What Is a Splenectomy?

1 Spleen rupture: splenic trauma of left upper abdomen or left hand rib penetrating injury and closed injury caused by splenic rupture or subcapsular rupture spontaneous spleen rupture and injury in surgery clinic can cause fatal blood, which must be performed immediately Spleen resection is an important life-saving treatment for hemostasis.

Jiang Hongchi

(Chief physician)

The First Affiliated Hospital of Harbin Medical University

Splenectomy is widely used in diseases such as congestive splenomegaly caused by spleen rupture, migratory spleen (ectopic spleen), local infection or tumor of spleen, cyst, intrahepatic portal hypertension and hypersplenism. The spleen is the largest peripheral lymphoid organ in the human body. It can produce a variety of immune-active cytokines. It is the main organ for the body's blood storage, hematopoietic, hemofiltration, and blood destruction. The role of properdin and phagocytosis. Based on the current understanding of spleen function and the consequences of increased susceptibility to infection caused by spleen resection, it is the consensus of surgeons around the world to perform spleen-preserving surgery as far as conditions and diseases allow. That is "to save lives first, to keep the spleen second, and the younger the younger, the better the spleen."

Chinese name: Splenectomy
Affiliated Department: General Surgery, Hepatobiliary Surgery

Applicable diseases: Spleen rupture, swimming spleen, etc.
Other name: Splenectomy, splenectomy

Indications for splenectomy

2 Migratory spleen (ectopic spleen): Because the transplanted spleen is too long, the spleen can be over-mobilized to form a migratory spleen. There was even a twist of the spleen, causing spleen necrosis. Whether the splenic pedicle is twisted or not, splenectomy should be performed.

3 Local infection of the spleen: Splenic abscesses often occur after sepsis. If the abscess is confined to the spleen, splenectomy is feasible. If inflammation and fatigue around the abscess have spread around the spleen, drainage can only be performed. Local splenic tuberculosis

4 Tumors: Primary tumors are still relatively rare, but splenectomy should be performed regardless of benign (such as hemangioma) or malignant (such as lymphosarcoma). Metastatic tumors that occur in the spleen are also not uncommon, and most have been extensively metastatic and are not suitable for surgery.

5 Cysts: Epithelial, endothelial, and true cysts, non-parasitic pseudocysts, and parasitic cysts (such as spleen cysticercosis) are all prone to secondary infection, bleeding, and rupture and should be removed.

6 When radical resection is performed on gastric body cancer, gastric cardia cancer, pancreatic body cancer, tail cancer, and colonic spleen curvature cancer, splenectomy should be performed to clear lymph nodes around the spleen artery or hilar. Especially when there is adhesion between the tumor and the spleen, the spleen should be removed together.

7 Patients with intrahepatic portal hypertension and hypersplenism, and patients with extrahepatic portal hypertension such as splenic aneurysms, splenic arterial, venous fistula, and splenic vein thrombosis should all undergo special splenectomy.

8 other hypersplenic diseases:

Primary thrombocytopenic purpura, suitable for the first episode of young re-examination patients, healed for half a year after reliable drug treatment, chronic recurrence of abdominal cavity, acute type, bleeding cannot be controlled after drug treatment (children should be operated within 1-2 weeks) ) And early pregnancy patients (surgery within 4-5 months);

Congenital hemolytic anemia, suitable for those who do not respond to the drug (hormones) after one month of treatment on Tuesday, who have severe heart side effects after long-term medication and cannot continue to use the medicine, should be measured before surgery. Surgery is performed on the place where the red blood cells are mainly damaged. If the liver is the place where the red blood cells are mainly damaged, the operation is not suitable;

Primary splenic neutropenia;

Primary pancytopenia;

Aplastic anemia, which is not suitable for drug treatment, compensatory hyperplasia in bone marrow examination (repeated red blood cell examination in peripheral blood for multiple times is not suitable for surgery);

Acquired hemolytic anemia (for selective cases). ^[1] ^[2] ^[2] ^[1]

Preparation before splenectomy

1. Emergency surgery: Emergency surgery is often required when spleen rupture occurs, and strive to perform the operation as soon as possible to save the patient's life. Patients with severe spleen rupture often suffer from hemorrhagic shock, so while preparing before surgery, there is also prevention and treatment of hemorrhagic shock, and a large number of blood products are provided for blood transfusion. For patients with traumatic spleen rupture, we should also pay attention to the damage of other organs and give treatment. In addition, appropriate antibiotics can be given before surgery to prevent infection. Before the operation, the gastric tube was left for gastrointestinal decompression.

