheduled for you at your local GP after discussion with the haematological doctors and surgical team. If giving these vaccinations before the surgery is not possible, particularly in emergency situations, then the course of immunisation can be given as soon as possible post-operation. The different vaccinations include:

1. Pneumococcal immunisation (to protect against streptococcus pneumoniae)
2. Haemophilus influenzae type b immunisation
3. A course of Meningitis vaccinations
4. Annual Influenza vaccination (11).

If you are a smoker, you will be given advice on stopping smoking. This will greatly increase the likelihood of successful surgery and help to reduce the chance of any complications arising.

You will be required to not have anything to eat from the night before your operation, and you can only have small sips of water on the day of your operation.

The Surgery

1. After being anaesthetised, you will be placed in the standard supine position (lying down). You may have a pillow placed under your left abdomen to enable the surgeons to gain better access to your spleen. The main surgeon will stand on your right side during the procedure.
2. There are usually two incisions that the surgeons can make to begin the open splenectomy. The choice of incision is based upon surgeon preference and experience. These are:
3. A left subcostal incision under your left rib
4. A supraumbilical midline incision above your belly-button

A midline incision may also be made in trauma situations where rapid and wide access to the abdomen is required.

1. Once the surgeons have gained access to your abdomen, they will identify the splenic artery branch of the celiac axis in the gastrohepatic ligament (the ligament that connects your stomach and liver).
2. At this point, a search for any accessory spleen is conducted. This step is especially important if the reason for splenectomy is haematological related rather than trauma related.
3. Once the surgeons are sure that no accessory spleens are present, the ligament connecting your stomach and spleen (gastrosplenic ligament) is dissected alongside the short gastric vessels. On dissection, these are ligated using hemoclips. At this point, damage can occur to the greater curvature of the stomach when ligating the shortest of the short gastric vessels.
4. The surgeons will now begin to divide any splenic attachments in order to mobilise the spleen. Small tears here can result in large amounts of bleeding, and hence curved scissors are used to dissect any attachments, with the surgeon using their left hand to mobilise the spleen.
5. Once the splenic attachments have been dissected, the focus shifts to the splenic hilum, which is the collection of blood vessels that enter and leave the spleen. At this point, the tail of the pancreas is moved away from the splenic vessels to protect it.
6. The splenic artery is divided and clamped, followed by the splenic vein.
7. The spleen is removed and all the divided vessels are double ligated. At this point, the surgeon will check the area of operation for any bleeding and ensure haemostasis (wound healing) can take place in the ligated vessels.
8. All equipment is removed from the abdomen and the abdomen is closed using sutures. A suction drain may also be used if necessary (12).

Post-operation

After the surgery has finished, you will be transferred to the high dependency unit while you recover. You will be given intravenous fluids in your arm, and your vital signs will be monitored and you will be given pain relief. Furthermore, your platelet and haemoglobin count will also be monitored. You can expect to spend a week in hospital before being discharged back home.

Breathing may be difficult or painful after having a major surgery such as splenectomy; and hence while you are in hospital, the nurses and physiotherapists will work with you to ensure your lungs recover and to prevent collapsing of the lung due to insufficient breathing (atelectasis) (13).

Open splenectomy typically carries with  it more pain than a laparoscopic approach, and hence you will be given adequate pain relief during your time recovering in hospital. Furthermore, you can get advice and pain relief on discharge by speaking to the medical team in charge of your care.

Caring for yourself at home

Although you would ideally have been given the course of vaccinations before the operation, the pneumococcal vaccination will be required to be repeated every 5 years to ensure the immunity is kept strong. Alongside this, you will also be required to take a life-long course of prophylactic antibiotics which will help reduce the effects of infections. Please speak with your local GP to coordinate these and to ensure that these steps in your care plan are not missed (14).

Your doctor will talk to you about seeking help urgently if you develop infections; as due to your reduced immune response you may require hospitalisation so that stronger antibiotics can be given. The doctor may also provide you with a bracelet or medical alert card in case of emergencies such that if you are ever admitted to hospital, the medical staff will be alerted to the fact that you no longer have a spleen and hence require extra infection control care.

Due to the fact that splenectomy is a major procedure, it can take up to 3 months for a complete recovery, depending on the patient and their background. You can expect to resume driving 5-7 days after your surgery, and you can begin to do daily activities as you see fit. You will have regular follow-up appointments to check on the progress of your recovery, during which time you can discuss any concerns of questions that you may have with the doctor.

Where can I find more information

NHS information on Splenectomy - https://www.nhs.uk/conditions/spleen-problems-and-spleen-removal/