A splenectomy is the surgical removal of the spleen. This is achieved through a midline abdominal or left subcostal incision or laparoscopically. The spleen is mobilized by dividing the lateral peritoneal attachments while the spleen is retracted medially. The splenic artery is ligated, the splenic vein is tied; the ligaments supporting the spleen are detached and the spleen removed. The spleen can be removed in pieces or as a whole.

Indications: trauma with uncontrolled bleeding; hematologic disorders, tumors, cysts, idiopathic thrombocytopenic purpura, hemolytic anemia, thrombosis of the splenic blood vessels, an accessory spleen is possible and is searched for, splenomegaly (spleen greater than 20 centimeters longitudinally), and staging of Hodgkin’s and non- Hodgkin’s disease

Splenectomy
Anesthesia type

General

Airway

ETT

Lines and access

2 large bore PIVs; +/- arterial line

Monitors

Standard; 5-lead ECG

Primary anesthetic considerations
Preoperative
Intraoperative

Consider RSI if pt has abdominal distention

Postoperative

PONV

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Overview

Preoperative management

Patient evaluation

System Considerations
Airway
Neurologic
Cardiovascular Patients with systemic disease requiring splenectomy may be chronically ill and have ↓ cardiovascular reserve
Pulmonary Patients who have splenomegaly may have a degree of left lower lobe atelectasis and compromised ventilation 2° intraabdominal pathology: ↓ FRC → ↑ A-a gradi- ent + ↓ PaO2
Gastrointestinal
Hematologic Cytopenia is very common → Preop replacement of platelets should be considered in patients with severe thrombocytopenia. Myelosuppression should be anticipated in all patients receiving active chemotherapy.
Renal
Endocrine
Other

Labs and studies

  • CXR, EKG may all be needed
  • Lab tests should include a CBC, electrolytes, PT/PTT/INR, platelet count, BUN and creatinine, blood glucose, type and screen
  • Check coagulation studies and platelet levels if patient is taking anticoagulants (i.e.: Plavix) before planning a spinal for neuraxial anesthesia

Operating room setup

Patient preparation and premedication

Usually type and screen; prepare 2 units PRBCs

Regional and neuraxial techniques

Epidural for post op pain management (not commonly used)

Intraoperative management

Monitoring and access

Induction and airway management

Positioning

Supine

Maintenance and surgical considerations

Emergence

Postoperative management

Disposition

Pain management

Potential complications

Procedure variants

Open Variant 2
Unique considerations
Position Supine
Surgical time 2-4 hrs
EBL 50-100 ml
Postoperative disposition
Pain management
Potential complications

References

Jaffe, R. A., Schmiesing, C., & Golianu, B. (2009). Anesthesiologist's manual of surgical procedures (4th ed.). Philadelphia: Lippincott Williams & Wilkins.

Macksey, Lynn Fitzgerald. (2012). Surgical procedures and anesthetic implications : a handbook for nurse anesthesia practice. Sudbury, MA :Jones & Bartlett Learning