2. Selective surgery: Selective surgery should be performed for chronic spleen diseases except rupture. Attention should be paid to improve the general condition, repeated small blood transfusions, protect liver function, correct coagulation insufficiency, and perform necessary laboratory tests (including hemoglobin determination, red blood cell count, total and classification of white blood cells, platelet count, vascular fragility test, bleeding time, clotting time, Prothrombin time, etc.). Gastrointestinal decompression should be performed before surgery. For patients with esophageal varices, a soft gastric tube should be selected. A small amount of liquid paraffin should be taken before the lower tube. Special attention should be paid to prevent major bleeding. An appropriate amount of blood should be prepared before surgery to prepare for blood transfusion. Sufficient antibiotics should also be given.

Key points of splenectomy

1. Technical points of conventional splenectomy: When selecting the location of the incision, full consideration should be given to the patient's condition, body shape and other factors to ensure that the incision can be fully exposed; pay attention to protect adjacent organs, fully free and cut the spleen ligament, and perform splenectomy. Surgery; do not use brute force when pulling and holding out the spleen, so as not to tear the spleen and cause large bleeding; pre-ligate the spleen artery to reduce spleen congestion, reduce spleen volume and reduce bleeding.

2. The technical points of giant spleen (swelling above degree) resection: Giant spleen resection is not uncommon in clinical practice. Compared with general splenectomy, giant spleen surgery is risky and difficult. There are two reasons. First, Spleen pathological congestion and swelling, narrow peripheral space, rich collateral circulation, and more or less adhesions, a little carelessness during surgery can cause a large amount of blood loss; in addition, the spleen ligament contracture, the spleen pedicle is complicated, operation It is easy to accidentally injure the stomach wall, pancreatic tail and other organs. We have gradually explored several solutions to the above problems by adopting new surgical methods and combining advanced medical equipment, so that the feasibility and safety of giant spleen surgery can be significantly improved. The treatment of the disease involves portal hypertension, primary myelofibrosis, hemolytic anemia, etc.The spleen is excised at a weight of up to 13.5 kg, and no surgical death, major hemorrhage during the operation, and severe complications such as pancreatic leakage, stomach and colon injury, etc. The effect is satisfactory.

The main technical points are:

Pretreatment of the splenic artery and injecting epinephrine: The spleen artery is freed in the upper margin of the tail of the pancreas, and the diluted adrenaline 0.3 mg can reduce the spleen and return the blood. Not only conducive to operation, but also to patient safety;

Spleen lavage technique: if the spleen is large and has a large blood storage, a trocar can be inserted into the spleen artery to inject 500 ml of normal saline to obtain more recovered blood;

Treatment of the spleen pedicle by bundle: The first-grade spleen pedicle treatment method, the general splenectomy spleen pedicle treatment, is a bundle of three clamp method. It is not suitable for giant spleen. The spleen hilum should be used to show the space between arteriovenous and venous segments of the spleen lobe by hand, thumb, and pinch techniques. Its benefits are many: reduce the possibility of knot detachment, ligation is safer and more reliable; reduce the chance of pancreatic tail injury and pancreatic fistula; reduce the chance of large tissue ligation and postoperative spleen fever;

Recovery of spleen blood: In the absence of contraindications to blood transfusion, the entire operation was performed using a cell saver to recover the bleeding in the surgical field. After the spleen was excised, a number of knives were cut across the spleen hilum side by side, and then the residual splenic blood was recovered. Blood, which not only saves blood products and time, but also avoids many transfusion complications (such as blood-borne diseases, immune rejection, etc.);

In-situ splenectomy: During the formation of giant spleen, due to the effect of gravity, the spleen ligament is relatively loose and the spleen is free. The surgical operation can be carried out after the initial detachment, and then the spleen can be moved for further operation. However, in the following cases: perisplenitis, spleen adhesions, especially sheet adhesions or even fixation, and perisplenic collateral circulation are abundant, etc.The above methods are dangerous, and there are few examples of severe hemorrhage during surgery, suspension of surgery or death during surgery. . In these cases, according to the aforementioned method, the spleen pedicle is processed and separated first, and then the spleen is processed, which is the orthotopic splenectomy, also known as antegrade splenectomy, which reduces the difficulty and increases the safety of the operation. ^[3] ^[3]

Complications and prevention after splenectomy

1. Hemorrhagic complications: Intra-abdominal hemorrhage is one of the more dangerous complications after splenectomy. The causes are mostly active bleeding and intra-abdominal bleeding. Including bleeding from pancreatic tail blood vessels, spleen pedicle blood vessels, short gastric blood vessels, and bleeding from diaphragm and spleen bed. Mainly due to inadequate hemostasis of the small bleeding point or the loss of the ligature, or due to insufficient preoperative preparations in the emergency department, liver function and coagulopathy cannot be effectively corrected, resulting in postoperative diaphragmatic and spleen bed bleeding. Hemorrhagic complications should be based on prevention, be fully prepared before surgery, be patient and meticulous during surgery, firmly ligate the stump of the blood vessel, and adhere to the "from shallow to deep, easy to difficult," Difficult but easy, step by step "principle, after surgery, after confirming that there is no bleeding and bleeding may close the abdominal cavity, there is no chance. If postoperative abdominal hemorrhage is found, surgical exploration should be performed immediately to stop bleeding.

