Splenectomy – procedures

What the Anesthesiologist Should Know before the Operative Procedure

There are several indications for splenectomy – traumatic injury, idiopathic thrombocytopenia purpura (ITP), hereditary spherocytosis, staging surgery, splenic infarction, and splenomegaly. Each has different associated comorbidities and risks involved. Depending on the indication, splenectomies can be performed either laparoscopically or in open fashion.

Traumatic injury was previously the leading indication for splenectomy, but with improved splenic preservation techniques, this is now second most common (35-40%), behind hematologic conditions (40-50%), with idiopathic thrombocytopenia purpura being most common.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Except for traumatic injury, rarely is a splenectomy emergent. Most of the other indications maybe urgent or even semi-elective.

Emergent: Unstable trauma patients who have suspicion of splenic injury and evidence of blood, either by deep perintoneal lavage or by a focus abdominal songraphic technique study, should proceed straight to the operating room for exploration, and preferably undergo a splenic repair versus splenectomy.

Urgent: Depending on the exact indication for splenectomy and underlying co-morbidities, a splenectomy can be either urgent or semi-elective. The urgency should be balanced against appropriate vaccinations, exhaustion of other treatment modalities, and a full evaluation of other morbidities contributing to the need for a splenectomy, such as evidence of iron overload in patients with hereditary spherocytosis or optimization of a chemotherapy regimen in a cancer patient.

Elective: There is never a truly elective splenectomy; mostly, the decision to continue with splenectomy is made only after all other treatment options have been explored. Many patients may have required transfusions in the past and should have blood type and crossed in advance.

2. Preoperative evaluation

The indication for splenectomy can be divided into six categories: hypersplenism, trauma/injury, autoimmune/erythrocyte disorder, primary tumor/mass, incidental, and diagnostic.

Hypersplenism:

This is a general category describing both a diffuse enlargement of the spleen as well as an increase in its normal function of eliminating circulating red blood cells or platelets. It is important to point out that hypersplenism does not necessarily require the physical size of the spleen to enlarge (as seen in ITP, where splenomegally is rare).

Traumatic splenic injury:

Typically it is now routine for all trauma patients to undergo a “FAST” exam (focused assessment with sonography in trauma) to identify any free fluid in the abdomen suggestive of bleeding in conjunction with the patient’s clinical status. If the patient is hemodynamically unstable, then the decision is to proceed directly to the operating room for exploration, usual in open fashion. Otherwise, further imaging and possible observation or embolization techniques can be employed.

Erythrocyte and autoimmune disorders

Erythrocyte and autoimmune disorders such as hereditary spherocytosis (congenital hemolytic anemia) often require a splenectomy, including careful removal of the accessory spleen.

Splenic neoplasms

Splenic neoplasms (lymphoma, metastatic cancers) are rare but important indications for splenectomy.

Occasionally, tumors of surrounding structures (stomach, spleen, and kidney) extend or involve the spleen, necessitating an en-bloc resection.

Splenectomy for the purpose of diagnosis is rare.

• Medically unstable conditions warranting further evaluation include working up the exact disease process and ensuring that splenectomy is the appropriate treatment choice.

• Delaying surgery may be indicated if the procedure is semi-elective and all immunization for encapsulated organisms (Pneumococcal vaccination) have not been administered at least two weeks prior to the surgery date. Furthermore, for patients with hypersplenism, it is important to attempt medical optimization before even deciding to proceed with a splenectomy. For example, with ITP, it is possible to have cases of remission after treatment with steroids and/or IVIG.

3. What are the implications of co-existing disease on perioperative care?

Perioperative evaluation

As always, it is important to take a thorough history and physical. Depending on the exact indication for splenectomy and length of time with the given affliction, the concerns can be quite varied. For example, if a patient had hypersplenism because of sarcoidosis, it may be appropriate to fully evaluate the other systems affected by the disease. Similarly, if a patient failed medical therapy and has relapsed ITP, discussing all previous treatments and responses, including any recent steroid administration, may be important.

Perioperative risk reduction strategies

Specific therapies can be developed, depending on important co-morbidities and planned surgical approach.

b. Cardiovascular system

Acute/unstable conditions

Most patients (from trauma to erythrocyte disorders to ITP) undergoing a planned splenectomy tend to be younger and free of cardiac disease. Except in trauma patients, splenectomy is never an emergent surgery. If history, exam, or clinical suspicion suggests that the patient has cardiac risk factors, an appropriate evaluation should be planned. For trauma patients, significant hypovolemia may exist with hemodynamic instability. Consider a gentle induction with adequate IV access and the surgeon should be ready to start quickly.

