Partial splenectomy, as an important procedure for splenic preservation surgery, has great clinical utility in the treatment of splenic trauma and certain nontraumatic splenic diseases by removing the diseased splenic tissue while effectively preserving the function of the spleen. Since the first systematic report of partial splenectomy by the Brazilian surgeon Christo in 1962, this procedure has been promoted in clinical practice, and new experiences have been accumulated and new procedures created. In this paper, we review the progress of research on partial splenectomy in the past five years.
I. Overview
Partial splenectomy is an operation in which the diseased splenic tissue is removed from the spleen due to trauma or other non-traumatic diseases such as splenic cysts and splenic hemangiomas, while preserving part of the healthy splenic tissue, and it includes both regular partial splenectomy and irregular splenectomy. The former refers to splenic segmental resection, lobectomy and hemi-splenectomy, which are performed according to the distribution of blood vessels in the spleen. However, due to the overemphasis on the applied anatomy of preserved spleen surgery and the fact that in practice, the extent and degree of splenic rupture has exceeded the theoretical anatomical limits in a significant number of patients, it has, to a certain extent, limited the clinical application and promotion of partial splenectomy, not to mention the fact that in the actual surgical procedure, it is sometimes unrealistic to clarify the distribution pattern of the splenic hilar vessels and then use it to determine the location of the avascular plane. Sometimes it is unrealistic and unnecessary. Therefore, it is more practical to choose according to the actual situation of the injury (in fact, most of them are non-regular partial splenectomies), and it is also easy to master and apply [1].
II. Indications for surgery
At present, this procedure is mainly used in the treatment of traumatic splenic rupture (grade III-IV), non-parasitic splenic cysts, benign tumors of the spleen, splenic infarction, hematologic diseases, and unexplained splenomegaly with satisfactory results.
The application of partial splenectomy to children requiring hematopoietic stem cell transplantation showed that partial splenectomy before hematopoietic stem cell transplantation was feasible and similar to total splenectomy, improved the hematopoietic stem cell transplantation outcome while reducing the incidence of sepsis after splenectomy. Dutta et al [4] applied laparoscopic partial splenectomy to three children with hereditary spherocytosis and showed significant improvement in symptoms and a mean hemoglobin level of 133 g/L after surgery, with no recurrence of anemia at 1 to 2 years of follow-up.Czauderna et al [5] showed through a multicenter investigation that applying partial splenectomy to non-parasitic splenic cysts was efficacy was more definite than open drainage and effectively reduced the recurrence rate and if technically possible, laparoscopic surgery could be used.Gajin et al [6] found that in patients with hypersplenism in portal hypertension, the application of Warren surgery + partial splenectomy was more effective than Warren surgery alone, with significant differences in postoperative splenomegaly and platelet count between the two. Sheikha et al [7] pointed out in a comparative study that partial splenectomy is superior to total splenectomy for the treatment of thalassemia, especially in some countries and regions with limited health resources, and that it is effective in preventing the occurrence of aggressive infections after splenectomy.
III. Surgical options
3.1 Open surgery
The real widespread rise of open partial splenectomy is attributed to Brazilian surgeons Christo and Morgenstern, who systematically reported the animal experiments and clinical applications of partial splenectomy in the 1960s, thus drawing widespread attention of clinicians to this procedure. The specific procedures include minor partial splenectomy (superior splenectomy, inferior splenectomy), hemi-splenectomy, and major splenectomy. In 2005, in response to the high recurrence rate of hemolysis due to splenic regeneration in patients with hereditary spherocytosis treated with conventional major splenectomy, Gerhard et al [8] pioneered a new type of major splenectomy, near-total splenectomy, in which only 10 cm3 of splenic tissue is preserved. 10 cm3 size of splenic tissue, which allowed patients to obtain a longer period of disease remission while ensuring immune and clearance function of the spleen.
Open surgery is still the usual surgical approach for partial splenectomy.
3,2 Laparoscopic surgery
Since Delaitre et al. performed the first laparoscopic total splenectomy in 1991, laparoscopic techniques have been used in splenic surgery, and various experimental and clinical studies on laparoscopic splenoprotective surgery have been carried out, and various types of splenoprotective surgery, including partial splenectomy, can now be performed laparoscopically, which avoids the pain caused by unnecessary open surgery and has both diagnostic and therapeutic effects. However, this technique (especially laparoscopic partial splenectomy) has not been widely promoted because of its difficulty and high risk.
The application of ultrasonic knife and ligsure vascular closure system has effectively improved the safety of laparoscopic total splenectomy and partial splenectomy and effectively shortened the operation time. In recent years, radiofrequency technology has been applied to clinical and experimental studies in laparoscopic partial splenectomy [14,15], further promoting the development of this procedure.