2. Infection: Early postoperative infections include lung infections, submental abscesses, incision infections, and urinary system infections. Depending on the pathogenic factors of the infection and the condition of the patient, their effects are different. In addition to the general symptoms of infection (fever, local inflammation, etc.), there may also be local symptoms. Prophylactic broad-spectrum antibiotics before and after surgery can prevent infections. The spleen bed is usually placed for drainage during the operation, and the management of the drainage tube is strengthened after the operation to keep the drainage tube open, which can prevent the occurrence of post-condylar abscess. If the patient develops fever and discomfort in the left upper abdomen, the possibility of left subcondylar effusion and abscess is not ruled out, and further ultrasound and CT examinations can be performed to confirm the diagnosis. For those who have formed sub-condylar abscesses, they can first perform B puncture drainage or catheter drainage under B ultrasound. According to the results of bacterial culture and drug sensitivity, antibiotics can be targeted. But if the drainage is not smooth, the drainage should be cut in time.

Overwhelming postsplenectomy infection (OPSI) is a unique infectious complication after total splenectomy, with an incidence rate of 0.5% and a mortality rate of 50%. Patients are at risk for life, but most of them occur in the first 2 years after total splenectomy, especially in children after splenectomy. The younger the child, the earlier the onset. 50% of patients are pneumococcal, and others such as Haemophilus influenzae, E. coli, and B hemolytic streptococcus. The clinical feature is occult onset, which may start with mild flu-like symptoms, and then develop high fever, headache, nausea, unconsciousness, and even coma and shock within a short time, often dying within a few hours to a dozen hours. Often complicated by diffuse intravascular coagulation and bacteremia. In view of the onset characteristics of OPSI, total splenectomy for children (especially under 4-5 years old) should be carefully considered. Once OPSI occurs, large doses of antibiotics are actively used to control infection, and anti-shock treatment is given by infusion and blood transfusion.

3. Thrombosis and embolism: caused by increased platelet count and increased blood viscosity after splenectomy. The platelet rebounded 24 hours after splenectomy, and peaked at 1 to 2 weeks after the operation, which is the high incidence of thrombosis. The most common is the embolization of the portal vein, which can also occur in retinal arteries, mesenteric arteriovenous and other parts, causing corresponding clinical manifestations. Portal vein thrombosis often occurs 2 weeks after splenectomy, with clinical manifestations of dull pain in the abdomen, nausea, vomiting, bloody stool, elevated body temperature, increased white blood cell count, and accelerated erythrocyte sedimentation. There were also no clinical manifestations. For the diagnosis of portal vein thrombosis after splenectomy, the most effective method at present is color contrast and CT contrast-enhanced scanning. Once diagnosed, it should be dealt with in time, if there are no contraindications, try fibrinolytic therapy. After passing through the acute phase with anticoagulation, fasting, infusion, and antibiotic therapy, the portal vein can also reopen. Heparin therapy can be used to prevent thrombosis after splenectomy.

4. Spleen fever: After splenectomy, patients often have fever that lasts for 2-3 weeks, usually less than 1 month, and body temperature does not exceed 39 ° C. The duration and extent of spleen fever is proportional to the surgical trauma. Spleen fever is self-limiting fever. If other infectious complications and subcutaneous infections can be ruled out, only symptomatic treatment including traditional Chinese medicine and traditional Chinese medicine is required.

5. Pancreatitis: It is related to the injury of the pancreas when the spleen bed is freed during the operation. If the postoperative serum amylase rises for more than 3 days with symptoms, the diagnosis can be determined. Somatostatin treatment is effective.

6. Gastric fistula after splenectomy: Rare but serious consequences. It usually occurs after splenectomy and pericardial vascular disconnection, and a few can also be caused by simple splenectomy. Leakage of gastric contents can cause local secondary infections such as fever, left upper abdomen dull pain, etc. if localized, and spread to the abdominal cavity can cause full abdominal infections, acute abdomen, etc.

Preventive measures include: gentle operation to reduce bruises on the stomach wall. If the gastric fundus serous membrane damage is found during surgery, the large curved side of the gastric fundus should be embedded in the plasma muscular layer. The large curved side of the gastric fundus has poor blood supply. The large curvature of the stomach should be folded and sutured. Drainage in the operation area is sufficient to prevent the weakened stomach wall due to pancreatic fistula, subcondylar infection, etc .; Properly extend the fasting time after surgery and maintain smooth gastrointestinal decompression.

