Splenectomy and Spleen Removal: The Role of the Spleen, Asplenia, and Protection Against Infection — Important Information About Spleen Removal

The spleen is an organ located in the upper left abdomen. With an average size of 4x7x11 cm, it weighs about 200 g. It is part of the hematological-lymphatic system.

The spleen has two main functions:

• Removing old red blood cells and platelets (sequestration),
• playing a crucial role in the function of the immune system.

In rare cases, so-called accessory spleens may be present. These are small clusters of spleen tissue that develop separately from the spleen during embryonic development. Knowledge of such abnormalities is very important for further surgical planning to avoid complications and recurrences.

Malignant diseases (cancer) can develop directly in the spleen (primary tumor). However, a primary spleen tumor is rare. More commonly, the spleen is secondarily affected by cancer in other organ systems, such as in cases of blood cancer or metastases. Metastases are cancer cells that spread from a tumor in one organ to another—for example, via the bloodstream—and form new tumors. In ovarian cancer, for example, cancer cells often reach the spleen and form a secondary tumor there.

In most cases, a splenectomy is performed to treat

• benign conditions (e.g., cysts),
• immunological disorders (Werlhof’s disease), and
• traumatic spleen injuries

.

Less commonly, a malignant condition is the reason for a splenectomy. In cases of hematologic malignancies, splenectomy may be necessary to treat spleen-related symptoms. These symptoms include, for example, anemia or functional hypersplenism (overactive spleen) with consequent loss of

• red blood cells,
• platelets, and
• leukocytes.

A splenectomy may also be necessary in cases of metastases. In such cases, the goal is to surgically remove as much tumor tissue as possible from the body before chemotherapy kills any remaining cancer cells.

A complete splenectomy is not always necessary. In some cases, a partial removal is sufficient to achieve the surgical goal.

A splenectomy can generally be performed in two ways:

• minimally invasive (so-called “keyhole surgery,” laparoscopy)
• open surgery via an incision in the abdomen or flank (“conventional surgery”)

In the minimally invasive surgical technique, the abdominal cavity is first filled with harmless CO2 gas. This lifts the abdominal wall. The surgeon then makes four to five additional incisions into the abdominal cavity. Through these incisions, which are 0.5 to 1.5 cm in diameter, trocars are inserted into the abdominal cavity. A trocar is a type of metal sheath through which instruments and a camera connected to a light source are guided to the surgical site.

This camera allows the entire abdominal cavity to be viewed by transmitting the images to large monitors in the operating room.

The advantage of this minimally invasive method is that it does not require a large abdominal incision. For the patient, this generally means

• a lower risk of complications,
• faster healing, and
• less scarring.

This minimally invasive splenectomy is being used more and more frequently due to its many advantages.

Every surgery carries a risk of complications. However, this risk is reduced through careful preoperative preparation of patients as well as advances in surgical techniques and instruments. For example, the rate of wound infections and incisional hernias has decreased significantly due to the use of minimally invasive methods.

Since the spleen is a well-perfused organ, there is always an increased risk of bleeding during and after surgery. Injury to neighboring organs, such as the intestine, is also a potential complication.

A specific potential consequence of splenectomy is what is known as post-splenectomy syndrome (“OPSI” = Overwhelming Post-Splenectomy Infection). This severe condition can occur in up to 5% of patients following a splenectomy. It is caused by an isolated dysfunction of specific phagocytes (macrophages). The result is an impaired immune response to encapsulated bacteria, such as

• Streptococcus pneumoniae (pneumococci),
• Haemophilus influenzae type B, and
• Neisseria meningitidis.

Pneumococci are the most common cause of OPSI. Children are particularly at risk. Therefore, vaccination against the most common encapsulated bacteria is recommended prior to splenectomy. If a patient has accessory spleens, the underlying disease may recur after splenectomy. This is considered a late complication.

The focus of routine postoperative inpatient monitoring is particularly on possible

• postoperative bleeding,
• wound healing complications, and
• the risks of infection already described.

As part of so-called “fast-track” surgery, which aims to help patients return to their daily lives quickly, doctors must

• provide adequate pain management,
• early mobilization of patients, and
• a rapid return to a normal diet

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Spleen surgery has undergone fundamental changes, particularly due to the use of minimally invasive techniques. The size of the spleen, which was often a limiting factor in the past, no longer stands in the way of safe splenectomy—including partial splenectomy—thanks to advances in technology (e.g., ultrasonic cutting devices).