The spleen is the largest peripheral lymphoid organ in the body, capable of producing a variety of immunologically active cytokines, and is the main organ of blood storage, hematopoiesis, blood filtration, and blood destruction in the body, with important immunomodulatory, anti-infective, and anti-tumor effects. Based on the current understanding of the function of the spleen and the consequences of the increased susceptibility of patients to infection after spleen excision, spleen preservation surgery should be performed as much as possible when conditions and diseases allow. In other words, “save life first, preserve spleen second, the younger the patient, the more priority is given to spleen preservation”.
I. Which spleen needs surgery
1. Splenic rupture: Splenic rupture or subepithelial rupture caused by traumatic left upper abdominal or left hand rib penetrating injury or closed injury, spontaneous splenic rupture and injury in the surgical clinic can cause fatal hemorrhage and require immediate splenectomy to stop hemorrhage and important life-saving treatment.
2. Wandering spleen (ectopic spleen): Due to the excessive length of the transplanted spleen tip, the spleen can become excessively mobile and become a wandering spleen. This may even lead to twisting of the spleen tip, resulting in splenic necrosis. Splenectomy should be performed regardless of whether the spleen is twisted or not.
If the abscess is confined to the spleen, splenectomy is feasible. If the inflammatory fatigue around the abscess has spread to the spleen, only drainage can be performed. For limited splenic tuberculosis, splenectomy is also feasible
4. Tumors: Primary tumors are still relatively rare, but splenectomy should be performed regardless of whether they are benign (e.g., hemangioma) or malignant (e.g., lymphosarcoma). Metastatic tumors occurring in the spleen are not uncommon, and most have metastasized extensively and are not suitable for surgery.
5.Cysts: epithelial, endothelial and true cysts, non-parasitic pseudocysts, parasitic cysts (such as splenic cysticercosis) are prone to secondary infection, bleeding and rupture, and should be removed.
6. When radical resection is performed for cancer of the body of stomach, cardia of the fundus, body and tail of pancreas, or splenic flexure of colon, splenectomy should be performed to remove lymph nodes around splenic artery or splenic hilum. Especially when there is adhesion between the tumor and the spleen, the spleen should be removed together.
7.In cases of intrahepatic portal hypertension combined with hypersplenism, and extrahepatic portal hypertension such as splenic artery aneurysm, splenic arteriovenous fistula and splenic vein thrombosis causing congestive splenomegaly, splenectomy should be performed specifically for splenectomy.
8. Other hypersplenic diseases.
(1) primary thrombocytopenic purpura, suitable for young review patients with first attack, not cured by trusting medication for six months, chronic recurrent abdominal seizures, acute type, bleeding cannot be controlled after medication (surgery within 1-2 weeks is appropriate for children) and early pregnancy patients (surgery within 4-5 months).
(2) congenital hemolytic anemia, suitable for those who do not see any effect after 1 month of drug (hormone) Tuesday treatment, those who have serious cardiac side effects after long-term drug use and cannot continue to use drugs, preoperative radioactive 51 chromium liver and spleen area determination should be performed, indicating that surgery is performed if the spleen is the main destruction site of red blood cells, and if the liver is the main destruction site of red blood cells, surgery is not appropriate.
(3) Primary splenic neutropenia.
(4) Primary alloglobulinemia.
(5) aplastic anemia, suitable for those who have failed drug therapy and have compensatory hyperplasia on bone marrow examination (surgery is contraindicated for those with multiple zero reticulocyte tests in peripheral blood)
(6) Acquired hemolytic anemia (for selective cases).
II. What the surgeon will do pre-operative preparation
1.Emergency surgery: Emergency surgery is often required when splenic rupture occurs, so along with the preoperative preparation, there is prevention and control of hemorrhagic shock and allocation of large amounts of blood products for blood transfusion. For patients with traumatic splenic rupture, attention should also be paid to the presence of other organ injuries and treatment. In addition, appropriate antibiotics can be given preoperatively to prevent infection. Gastric tube should be left in place for gastrointestinal decompression before surgery.