Baseline coronary artery disease or cardiac dysfunction

Older patients with coronary artery disease or patients who have been treated with chemotherapeutic agents affecting cardiac function should be fully evaluated with a thorough history documenting functional status and symptoms. Any previous testing (ECG, echocardiogram, or stress test) should also be documented. Active cardiac issues (such as acute MI or CHF decompensation) need to be resolved prior to surgery. A splenectomy is considered mostly an intermediate risk procedure (possibly high risk if done as part of a major tumor resection operation). Based on the most recent ACC/AHA guidelines, there is increasing evidence to suggest that functional asymptomatic patients should proceed to surgery without further testing.

If a patient has cardiac risk factors, a pre-induction arterial line and full intraoperative hemodynamic monitoring, including central venous pressure and transesophageal echocardiography, may be appropriate. The primary goals are to optimize myocardial supply and reduce demand. It may be important to rely on beta blockers to slow the heart rate to improve diastolic filling time and transfuse red blood cells to improve oxygen carrying capacity.

c. Pulmonary

Acute/unstable conditions

Many patients undergoing a planned splenectomy tend to be younger and free of long standing chronic lung disease. However, asthma or reactive airway disease is the most common co-morbidity, with a prevalence of 7.5% in patient younger than 18 years of age or a prevalence of 5.7% in all patients. If splenomegally is present, then significant atelectasis and restriction on lung excursion can be noticed. Again, an appropriate history and exam should delineate any existing pulmonary disease. Routine CXR and studies should only be reserved if clinical suspicion is high for underlying disease so that appropriate risk stratification or modification can occur.

Baseline pulmonary disease

Patients with pre-existing pulmonary disease are at increased risk of postoperative complications, such as pneumonia after general anesthesia. With laparoscopic surgery, muscle relaxants are often used to aid in improving surgical operating conditions. Once the spleen is removed, laparoscopic closure is relatively quick. It is important to ensure adequate resolution of neuromuscular blockade before reversing and extubating.

Perioperative risk reduction

For open splenectomies, when not contraindicated (i.e., thrombocytopenia, coagulopathy, or use of anti-platelet drugs), epidural anesthesia can significantly improve pain scores and reduce post-operative pulmonary complications (i.e., pneumonia, hypoxia, and re-intubation). Incentive spirometer and rapid post-operative mobilization also can help with lung recruitment and minimize pulmonary complications.

d. Renal-GI:

Patients undergoing emergent splenectomy secondary to trauma may be hypovolemic from hemorrhage and have a full stomach. It may not be entirely possible (nor desired) to completely restore volume status prior to surgical intervention. These patients should proceed with rapid sequence intubation.

Depending on the exact indication for splenectomy, there may be some hepatic dysfunction due to either the primary disease or previous treatment for the disease. Medication choice and dosage may need to be modified accordingly.

e. Neurologic:

Patients undergoing splenectomy do not typically have any significant associated neurologic conditions.

f. Endocrine:

Some patients have chronic steroid dependence and may need stress dose steroids administered in the peri-operative period.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Depending on the exact indication for splenectomy, other appropriate systems should be reviewed (i.e., various cytopenia for hypersplenism or autoimmune disorders). Cancer patients may have other affected systems from either the tumor or treatment of the tumor.

Splenectomized and sickle cell patients had a strongly reduced phagocytic and immunological function and should be considered for prophylactic vaccination if there is time. If there is not time preoperatively, then postoperatively, patients should receive pneuococcal vaccination, Haemophilus influenzae type B vaccination and meningococcal group C vaccination. Patients should be considered for prophylactic antibiotics when presenting postoperatively with fever, given to their increased risk of sepsis.

4. What are the patient's medications and how should they be managed in the perioperative period?

Medication regimens should be decided on a case by case basis.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

This may include medications specific to diseases prompting surgery. The single most common diagnosis for splenectomy is ITP. Many of these patients have taken large doses of steroids and may need stress dose steroids throughout the perioperative period.

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac

Beta blockers and statins should be continued through the perioperative period. Other anti-hypertensive agents should be continued on a case-by-case-basis. Continuation of antiplatelet agents, such as cloidogrel and aspirin, should be decided depending on other associated conditions (i.e., drug eluting stent placement, timing, and location) and after discussion with the patient’s cardiologist and surgeon.

Pulmonary

Bronchodilators, anti-cholinergics, leukotriene inhibitors, and steroids should be continued through the perioperative period.

Renal

N/A

Neurologic

N/A

Anti-platelet

See above.