3,3 Radiation interventional techniques
In 1973, Maddison first applied interventional radiological techniques to do total splenic artery embolization to treat a patient with advanced cirrhosis with portal hypertension, and due to the high postoperative mortality of this method, total splenic embolization has been largely abandoned. In its place, partial splenic artery embolization, a technique pioneered by Spigos in 1979, has been used mainly for the treatment of hypersplenism. After embolization, ischemic infarction of the splenic parenchyma occurs, followed by mechanization and atrophy, which weakens the spleen’s ability to destroy leukocytes and platelets, reduces the size of the spleen, and improves the symptoms of hypersplenism, indeed acting as a synergistic partial splenectomy. In addition, it helps to reduce the occurrence of variceal rupture bleeding, improve hematological parameters, enhance hepatic protein synthesis and reduce the severity of hepatic encephalopathy [16].Jonasson used partial splenic embolization to control rejection after allogeneic renal transplantation (124 cases), hematological disease (8 cases), and esophageal varices in portal hypertension (4 cases) with 18 years of postoperative follow-up, 15 deaths and 3 cases were related to embolism, which can be considered relatively safe and effective. There have been more reports in China [17] with good results. However, some scholars [18] pointed out that how to control splenic embolization volume in real time, objectively and accurately during PSE, although many useful explorations have been made by Chinese and foreign scholars, this problem is still not well solved clinically, and the visual method is still most widely used in clinical practice, and this method is too subjective and has a large error, and it is difficult to avoid both under- and over-embolization. With the continuous development of interventional techniques, this procedure has received wide attention from scholars at home and abroad, and is called “endoscopic splenectomy”, so it is briefly introduced here.
IV. Operation points
4. Exposure of the spleen and vascular treatment
In partial splenectomy, non-invasive freeing should be emphasized, not only to free the spleen well, but also to ensure that the part of the spleen to be preserved is safe and secure, and not to free the spleen blindly and excessively with the fingers. The operator should gently lift the spleen forward and downward and inward with the right hand, and the opposite direction of the splenic fossa should be padded with a splenic pad or several large pieces of gauze, while the assistant pulls the abdominal wall upward and outward and backward to reveal the spleen as much as possible. If the spleen is partially resected, a small partial splenectomy (superior splenectomy, inferior splenectomy), half splenectomy, or most of the splenectomy can be performed depending on the situation. If partial splenectomy with preservation of the upper pole of the spleen is proposed, the upper part of the splenogastric ligament should not be cut in order to preserve the short gastric vessels+ and the blood supply to the upper pole of the spleen. If partial splenectomy with preservation of the lower pole of the spleen is proposed, the lower part of the splenogastric ligament should be preserved in order to preserve the left vasculature of the gastric omentum and the blood supply to the lower pole of the spleen [19]. It is generally accepted that partial splenectomy should not exceed 2/3 of the spleen, because only 1/3 of the spleen can be preserved to maintain the function of the spleen.
After splenogastric ligament dissection, if there is not much splenic tissues and the direction and distribution of the vessels can be identified, the corresponding vessels can be treated accordingly; otherwise, the corresponding vessels can be treated in a bottom-up or top-down sequence immediately adjacent to the vessels into the splenic hilum. The key point is to ligate the vessels immediately at the splenic hilum and in bundles, each bundle should be small, and the blood flow should be observed while processing. It should also be noted that there are non-splenic arteries supplying the superior and inferior splenic pole arteries, which mostly originate from the left vascularity of the gastroretinal or colonic splenic flexure vessels. The splenic pole arteries supply the upper and lower pole segments of the spleen, respectively, and should be protected as much as possible when performing surgery on preserved splenic pole segments. After treatment of the corresponding vessels, the spleen shows a clear boundary between impaired and good blood flow, which is the corresponding avascular plane.
It is important to note that laparoscopic partial splenectomy differs from open splenectomy in that only the part of the spleen to be removed needs to be freed intraoperatively; the corresponding vessels can be treated with the Ligsure vascular closure system, titanium clips, or endoscopic vascular cutting closures [20].
4.2 Dissection of the spleen parenchyma and hemostatic treatment of the section
After the corresponding vascular treatment is completed, an interlocking U-shaped suture is made by retracting 0.5 cm from the revealed relatively non-vascular plane to the healthy side with good blood flow, and then the spleen is cut by the clamp method and the vessels encountered are ligated one by one, and if there is still blood oozing from the splenic section, hot saline gauze can be used to stop the bleeding by wet compression, or a figure-of-eight suture can be used [21].