2. Elective surgery: All chronic splenic diseases other than rupture should be operated electively. Pay attention to improving the general condition, transfusing small amount of blood several times, protecting liver function, correcting coagulation insufficiency, and performing necessary laboratory tests (including hemoglobin determination, red blood cell count, total white blood cell count and classification, platelet count, vascular fragility test, bleeding time, coagulation time, prothrombin time, etc.). Preoperative gastrointestinal decompression should be performed. An appropriate amount of blood should also be prepared for blood transfusion before surgery. Adequate amount of antibiotics should also be given.
Third, the patient needs to pay attention to the problems
Eat less food that is not digestible, less spicy things, such as chili, etc. Do not drink alcohol, do not eat too much at night, and eat a light diet; usually do more soothing exercises and as little strenuous exercises as possible. With an enlarged spleen, it is very easy for the spleen to rupture and cause fatal hemorrhage once the abdomen is hit by a fall or other trauma.
IV. Difficulties faced by doctors
Compared with general splenectomy, surgery for giant spleen is risky and difficult because of two reasons: first, the spleen is pathologically congested and enlarged, the surrounding space is narrow, and there is abundant collateral circulation, and there are more or less adhesions. In addition, the peripleural ligament is contracted and the splenic hilum is complicated, so it is easy to accidentally injure the stomach wall and the tail of the pancreas. By adopting new surgical methods and combining advanced medical equipment, we have gradually developed several solutions to these problems, which have significantly improved the feasibility and safety of giant spleen surgery. The diseases treated involved portal hypertension, primary myelofibrosis, and hemolytic anemia, etc. The heaviest spleen removed exceeded 20 pounds, and no serious complications such as surgical death, intraoperative hemorrhage, and pancreatic leakage, gastric and colonic injury occurred, and the clinical results were satisfactory.
V. How great is the danger of splenectomy
1, bleeding complications: intra-abdominal hemorrhage is one of the more dangerous complications after splenectomy, and the causes are mostly active bleeding and intra-abdominal oozing blood. This includes bleeding from the tail vessels of the pancreas, the splenic tip vessels, the short vessels of the stomach, as well as bleeding from the diaphragm and splenic bed. It is mainly due to incomplete hemostasis of small bleeding points or detachment of ligature wires, but also due to postoperative diaphragm and splenic bed oozing. If active bleeding in the abdominal cavity is found after surgery, immediate surgical exploration should be performed to stop the bleeding.
2. Infection: Early postoperative infections include pulmonary infections, subdiaphragmatic abscesses, and incisional infections, etc. The impact of which varies according to the causative factors of infection and the patient’s condition. Prophylactic application of broad-spectrum antibiotics before and after surgery can prevent the occurrence of infections. Routine intraoperative placement of drainage in the splenic bed and enhanced postoperative management of drains to keep them open can prevent the occurrence of postoperative subdiaphragmatic abscesses.
Postsplenectomy fulminant sensation, a unique infectious complication occurring after total splenectomy, has an incidence of 0,5% and a mortality rate of 50%. Patients are at lifelong risk of developing the disease, but the vast majority occur in the first 2 years after total splenectomy, especially in children, and the younger the child, the earlier the onset. 50% of patients have pneumococci as the causative organism.
3. Thrombosis and embolism: caused by elevated platelet count and increased blood viscosity after splenectomy. The platelet count rises 24h after splenectomy, and generally peaks 1-2 weeks after surgery, which is the high incidence of thrombosis. The most common is embolism of the portal vein, but it can also occur in the retinal artery and mesenteric artery. Heparin therapy can be used to prevent thrombosis after splenectomy.
4. Splenic fever: Patients often have fever lasting for 2-3 weeks after splenectomy, and generally the duration rarely exceeds 1 month, and the body temperature does not exceed 39℃. The duration and degree of splenic fever are directly proportional to the surgical trauma. Splenic fever is self-limiting fever.
5. Pancreatitis: it is related to damage to the pancreas during intraoperative freeing of the splenic bed. If the postoperative serum amylase is elevated for more than 3 days and accompanied by symptoms, the diagnosis can be confirmed. Treatment with growth inhibitor is more effective.
