LAPAROSCOPIC SPLENECTOMY

1. What is a splenectomy?

Splenectomy is a term referring to the surgical removal of the spleen.

2. What is the spleen and what functions does it serve in our body?

The spleen is a soft organ approximately the size of a fisted hand located behind the stomach in the left upper abdomen and is protected by the lower ribcage. It is part of the blood and lymph system. It functions as a filter, removing bacteria, foreign cells and old red blood cells from the circulation. It also produces red blood cells in children. In addition, spleen produces proteins that help in the immunity against certain bacteria.

3. Why remove the spleen then?

Like any other organ in the body, the spleen can be affected by diseases or injured. The commonest reason for removing the spleen is trauma to the spleen (such as road traffic accident or fall from height) resulting in internal bleeding. Removal of the spleen in such situation is necessary to stop the blood loss and save life.

Spleen may be involved in some blood disorders - causing low platelets counts (as in autoimmune thrombocytopenic purpura, AITP) and decreased life span of red blood cells (eg spherocytosis or other forms of chronic hemolytic anemia). It can also be affected by diseases such as cyst, abscess or hematological malignancy eg. Hairy cell leukemia. Sometimes the spleen can reach a massive size causing significant discomfort to the patient and is associated with increased risk of rupture.

Splenectomy can improve the blood profile of patients with specific blood disorders - in AITP, up to two-third of the patients can be rendered medication-free and have sustained normal platelets count following splenectomy. In hairy cell leukemia, splenectomy can improve the cell count and delay chemotherapy. In those with chronic hemolytic anemia, splenectomy helps to enhance red blood cell lifespan and therefore reduces transfusion requirement. And in those patients with massive enlargement of the spleen, splenectomy can relieve symptoms and eliminate the risk of rupture.

Removal of spleen affected by benign disease such as cyst, abscess or chronic infection can lead to cure of the disease. However, in malignant disease involving the spleen, splenectomy often does not confer a cure, but as part of overall staging (assessment of the severity) of the underlying malignancy.

4. How is the spleen removed?

The spleen is deeply position in the abdominal cavity and closely related to the stomach, the pancreas and the left kidney. These important organs need to be carefully separated from the spleen before it can be safely removed. The operation has traditionally been done via conventional open surgery i.e. through a large incision on the abdominal wall, through the skin and muscle. Now a day, splenectomy can be done laparosocpically. This is done with the patient under general anesthesia and in the right later position. The abdominal cavity is distended with carbon dioxide to create space for the operation. Visualisation is achieved with a 10mm diameter telescope and the operation performed with two to three slim 5mm diameter instruments placed at just below the left ribcage.

5. What are the benefits of laparoscopic splenectomy?

The benefits include: -
" Smaller wounds and therefore less pain
" Shorter hospitalization stay
" Faster recovery and return to work
" Reduce overall hospitalization cost
" Better cosmetic outcome

However, in patients with very large spleen or those with severe bleeding tendency, the open operation would be more appropriate.

6. Are there potential complications associated with the operation?

Complications following splenectomy are not common, they include - wound infection, bleeding at surgical site, blood clots in the deep vein of the legs & embolism of the clot to the lungs, pancreatitis (inflammation of the pancreas), collapse of the lung and pneumonia.

7. How do I prepare for the operation?

Prior to the operation, radiologic imaging (commonly computerized tomography {CT scan} or ultrasonography) of the spleen will be done to delineate the spleen and its congenital accessories.
You will be reviewed by an anesthesiologist to assess your general fitness for general anesthesia. Blood tests, chest X-ray and ECG are done during this review. We will also discuss with you on the pain control option you prefer after the operation.

You will need to have vaccinations to certain bacteria at least one week to 10 days prior to the operation.

You will be admitted to the hospital one day prior to the operation. Upon your admission, blood tests need to be repeated in order to arrange for blood or blood product necessary for the operation. You will meet the physiotherapist who will instruct you on the exercises to help you breathe better following operation.

There will be restriction on the diet and liquid laxative will be given to clear your bowel in preparation for the operation.

8. What is it like after the operation?

This can be broadly divided into 3 categories -

a. The after effects of general anesthesia - headaches, nausea and sore throat. There are medications that can help lessen these unpleasant feelings and they usually improve over the next 24-48 hours.

b. Wound pain - Pain from the laparoscopic wounds are usually minimal. Majority of patients find oral analgesics adequate in relieving pain. If need arise, additional patient-control-analgesia can be prescribed.

c. Surgical tubes and drains - This will include intravenous line for drip, nasogastric tube, urinary catheter as well as surgical drain for residual blood and fluid at the surgical site brought out through the abdomen near the surgical wounds. These tubes do cause some discomfort but are necessary for the first couple of days after operation. Please do bear with the discomfort and inconvenience, they will be removed as soon as they are not needed.

You will be allowed only small amount of clear fluid initially after the operation. As your condition improves and gut function returns, you can progress to more substantial diet.
You are likely to stay in the hospital for 3-4 days after the operation.

9. What should I look out for after discharge from hospital?

You should have recovered to a good extent from the operation when leaving the hospital. You should ambulate as much as the pain / discomfort in the wound permits and take a balance diet and ensure adequate fluid intake to avoid dehydration.

You will be given a date to remove the stitches (or metallic clips) from the skin wound approximately one week after the operation. This is a simple clinic procedure and will not be painful. Meanwhile, you should look out for redness, pain and discharge from the wound that may suggest infection. Consult your surgeon if you develop wound infection or if you have high fever especially when it's associated with abdominal pain.

After laparoscopic splenectomy, most patients are able to return to normal daily activities or deskwork by the end of first week. Strenuous physical exercise should be postponed until 4-6 weeks later. You should return for review with your surgeon and your primary physician on the scheduled date.

10. What are the long term effects of splenectomy?

The bone marrow and the other lymph nodes in the body will take over most of the splenic functions after splenectomy. However, there is still an increased in risk and susceptibility to infection by certain bacteria - pneumococci, meningococci and hemophilus influenza typeB etc. Young children are at a higher risk of infection than adults. Asplenic patients are also at increased susceptibility to malaria.

11. What can be done to reduce the risk of infection?

Awareness of the increased susceptibility to infection after splenectomy and vigilance to minor infection will help a great deal and may potentially be life saving. The following measures helps in reducing the risk of overwhelming infection -

a. Vaccination against pneumococci, meningococci and helomphilus influenza type B are now available and should be given at least one week prior to the operation. A booster is usually necessary every 5-10 years after that.
b. Antibiotic is given during the operation, this usually covers a broad spectrum of gut organisms.
c. Long term antibiotics, usually in the form of penicillin, is recommended in pediatric patients
d. Prophylaxis to malaria when traveling to malaria endemic region.
e. Be mindful of your increased risk to infection and vigilant to potential infective organism such as when you have high fever, severe sore throat, unresolved cough, sudden acute abdominal pain, severe headache and phobia to light or a skin rash. Seek medical attention early to prevent early infection from escalating to potentially fatal septicemia.
f. Seek medical attention early when bitten by animal as there is increased risk of infection. Antibiotic should be started early.
g. Always volunteer the information that your spleen had been removed when consulting a doctor or carry with you an information item stating you are without a spleen (eg information card from your surgeon or a bangle engraved with the information). This is especially important after laparoscopic splenectomy because the surgical wounds can become quite inconspicuous after some time. This will alert the medical personnel attending to you to be more vigilant with potential infection, and more aggressive in treating the infection once detected.