Splenectomy (Open or Laparoscopic)
Patient phenotype
Indications: ITP, hereditary spherocytosis, lymphoma staging, traumatic rupture (emergent), splenic abscess. Elective patients often pre-vaccinated (encapsulated organisms). Trauma patients hemodynamically unstable.
Procedure
Laparoscopic for elective (left lateral decubitus, 4 ports) — 1.5-3 h. Open midline for trauma or massive splenomegaly — 1-2 h. Splenic vessels controlled, spleen removed in retrieval bag.
Anesthetic plan
GETA. Elective: standard induction, A-line if comorbidities, type & screen. Trauma: RSI, large-bore access, MTP availability, A-line, cell saver. Pneumococcal/Hib/meningococcal vaccines verified preop (or planned for postop).
Setup
- ·Standard ASA monitors + temp
- ·1-2 PIVs (16-18g)
- ·A-line if comorbidities or trauma
- ·Type & screen (cross 2 units PRBC if bleeding risk)
- ·OG tube (decompresses stomach during left-side approach)
- ·Forced air warmer
Biggest concerns by phase
Platelet transfusion timing in ITP
Platelets given AFTER splenic artery ligation in ITP — earlier transfusion is consumed by spleen. Coordinate with surgeon. Steroids continued. IVIG sometimes given preop to boost count.
Splenic vessel injury + sudden hemorrhage
Splenic artery + vein control = highest-risk moment. Sudden bleeding can be catastrophic in laparoscopic — surgeon converts to open. Have blood checked + accessible. Anticipate the moment with surgeon.
Pancreatic tail injury
Tail of pancreas lies at splenic hilum — injury during dissection = postop pancreatitis, pancreatic fistula. Watch for elevated lipase postop.
Diaphragmatic injury → pneumothorax
Spleen abuts diaphragm. Inadvertent injury → pneumothorax (left). Watch for sudden ETCO₂ drop, peak pressure rise, asymmetric breath sounds. Ultrasound confirms.
Overwhelming post-splenectomy infection (OPSI) education
Lifetime risk of fatal sepsis from encapsulated organisms (pneumococcus, H. influenzae, meningococcus). Vaccines + patient education essential. Antibiotic prophylaxis for some (children, immunocompromised).
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
32-yo F with refractory ITP, plt 18k, on prednisone + rituximab. Scheduled for laparoscopic splenectomy. Walk through your plan.
What an examiner probes for
- ▹Reviews preop platelet, IVIG, steroid plan
- ▹Discusses plt transfusion timing (after artery ligation)
- ▹Stress-dose steroids
- ▹Vaccination verification
- ▹Avoids regional/neuraxial given thrombocytopenia
Sources
- Miller's Ch 71
- ASH ITP Guidelines 2019
Anatomy reference
Sourced reference images. 4 matches for "spleen abdomen".
