Laparoscopic splenectomy
Indications
A splenectomy may be indicated in children for a variety of disorders. The most common diseases that are improved by splenectomy are those in which the spleen consumes abnormal red blood cells or platelets. When red blood cells are destroyed anemia results. When platelets are consumed, normal blood clotting is impaired and easy or spontaneous bleeding may occur.
Hereditary spherocytosis is a condition in which red blood cells are abnormally spherical instead of disc-like and therefore recognized by the spleen as abnormal and destroyed. Splenectomy is usually indicated after five years of age. Beta-thalassemia is another congenital disorder of the red blood cells in which splenectomy is often helpful. Occasionally, a splenectomy is necessary in sickle cell anemia, although the spleen usually disappears by itself in this disease.
Idiopathic thrombocytopenic purpura (ITP) is a disease in which the antibodies are formed against platelets making the platelets recognized as abnormal by the spleen and destroyed. Most cases resolve on their own or with medications, but in some cases these measures are ineffective and splenectomy is required to prevent life-threatening bleeding with normal childhood activities.
Pediatric hematologists treat these disorders until they believe a splenectomy would be beneficial. Children are referred to us at this time.
Preparation for the operation
The major risk of splenectomy is overwhelming infection from a group of bacteria that are called "encapsulated" and are usually destroyed by the spleen. These include the pneumococcus, which causes pneumonia. In children under two years of age, the spleen is the primary defender against these organisms and splenectomy is particularly risky. In children over about five years of age the risk of overwhelming infection from these organisms after splenectomy is less than 1 in 1000 over a lifetime. But, to minimize this risk, we administer a vaccine for pneumococcus prior to the operation. A vaccination for H. influenza, another of the "encapsulated" bacteria, is part of routine school shots.
Children with significant anemia will undergo a blood transfusion prior to the operation to increase the child's safety. When a child has a low platelet count, platelets will be made available for administration during the operation, but the transfusion of platelets in advance is not helpful as they are rapidly consumed by the spleen.
The operation
When splenectomy is performed for "elective" indications like those discussed above it can usually be done using a laparoscopic, minimally-invasive technique. In this way, a large incision through the abdominal wall muscles is avoided and postoperative recovery is accelerated. However, in some cases the spleen may not be amenable to laparoscopic removal. This may be because the spleen is too large or because previous operations and scar formation make laparoscopy too difficult. Inability to remove the spleen using the laparoscope may be determined prior to the operation or during the course of an attempted laparoscopic splenectomy.
During laparoscopic splenectomy, four "stab" incisions between 1/4 and 1/2 inch in length are made in the abdominal wall. The spleen is cut away from its attachments to the diaphragm, colon, and stomach, and the splenic artery and vein are cut using a special stapling device. Since the spleen may be as much as 10 inches long, it obviously can't be removed through a 1/2 inch hole. Instead, the spleen is placed within a strong plastic bag inside the abdomen and ground up. It is then pulled out in small pieces. Absorbable sutures are used to close the abdomen.
Children usually resume eating on the day of the operation and most go home within two to three days.
During the operation, parents are asked to wait in the Children's Hospital waiting area located on the lobby level. After the operation, children are recovered in the post anesthesia care unit for one to two hours before they are returned to a pediatric unit.
The hospital stay
Nurses will make every effort to keep your child comfortable and pain-free. The pediatric surgery team will make daily rounds as a group. We are available to answer any questions you may have concerning the progress of your child.
Pain control
Pain medication will initially be administered through the IV which was started prior to the operation. When your child is eating well, pain medication will be given by mouth.
Tubes
- IV tubes: All children return from the operating room with attached IV (intravenous) tubing. This tubing connects to the child's circulation by a catheter inserted into a vein. The IV allows delivery of routine or emergency medications during anesthesia, and it also provides a way to deliver fluids, antibiotics and pain medication after the operation.
- Nasogastric tubes are rarely required, especially if the spleen was removed laparoscopically, except when there is relentless vomiting.
Diet
Children are usually able to drink on the evening of the operation, although it may take 12-24 hours for the stomach to return to normal function.
Post-hospital care
Wound care
The stab wounds are closed with absorbable sutures and will have clear, watertight dressings covering them. Your child's surgeon will ask that the dressings remain in place for at least two days and that your child stay out of the bathtub for two days.
Always wash your hands before touching or cleaning the incision areas. Some blood staining of the paper tapes on the incision is common. If the blood is dry and not spreading, the staining is not a problem. If the blood seems fresh, the amount is increasing, or if the paper tape is blood soaked and partially floating above the skin, apply gentle pressure with a clean washcloth for five to six minutes. Then, contact the pediatric surgery resident on call (909) 558-1000. The problem is usually minor; however, the surgeon needs to know about it.
Activity
After laparoscopic splenectomy, children may usually return to school within less than a week of discharge from the hospital, although they may find that they tire quickly. Children may resume their usual physical activities as soon as they feel ready--there are no activity constraints.
Antibiotics
Despite the fact that we administer a vaccination against the pneumococcus bacteria, we still ask children to take daily oral penicillin to further reduce the risk of infection after a splenectomy. This is continued throughout the childhood and adolescent period.
When to call your child's surgeon
- Fever above 101 degrees Fahrenheit that is not reduced with Tylenol (mild fever is common)
- After the immediate postoperative period, children should be evaluated by their pediatrician for any illness that produces a fever to assure that it is not caused by pneumococcus
- Persistent vomiting
- Difficulty breathing, with or without a Corey cough
- Active bleeding from the incisions
- Redness, swelling, drainage of fluid or persistent pain in the incision
Follow-up
A clinic appointment needs to be scheduled one to two weeks after the operation. Please call (909) 558-4848 to schedule this appointment.
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Revised March 2, 2004
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