VI. Key points of observation after splenectomy
1. Observe for internal bleeding and routinely measure blood pressure, pulse and hemoglobin changes. Observe the condition of the drainage tube of the splenic fossa under the diaphragm. If there is a tendency of internal bleeding, blood and fluid should be transfused in a timely manner, and if there is indeed persistent hemorrhage, re-operation should be considered to stop the bleeding.
2. Splenectomy is a major stimulus to the abdominal organs (especially the stomach), so a gastrointestinal decompression tube should be placed to prevent postoperative gastric dilatation. Resume eating 2-3 days after surgery.
If the platelet count rises rapidly to more than 50×109/L, splenic vein thrombosis may occur. If severe abdominal pain and bloody stool occur again, it indicates that the thrombosis has spread to the superior mesenteric vein, and anticoagulant therapy must be used in time.
Seven, the difference between open and laparoscopic
Minimally invasive techniques, represented by laparoscopy, have been introduced and matured in splenectomy. Compared with traditional transabdominal surgery, laparoscopic splenectomy has the following significant advantages.
(1) Small surgical incision.
(2) The laparoscopic field of view is open and clear, and has a field of view that is not available in transabdominal surgery. (2) The laparoscopic field of view is wide and clear, which is not available in transabdominal surgery.
(3) The laparoscope can reach the narrow space around the spleen, magnify the local field of view, and deal with the splenic colonic ligament, splenogastric ligament, splenodiaphragmatic ligament and splenorenal ligament in a simpler and easier way than transabdominal surgery, plus only the arteriovenous vessels entering and leaving the splenic hilum need to be dealt with, which makes the operation of laparoscopic splenectomy more convenient than transabdominal surgery.
(4) Light post-operative pain, which facilitates early activity and generally allows patients to get out of bed one or two days after surgery, which helps promote recovery of post-operative gastrointestinal function and therefore allows patients to eat earlier.
(5) No pain caused by the large incision after transabdominal surgery, which facilitates deep breathing and coughing and sputum excretion, minimizing the incidence of pulmonary atelectasis and pulmonary infection, so this minimally invasive surgery is especially suitable for elderly and frail patients.
(6) The length of hospital stay is significantly reduced.
Of course, not all splenomegaly can be removed by a minimally invasive approach. In a small number of patients with portal hypertension and giant spleen, due to the increased number of collateral circulation vessels around the spleen, varicose veins and thin venous vessel walls that are easily torn, as well as the narrow operating space in the abdominal cavity caused by the giant spleen, it is easy to damage the angry veins during laparoscopic splenectomy operation, resulting in hemorrhage. This group of patients may be referred for transabdominal surgery.
A problem that also perplexes specialists.
In the last half century, especially in the last 20 years with the in-depth research on the anatomy and physiological functions of the spleen, there has been further understanding and knowledge of the functions of the spleen such as blood storage, hematopoiesis, blood filtration, blood breaking, immune regulation, anti-infection, anti-tumor, endocrine and its relationship with diseases. The damage of splenectomy on human immune function is the reason why people realize the importance of preserving the spleen and how to maximize the preservation of splenic tissue and splenic function, but controversies still exist.
1. Splenic preservation in portal hypertension surgery: The question of whether to preserve the spleen in portal hypertension surgery has been controversial, focusing on how much splenic immune function is present in portal hypertension and whether it has a facilitating effect on liver fibrosis. Some scholars believe that splenectomy for portal hypertension does not affect the immune function of the organism; others believe that splenomegaly and hyperfunction can be recovered after liver transplantation in patients with cirrhosis, and that cutting the spleen can still cause damage to the organism. The research and debates on this are still going on, and no premature conclusion should be made.
2. The problem of spleen-preserving surgery for malignant tumor treatment: for tumors of organs adjacent to the spleen, such as gastric cancer, pancreatic cancer and colon tumors, joint resection is mostly adopted because of the requirement of radical tumor surgery or because the splenic vessels cannot be preserved.