Laparoscopic Splenectomy

Elective (planned) splenectomy is usually indicated for blood disorders such as idiopathic thrombocytopaenic purpura (ITP), autoimmune haemolytic anaemia (AHA), lymphoma or suspected lymphoma and others; the need for splenectomy in those scenarios is a decision made by the haematologist after exploration of medical therapy. Occasionally, splenectomy is performed for symptomatic splenic cysts or for solid lesions within the spleen.

Professor Ammori performs splenectomy routinely by keyhole surgery (laparoscopically) regardless of spleen size, and has had a very low conversion rate to open surgery (two patients amongst few hundreds; these had massively enlarged spleens).

The spleen is an organ approximately the size of the fist and sits in the left upper part of the abdomen just under the diaphragm. It is attached to the stomach and to the pancreas gland and sits immediately in front of the left kidney. Under normal situations it has two functions both related to its properties as a filter for the high volume of blood passing through it. The first is to remove dead and dying blood cells which have reached the end of their natural lifespan. This is particularly important for platelets (which are present to speed blood clotting after cuts and grazes) and erythrocytes or red blood cells (which carry oxygen to the tissues). Both of these cell types are normally produced on a regular basis by the bone marrow and when they naturally decay are removed from the circulation by the spleen.

Other organs can perform this function but are generally less efficient than the spleen. The second function of the spleen is to assist the white cells of the blood in dealing with certain types of infections. Removal of the spleen therefore reduces these two filtering activities.

Many, indeed most, people who do not have a spleen (asplenia) live perfectly normal lives without any clinical side effects at all. However the absence of a spleen may occasionally have consequences which merit further consideration. 

The effects of losing the spleen on platelet function. Platelets are microscopic blood components which exist in the circulation to initiate the clotting process in the event of cuts and bruises. They are normally produced by the bone marrow and survive for up to two weeks when, if not required, are removed and replaced by fresh platelets from the bone marrow. The spleen is the most important organ in this removal process with some help from the liver (to a variable extent in different people). Loss of the spleen frequently results in a rise in the platelet count in the blood and indeed this effect is the purpose of removing the spleen in people with clotting disorders caused by too few platelets being present. In some people however removing the spleen results in the platelet count rising higher than is thought desirable. Theoretically this may result in the blood having too great a tendency to clot and the worry is that this could predispose to the development of strokes or heart attacks. To reduce this risk therefore it is sometimes necessary to advise people at risk of these complications to take daily aspirin tablets after the spleen has been removed. Your doctor will discuss this with you to decide whether this applies to you.

The effects of losing the spleen on immunity. This is the most important consideration. White cells in the blood stream are responsible for identifying infections and for controlling them. It is evident that for some types of infection white cells are aided considerably in this process by the spleen, which probably traps the cells dealing with the bacteria in one place and allows a more efficient attack. This help is particularly important in younger patients as the immune system generally becomes more efficient with aging (and experience!) but even in adults loss of the spleen may result in impaired defence against these bacteria. For this reason all people without a spleen are advised to seek medical advice AT AN EARLY STAGE if any infection occurs. It would appear that these infections pose greatest risk in children less than 18 years of age, or within two years of having the spleen removed or for those patients who have other reasons to be susceptible to infections. Your doctor will advise you about the risks of infection and may even recommend routinely taking antibiotics (usually penicillin) on a twice daily basis after splenectomy to mop up these bacteria before the white cells are asked to deal with them. It is also advisable that you be vaccinated against these bacteria. The ideal time to receive these vaccines is at least one week before the operation but if this is not possible then they should be given once you have recovered from your surgery. These may need to be “topped up” on a five yearly basis.

You may be advised to carry a card advising future Doctors that your spleen has been removed
It should be emphasised that the development of these infections is very uncommon but when they do occur (approximate risk is thought to be a risk of 1 in 100 per decade) they are severe hence the precautions outlined above.

Traditionally splenectomy was performed through an abdominal incision through which the spleen could be separated from the attached structures and removed. Whilst this is still sometimes necessary (usually when the spleen is very large or in an emergency situation) “keyhole” surgery is increasingly appropriate for this operation with its associated benefits. With keyhole surgery you will receive a general anaesthetic. A telescopic camera is inserted into the abdomen through a small incision and the structures viewed on a television monitor. Long slender instruments are then passed into the abdomen and the spleen may be freed and then removed. Four small incisions are usually required. Most people are discharged home within 1-2 days.

All surgical procedures carry a small degree of risk and complications, whilst uncommon, do unfortunately occasionally occur. The most important complication in the hours immediately after surgery is that of bleeding and this may occur in 2% of patients and may require further surgery. Occasionally the wall of the stomach or the tail of the pancreas may be affected by the surgery leading to peritonitis, which again may need further surgery but both of these complications are rare. The late side effects from splenectomy relate to its effect on the immune system and these have been detailed above.

Your doctor will be happy to discuss these issues with you and it is important that you discuss with him/her anything with which you are unclear together with specific queries you may have.