Psychiatric

Continue any anti-anxiety and anti-depressant medications perioperatively.

Herbal

Any over-the-counter herbal supplementation should be stopped, since they may result in worsening platelet function.

Oncologic:

Cancer patients on chemotherapy should be monitored for hematologic effects of treatment to appropriately time the surgery.

j. How To modify care for patients with known allergies

Avoid all medications or components which might possibly cause/result in allergic reaction.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

Remove all latex-containing materials from the OR. Most anesthesia equipment, including circuit, NIBP cuff, and tourniquets, are now latex-free. There is minimal latex still found in the rubber tops of the medication vials.

l. Does the patient have any antibiotic allergies?

All antibiotic administration should be complete by the time of surgical incision, but not greater than one hour prior. Typically, for a simple splenectomy, surgical prophylaxis should cover skin flora with cefazolin 1 g IV every 4 hours (2 g if > 80 kg).

For patients with a penicillin allergy, consider vancomycin (1 g IV Q12 of weight less than 70 kg, 1.25 g Q12 hours between weight 70-100 kg and 1.5 gram IV Q12 if weight greater than 100 kg) or clindamycin (600 mg IV).

For traumatic splenec injury or splenectomy involving any GI structure, consider ertapenem 1g or cefotetan/cefoxitin with PCN allergy (clindamycin 600 mg IV and gentamicin 5mg/kg).

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia

Documented

Avoid all trigger agents, such as succinylcholine and inhalational agents:

Proposed general anesthetic plan: Proceed with total intravenous anesthesia, likely using a propofol infusion with boluses of opioid. Nitrous oxide can be utilized, but this can sometimes lead to bowel distention and interfere with surgery. Nitrous oxide can also increase post operative nausea. However, nitrous can be used safely if needed.

Insure malignant hyperthermia (MH) cart available: Each operating room should have a MH cart and protocol available (i.e., with dantrolene, irrigation tubing, etc.). The Malignant Hyperthermia Association of the United States (MHAUS) hotline can also be called for advice.

Family history or risk factors for MH:

Proceed as outlined above.

Local anesthetics/ muscle relaxants

Local anesthetics and nondepolarizing muscle relaxants are safe to use.

5. What laboratory tests should be obtained and has everything been reviewed?

Laboratory tests should be only ordered based on information gathered from the history and physical intake. However, cytopenias are very common, and a CBC with differential should be reviewed along with at least a type and screen (and if the antibody screen is positive, cross match performed).

Common laboratory normal values will be same for all procedures, with a difference by age and gender.

• Hemoglobin/Platelet levels: Patients with hypersplenism or autoimmune disorders may have low hemoglobin or platelet levels. The decision to transfuse red blood cells is based on comorbidities, end organ damage, and signs or symptoms of inadequate oxygen carrying capacity. In general, patients undergoing elective surgery should have platelet counts above 50,000. However, if transfusions are needed, it should be given after ligation of the splenic vessels to minimize sequestration.

• Electrolytes: N/A

• Coagulation panel: N/A

• Imaging: Review any abdominal imaging (spleens greater than 20 cm have a high conversion rate to open splenectomy)

• Other tests: As needed, based on other co-morbidities.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Many elective splenectomies can be performed laparoscopically. An absolute contraindication to laparoscopic technique is massive splenomegally (spleens > 30 cm in the longitudinal axis).

For laparoscopic cases, the patient is typically placed in the right lateral decubitus position with some flexion in the bed. An axillary roll should be place to prevent brachial plexus injury. Open splenectomies are generally performed in the supine position.

A balance general anesthetic can be used for either splenectomy technique, but epidural anesthesia may be beneficial for post-operative pain control and reduction of post operative pulmonary complications.

Regional anesthesia

Neuroaxial anesthesia with an epidural may be appropriate as an adjunct for open splenectomy cases. Though the American Society of Regional Anesthesia does not provide an exact platelet count guideline for safe placement and maintenance of an epidural catheter, many anesthesia providers would be reluctant to employ neuroaxial blockade for platelet counts less than 100,000.

Neuraxial

An indwelling epidural catheter can be useful for both improved pain control and reduction of pulmonary complications.

• Benefits: As described above. Epidurals have also been associated with decreased venothromboembolism events.

• Drawbacks: Thrombocytopenia (typically less than 100K), coagulopathy, or anti-platelet agents may preclude the use of an epidural catheter because of increased risk of epidural hematoma.

General anesthesia

• Benefits: Ensures a secure airway and the ability to provide positive ventilation with PEEP.

