Our body is formed of many systems that are, in turn, formed of organs. Most organs of the body are essential for life and their removal can cause immediate or delayed death however, some organs in our body are removable, and some conditions necessitate such removal either as a life-saving measure, to remove a certain diseased organ or even for general health considerations or as protection against a certain expected disease in such organ.
The spleen
The spleen is one of the least known organs in the human body that if you asked random individuals what it does, 9 out of 10 would not know. This underrated organ is located in the left upper abdomen behind the stomach and just under the left side of the diaphragm. It has a convex smooth outer surface that is related to our last 3 ribs and the diaphragm and an inner surface that has the blood supply. The spleen is supplied by the splenic artery and is drained by the splenic vein, which is a part of the portal circulation which connects to the liver and the gastrointestinal system.
What does the spleen do (spleen function)
The spleen has 2 main functions:
1- It has the “red pulp” which is responsible for the destruction of aged red blood cells. It is the main site for such function and that is why it may be enlarged in some red cell disorders.
2- The “white pulp” of the spleen has an immune function where it serves many immune mechanisms mostly against some types of bacteria such as meningococci which cause meningitis and pneumococci and hemophilis influenza which cause pneumonia.
Both of those functions need the spleen to be very vascular that for the inexperienced eye, a spleen looks very similar to a sack of blood.
What is splenectomy?
Splenectomy is the surgical removal of the spleen, and in the near past, surgical removal of the spleen was a commonly used procedure for many conditions, but as time passed and the consequences and complications of splenectomy became well established, more conservative approaches and even less invasive surgeries became preferred except in selected cases.
Indications of splenectomy
Generally speaking, the spleen is removed for 2 main causes which are either trauma that caused the spleen to rupture or a blood disorder that is directly or indirectly linked to the spleen.
1) Ruptured spleen
Splenic rupture can result from a sharp penetrating object at the left upper abdomen or the left lower chest or from a blunt injury that either damaged the spleen directly or caused a rib fracture that acted as a secondary sharp object and lacerated the spleen. Regardless of the injury, if the spleen is injured enough, profuse bleeding can occur in the abdomen which can be life-threatening. The patient is first managed conservatively, and surgery is only resorted to if conservative measures prove unsuccessful or if the patient developed a severe drop of blood pressure.
Another less invasive method includes interventional radiology, where we use a catheter to inject a material into the splenic artery occluding it and effectively stopping bleeding. This procedure, however, needs expert hands and a stable patient. Surgery is reserved because operating on a patient with a low blood pressure and profuse bleeding tends to be hazardous and success rates are low. It is worth noting, however, that not all surgeries done for splenic rupture are splenectomies, and various methods to conserve the spleen are present and are increasingly being used nowadays. The main determinants of whether a splenic preservation approach should be followed is the degree of splenic damage as well as the surgeon’s expertise and judgement.
2) Blood disorders that necessitate splenectomy
As mentioned above, the spleen is the main organ that deals with red cells after they exit their manufacturing plant, the bone marrow. That is why when there are disorders of red cell shape or content, the spleen enlarges to deal with the dysfunctional red cells, and such enlargement can cause clinical complications in 2 forms:
- When the spleen enlarges, it becomes heavier, putting a load on the ligaments attaching it to the surround structures like the diaphragm. This tension causes a dragging pain in the abdomen that can cause significant discomfort to the patient. The pain is usually worse on standing up or sitting and is relieved partially by laying back. The rapid enlargement can also cause the blood supply to be relatively inadequate. This causes splenic infarction which, in turn, causes the splenic capsule to inflame producing the characteristic stitching pain.
- One of the complications of the enlarged spleen is the development of It means that the spleen’s function to eat up cells spirals out of control and it becomes aggressive towards healthy cells, causing deficiencies of red cells, white cells and platelets. This condition can manifest by one or more of the following: anemia, increased susceptibility to infection and easy bruising/bleeding.
Hematological disorders that need or may benefit from splenectomy include:
1. Idiopathic thrombocytopenic purpura
This is one of the commonest indications of splenectomy. In this disorder, platelets are deficient because they are destroyed via an autoimmune reaction that develops following viral infections. The spleen is not the cause of the condition but is the site in which platelets are destroyed. Its removal ameliorates the platelet deficiency; however, it is only performed in chronic cases that do not respond well for medical therapy -which remains a minority- and is avoided in surgery.