In recent years, with the advancement of modern medical technology, the application of hemostatic materials such as fibrin glue, collagen adhesives, and technical devices such as microwave, radiofrequency, and tissue cutters and closers are also more effective means of hemostasis; Stacey [22] et al. applied the collagen adhesive FloSeal to a partial splenectomy, and the effect of hemostasis on the section was precise. The results of animal experiments and clinical applications of microwave tissue coagulation techniques conducted by Juxinhua et al [23,24] showed that, using the effect of microwave radiation to convert microwave energy into thermal energy, the temperature of MTC can be as high as 60 ℃ or more, causing denaturation and coagulative necrosis of the surrounding tissue of about 1. 0-1.2 cm; after tissue coagulation and then dissection, except for vessels with a diameter of more than 0. 3 cm still need to be ligated, MTC splenic sections The damage to splenic tissue is temporary and slight, and the body can complete the repair through its own regulation. They believe that MTC for partial splenectomy is reliable, safe, simple, and can preserve the structure and function of the spleen to the maximum extent.
Zacharoulis [25] et al. demonstrated the safety of RF technology in partial splenectomy by animal experiments, and Itamoto et al [26] performed a partial splenectomy in a patient with a giant splenic cyst using a device that uses RF energy for blunt cutting and vascular closure in combination with an ultrasonic knife. They performed a partial splenectomy in a patient with a large splenic cyst, and the cutting speed was significantly increased, with a parenchymal dissection time of only 10 minutes and definite hemostasis of the section without the need for sutures or other hemostatic measures, and they concluded that this technical device could achieve a truly safe and bloodless partial splenectomy. Some scholars [27] also pointed out that splenic tissue is more sensitive to RF, so when RF is performed on the spleen, the energy should be controlled and should not be too high to avoid injury to splenic tissue. In addition, Wang Kexin et al [28] showed that the experiment of hemostasis of the partially resected splenic wound in dogs by argon knife showed that the argon knife formed a layer of crust about 2.5 mm thick on the splenic wound when hemostasis was performed, which could close the blood vessels below 2 mm and thus effectively perform hemostasis, which has the advantages of rapid, effective, safe, and accurate, and is a more ideal method for hemostasis of the splenic wound.
In lumpectomy, dissection of the splenic parenchyma can be performed with a 60-mm intraluminal cutting closure, which starts by compressing the splenic parenchyma along the revealed proposed resection line (after vascular treatment) with a long noninvasive grasping forceps, which needs to be performed gradually and slowly to prevent damage to the splenic tegument, and then applying the cutting closure when the splenic parenchyma is sufficiently compressed [20].Khelif et al. applied radiofrequency ablation to create a 1-cm-thick parenchymal coagulation layer for partial splenectomy, effectively preventing section bleeding and splenic tissue detachment for implantation with satisfactory results. The results of a corresponding animal study [25] in lumpectomy were also very satisfactory.Wu et al [29] applied Lin’s liver clamp to five partial splenectomies and effectively controlled bleeding during splenic parenchymal dissection, noting that the application of this device has the advantages of easy operation, safe and economical hemostasis, and does not require the use of the aforementioned expensive instruments and equipment.
Since intraoperative hemostasis is the main reason limiting the spread of partial splenectomy, the dissection of the spleen parenchyma and the management of hemostasis at the section have now become a hot topic of research on techniques related to this procedure.
4.3 Peritonealization of the section
The large omentum with vascular tissues is freed and covered with medical bioglue after spraying on the splenic section, which is then fixed with several stitches with circular sutures around the periphery. The spleen peritoneal graft can also be used to treat the splenic section by peeling off the spleen peritoneum cut off and placed in heparin saline at 4°C, covering the splenic section with sutures of exactly the same size as the splenic section, and fixing it with circular needle sutures around the perimeter.
Jiang Hongchi et al [30] pointed out that the advantages of the operation of covering the splenic peritoneum are: (1) splenic peritoneal transplantation can avoid the risk of rebleeding and liquefaction necrosis of the section; (2) splenic peritoneal transplantation makes the splenic section peritoneal again and reduces the chance of abdominal adhesions; (3) the large omentum is not applied to cover the wound, so there is less interference with the abdominal cavity and the function of the large omentum is not destroyed; (4) splenic peritoneal transplantation is a waste use, which is its own (4) the splenic peritoneal graft is a waste material and is its own tissue containing plasma membrane, which has a high survival rate; (5) the collagen of the splenic peritoneal graft is exposed in the splenic section, which facilitates the initiation of the coagulation system for adequate hemostasis and eliminates the dead space. This method has been applied to some splenic graft sections, and the fact that the sections were unharmed despite several rejection reactions is evidence of reliable results.