• Drawbacks: Typical side effects of general anesthesia including post-operative nausea and vomiting.

• Airway concerns: No specific concerns for the semi-elective patient, though emergent trauma patients may have unstable cervical spines and require in-line-neck stabilization.

Monitored anesthesia care

MAC is not an option for splenectomy, but may be an option for embolization-type procedures if splenic preservation is the goal.

6. What is the author's preferred method of anesthesia technique and why?

A balanced general anesthetic is the preferred method, because it allows for patient tolerance of either an open or laparoscopic approach. Furthermore, though most elective splenectomies have limited blood loss (less than 500 mL), there is the potential for sudden unexpected blood loss, which may require ongoing resuscitation. If not contraindicated, an epidural is often helpful in open splenectomy cases for both pain control and reduction of post-operative pulmonary complications.

What prophylactic antibiotics should be administered?

Cefazolin is the preferred prophylactic antibiotic for simple splenectomy. Please see above for patients either with a penicillin allergy or have more involved procedures.

What do I need to know about the surgical technique to optimize my anesthetic care?

As with any other laparoscopic case, it is important to decompress the stomach with an oral gastric tube prior to incision. Several trochars (approximately five) are inserted, typically with one enlarged to a hand port. The various ligaments are dissected out, usually with a harmonic scapel, and the hilum isolated. The short gastrics are taken down, followed by the lateral and superior attachments. Once devascularized, the spleen can be removed, either through the hand port or morcellated.

What can I do intraoperatively to assist the surgeon and optimize patient care?

As with any laparoscopic case, it is important to ensure adequate relaxation to optimize operating conditions. Cell saver is typically not need for this type of surgery.

What are the most common intraoperative complications and how can they be avoided/treated?

Prioritize them by urgency. For laproscopic cases, pneumoperitoneum can lead to difficult ventilation – either high peak pressures or hypercarbia. This needs to be followed closely and may necessitate conversion to an open splenectomy if unresolved. Different ventilation schemes can be attempted (i.e., pressure control ventilation with manipulation of I:E ratios). Also, hypotension may be the result of either CO2 embolus, patient positioning (in reverse trendelenberg), or unexpected bleeding from unvisualized vessels.

• Cardiac complications: Hypotension may develop post-operatively if there is ongoing unrecognized bleeding.

• Pulmonary: Common reported complications similar to other patients undergoing abdominal procedures (atelectasis 38%, pneumonia 9%, and pleural effusion 6%). A subphrenic abcess or unrecognized pancreatitis can also compromise pulmonary function.

• Neurologic: N/A

a. Neurologic:

Unique to procedure: N/A

b. If the patient is intubated, are there any special criteria for extubation?

After splenectomy secondary to trauma, it is important to ensure that all injuries have been assessed, vital signs are stable, normothermia is restored, there is resolution of muscle relaxation, and return of appropriate mental status prior to extubation. For elective laparoscopic splenectomies, follow standard extubation criteria, but watch for possible subcutaneous emphysema, which may require higher ventilation requirements until resolved.

c. Postoperative management

What analgesic modalities can I implement?

For open procedures, if appropriate, epidurals can be greatly beneficial for reduction in pulmonary complications and pain relief; otherwise, a PCA opioid can be utilized. For laparoscopic surgery, toradol can be helpful in reducing referred shoulder pain when not contraindicated.

What level bed acuity is appropriate?

Most patients should be able to be monitored on a regular ward without additional monitoring unless significant bleeding or resuscitation was required intraoperatively.

What are common postoperative complications, and ways to prevent and treat?

The most significant post-operative complication is atelectasis and adequate pain control. For laproscopic procedures, toradol may be helpful for shoulder pain. Early use of incentive spirometer and mobilization is helpful to minimize atelectasis, but full recover of the functional residual capacity may take up to two weeks.

What's the Evidence?

Doherty, Gerard. “Current Diagnosis & Treatment: Surgery”. 2010.

Jaffe, R. “Anesthesiologist's Manual of Surgical Procedures”. 2009.

Rigg, J. “Epidural anesthesia and analgesia and outcome of major surgery: a randomised trial”. The Lancet. vol. Volume 359. April 13, 2002. pp. 1276-1282.

Coignard-Biehler, H, Lanternier, F, Hot, A, Salmon, D, Berger, A, de Montalembert, M, Suarez, F, Launay, O, Lecuit, M, Lortholary, O. “Adherence to preventive measures after splenectomy in the hospital setting and in the community”. J Infect Public Health. vol. 4. 2011. pp. 187-94.

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