2. Thalassemia
Thalassemia is a blood disorder that involves an abnormal hemoglobin production which causes the red cells to have a short life span. The spleen enlarges because of this rapid destruction and because of the anemia that causes what is called extramedullary hematopoiesis, which is the production of red cells in sites outside the bone marrow to compensate for the rapid destruction, and those sites include the spleen.
3. Sickle cell anemia
Sickle cell anemia is characterized by the sickle-shaped red cells which occlude blood vessels producing severe pain of the limbs. Splenectomy is generally rare in sickle cell anemia because the spleen suffers from such vascular occlusions causing it to die slowly and disappear, a condition called auto-splenectomy, however one complication of sickle cell anemia called splenic sequestration crisis may occur when the splenic venous drainage is occluded by red cells, causing the spleen to “pool” large amounts of blood leading to a severe drop of blood pressure. This condition usually necessitates emergency splenectomy.
4. Splenic abscess
Splenic abscess is a rare condition that mostly arises from infection in the heart (bacterial endocarditis). It may be drained without removal of the spleen, but in some conditions, removal of the spleen becomes essential.
5. Hereditary spherocytosis
In this condition, red cells are less deformed than in thalassemia with a spherical shape rather than a biconcave one. Anemia is usually mild but can become aggravated in some conditions. The peculiar feature of this disease is that clinical cure can be achieved only by splenectomy.
6. Malignant conditions
Splenectomy can be performed in malignant conditions either for diagnostic or therapeutic measures. Diagnostic measures are to confirm the presence of malignancy in the splenic tissue which affects the disease therapeutic plan and outcome.
Malignant conditions that need splenectomy include: Hairy cell leukemia, Hodgkin’s and Non-Hodgkin’s lymphoma as well as other myeloproliferative disorders like polycythemia vera and chronic myeloid leukemia.
How is splenectomy done?
Splenectomy can be done through an open approach or a laparoscopic one and the procedure is performed under general anesthesia.
The open approach: It has greatly been replaced by laparoscopic approach nowadays that its use is generally limited to major trauma when free bleeding into the abdominal cavity is suspected or when there is a lack of laparoscopic expertise. It is done via an abdominal incision; the splenic vessels are ligated and then the spleen is removed.
Laparoscopic approach: Laparoscopic surgery is preferred because it generally results in less hospital stays and more cosmetically acceptable scars with a lesser complication such as wound infection and incisional hernias. The drawback is that it does not allow for a good view of the abdominal cavity which makes it hard to manage traumatic ruptured spleen.
Complications of splenectomy
Any surgery has a percentage of complications even in the hands of the most expert of surgeons. They depend on several factors including the type of surgery, its site and the general condition of the patient. The expertise of the surgeon also plays a role in the rate of complications, but it is far from being the only factor. The most common complications of splenectomy include:
Bleeding: Bleeding is one of the most common complication of all surgeries. It can occur on the operating table, following wound closure or even after 48 hours after the surgery. Bleeding is the leading cause of death in splenectomies.
Pancreatic injury: The pancreas is in close proximity to the spleen and its tail can be injured in splenic surgery. The problem isn’t related to the pancreas specifically but to the release of pancreatic juice into the abdominal cavity. Pancreatic juice is extremely strong against fats and protein and can digest the abdominal cavity organs including arteries which can cause severe hemorrhage, for that reason if such injury is detected or suspected during the operation, a drain is placed to drain the pancreatic juice.
Infection: In the recent past, the role of the spleen in immunity was greatly underrated, but the removal of the spleen significantly affects immunity and that is why it is avoided in children except in very few instances. One of the life-threatening complications of splenectomy is the development of OIS or overwhelming infection syndrome. This syndrome is rare to develop but if it does, up to 1 in every 2 patients can die from it.
Portal vein thrombosis: The portal vein is the main venous drainage of the gastrointestinal tract. It is formed by the union of the inferior mesenteric artery and the splenic artery. During surgery, mediators are released from the injured tissue that cause coagulation to commence. These mediators can cause a blood clot to form in the portal vein. The condition is manageable and avoidable by effective anticoagulation which is given routinely.
Considerations after splenectomy
As mentioned above, removal of the spleen has an effect on the body’s immunity and therefore, it is usually avoided in children under 6, but if it has to be done, then vaccination is given prior to its removal as well as antibiotic prophylaxis -regular doses of antibiotics usually penicillin given to avoid infection and control it early-.