After the occurrence of gastric fistula, the following measures can be taken: Adequate drainage: the key to treating gastric fistula. After splenectomy and splenectomy cut-off, drainage should generally be performed in the left subcondylar site to ensure smooth drainage so as to drain all leaked gastric contents and prevent the leaked gastric contents from spreading in the abdominal cavity; gastric tube reduction Pressure: When a gastric fistula is found, you should fast your diet and place your stomach tube. Extract gastric contents and reduce gastric leakage; systemic nutritional support: adequate supplementation of blood, plasma and albumin, energy, vitamins and other nutritional support treatments.

7. Other rare complications: other complications, such as hepatic encephalopathy, hyperuricemia, etc., have a low incidence. The key to avoiding these two complications is to make adequate preoperative preparations to improve liver function as much as possible and Reduce blood uric acid levels. ^[4] ^[4]

Precautions after splenectomy

1. Observe the presence or absence of internal bleeding, and routinely measure changes in blood pressure, pulse and hemoglobin. Observe the condition of the spleen fossa drainage tube. If there is internal bleeding tendency, blood transfusion should be done in time. If it is a continuous major bleeding, you should consider reoperation to stop bleeding.

2. Splenectomy has a greater irritation to the abdominal organs (especially the stomach), so a gastrointestinal decompression tube should be placed to prevent gastric distension after surgery. After 2 to 3 days after surgery, eating was resumed.

3. Many patients undergoing splenectomy have poor liver function and should be fully supplemented with vitamins and glucose after surgery. If hepatic coma is suspected, appropriate preventive measures should be taken in time.

4. Pay attention to changes in renal function and urine output, and be alert to the occurrence of hepatorenal syndrome.

5. Routine application of antibiotics after surgery to prevent systemic and subcutaneous infections.

6. Measure the platelet count in time. If it rises rapidly above 50 × 109 / L, splenic venous thrombosis may occur. If severe abdominal pain and bloody stools occur again, it indicates that the thrombus has spread to the superior mesenteric vein, and anti-inflammatory drugs must be used in time. Coagulation treatment, surgery if necessary. ^[5] ^[6] ^[5] ^[6]

Expert opinion on splenectomy

In the past half century, especially in the past 20 years, with the deepening of the research on the anatomy and physiological functions of the spleen, the functions of the spleen such as blood storage, hematopoietic, hemofiltration, hemolysis, immune regulation, anti-infection, anti-tumor, endocrine and their related The relationship between diseases has been further understood and appreciated. The damage to human immune function caused by splenectomy is that people realize the importance of protecting the spleen and how to preserve the spleen tissue and spleen function to the greatest extent, but there is still controversy.

1. Spleen preservation in portal hypertension surgery: Whether spleen preservation in portal hypertension surgery has been controversial, the focus is on how big the spleen immune function of portal hypertension is and whether it can promote liver fibrosis. Some scholars believe that after splenectomy for portal hypertension, the immune function of the body will not be affected. Other scholars believe that spleen enlargement and hyperfunction can be restored after liver transplantation in patients with liver cirrhosis. Damage to the body. The research and controversy on this are still continuing, and we should not draw conclusions prematurely. The author believes that we can proceed from two aspects. On the one hand, we must deepen the basic research of spleen function. Depending on the degree, the immune function of the spleen and its role in regulating liver cirrhosis may also be different. On the other hand, from the perspective of evidence-based medicine, the groups are strictly grouped according to the degree of spleen fibrosis, and the preservation of spleen with different degrees of fibrosis is studied. Effects on body immunity and liver fibrosis. In clinical work, whether or not to preserve the spleen and the amount of retention during portal hypertension surgery should follow the principle of individualization, according to the patient's age, liver function classification, portal vein pressure, spleen size, progress of hypersplenism, bleeding, Based on previous surgical history and general conditions, the impact on the body and liver damage should be reduced as much as possible in order to achieve a good therapeutic effect.

2. Spleen-preserving surgery for malignant tumors: Combined resection is performed for tumors in adjacent organs of the spleen, such as gastric cancer, pancreatic cancer, and colon tumors. However, in view of the important role of the spleen in tumor immunity, how to choose the indications for splenectomy and how to evaluate the effect of splenectomy is a controversial issue. The spleen has a positive immune function in the early stage of the tumor, which is beneficial to the body's anti-tumor immunity; and a negative immune function in the late stage of the tumor, which is not conducive to the body's anti-tumor immunity. Tumors involving different parts and tissues, and considering the specific quantified time points of the early and late stages of the tumor and the anti-infection immunity of the spleen, the situation is much more complicated, so the decision to retain the spleen should be made with caution.