Splenectomy

Question 1

Splenectomy - Vaccinations

Answer 1

Following a splenectomy patients are particularly at risk from pneumococcus, Haemophilus, meningococcus and Capnocytophaga canimorsus* infections

Vaccination
if elective, should be done 2 weeks prior to operation
Hib, meningitis A & C
annual influenza vaccination
pneumococcal vaccine every 5 years

*usually from dog bites

Example Question:

A 34 year old man with chronic immune thrombocytopenia has not responded to medical therapy and so is scheduled to undergo an elective splenectomy. According to guidelines, he requires the following vaccinations:

Pneumovax (Pneumococcus), Haemophilus Influenzae, MMR (Measles, Mumps, Rubella), Annual influenza vaccine
Haemophilus Influenzae, Meningococcus C, Annual influenza vaccine
> Pneumovax (Pneumococcus), Haemophilus Influenzae, Meningococcus C, Annual influenza vaccine
Pneumovax (Pneumococcus), Haemophilus Influenzae, Meningococcus C
Meningococcus C, Haemophilus Influenzae, MMR (Measles, Mumps, Rubella), Annual influenza vaccine

Risk of infection following splenectomy is with encapsulated bacteria e.g Streptococcus pneumoniae. Haemophilus influenzae type B, Neisseria meningitidis. Therefore patients should be immunised against these infections. MMR vaccination is not required.

Question 2

Splenectomy - Antibiotics

Answer 2

Antibiotic prophylaxis
penicillin V: unfortunately clear guidelines do not exist of how long antibiotic prophylaxis should be continued. It is generally accepted though that penicillin should be continued for at least 2 years and at least until the patient is 16 years of age, although the majority of patients are usually put on antibiotic prophylaxis for life

Question 3

Splenectomy - Surgical Indications

Answer 3

Indications
Trauma: 1/4 are iatrogenic
Spontaneous rupture: EBV
Hypersplenism: hereditary spherocytosis or elliptocytosis etc
Malignancy: lymphoma or leukaemia
Splenic cysts, hydatid cysts, splenic abscesses

Question 4

Splenectomy following Trauma

Answer 4

Splenectomy following trauma
GA
Long midline incision
If time permits insert a self retaining retractor (e.g. Balfour/ omnitract)
Large amount of free blood is usually present. Pack all 4 quadrants of the abdomen. Allow the anaesthetist to ‘catch up’
Remove the packs and assess the viability of the spleen. Hilar injuries and extensive parenchymal lacerations will usually require splenectomy.
Divide the short gastric vessels and ligate them.
Clamp the splenic artery and vein. Two clamps on the patient side are better and allow for double ligation and serve as a safety net if your assistant does not release the clamp smoothly.
Be careful not to damage the tail of the pancreas, if you do then this will need to be formally removed and the pancreatic duct closed.
Wash out the abdomen and place a tube drain to the splenic bed.
Some surgeons implant a portion of spleen into the omentum, whether you decide to do this is a matter of personal choice.
Postoperatively the patient will require prophylactic penicillin V and pneumococcal vaccine.

Question 5

Elective Splenectomy

Answer 5

Elective splenectomy
Elective splenectomy is a very different operation from that performed in the emergency setting. The spleen is often large (sometimes massive)
Most cases can be performed laparoscopically. The spleen will often be macerated inside a specimen bag to facilitate extraction.

Question 6

Splenectomy - Cx

Answer 6

Complications
Haemorrhage (may be early and either from short gastrics or splenic hilar vessels
Pancreatic fistula (from iatrogenic damage to pancreatic tail)
Thrombocytosis: prophylactic aspirin
Encapsulated bacteria infection e.g. Strep. pneumoniae, Haemophilus influenzae and Neisseria meningitidis

Question 7

Post-Splenectomy Changes

Answer 7

Post-splenectomy changes
Platelets will rise first (therefore in ITP should be given after splenic artery clamped)
Blood film will change over following weeks, Howell-Jolly bodies will appear
Other blood film changes include target cells and Pappenheimer bodies
Increased risk of post-splenectomy sepsis, therefore prophylactic antibiotics and pneumococcal vaccine should be given.

Question 8

Post-Splenectomy Sepsis

Answer 8

Post-splenectomy sepsis
Typically occurs with encapsulated organisms
Opsonisation occurs but then not recognised