Special Surgery 31. Surgical Aspects of the Spleen. Surgical Methods for Retroperitoneal Diseases

I. Spleen: Indications and Types of Splenectomy

Key Surgical Function

• Spleen: lymphoid organ in left upper quadrant
• Functions: blood filtration, platelet/RBC sequestration, immune defense against encapsulated bacteria
• Loss of spleen → lifelong risk of overwhelming post-splenectomy infection (OPSI)

Indications for Splenectomy

1. Trauma

• Most common surgical indication
• Especially grade IV-V splenic injury with bleeding
• Unstable patient → emergency operation/splenectomy
• Stable selected patient → non-operative management ± splenic artery embolization

2. Hematologic disorders

• Immune thrombocytopenic purpura (ITP), refractory/selected cases
• Hereditary spherocytosis
• Thalassemia major with hypersplenism/transfusion burden
• Autoimmune hemolytic anemia, selected refractory cases

3. Other indications

• Hypersplenism with cytopenias
• Splenic tumor or cyst, rare
• Splenic abscess not controlled by antibiotics/drainage
• Symptomatic infarct/complication, rare
• Selected portal hypertension cases: e.g. sinistral portal hypertension from splenic vein thrombosis

Types of Splenectomy

• Total splenectomy: complete removal of spleen
• Partial splenectomy: preserves splenic tissue → maintains some immune function
• Laparoscopic splenectomy: standard for many elective cases
• Open splenectomy: trauma, hemodynamic instability, massive splenomegaly, complex malignancy/adhesions

II. Perioperative Care and Post-Splenectomy Complications

Preoperative Considerations

• Vaccination against encapsulated organisms:

• Streptococcus pneumoniae
• Haemophilus influenzae type b
• Neisseria meningitidis
• Give ideally at least 2 weeks before elective splenectomy
• Emergency splenectomy → vaccinate postoperatively when stable

• Blood typing and crossmatch → bleeding risk
• Correct coagulopathy if possible
• Review anticoagulants/antiplatelets
• Imaging: US/CT to assess spleen size, lesion, bleeding, accessory spleens
• Hematology input for ITP/hemolytic disease
• Patient education: fever after splenectomy = urgent medical review

Complications

• Bleeding: splenic hilum/short gastric vessels → transfusion or reoperation may be needed
• Pancreatic tail injury → pancreatic fistula
• Subphrenic abscess, wound infection, left pleural effusion/atelectasis
• Venous thrombosis: portal/splenic/mesenteric venous thrombosis
• Reactive thrombocytosis → aspirin/anticoagulation may be needed depending on platelet count and risk
• Accessory spleen → persistent/recurrent hematologic disease, e.g. ITP

OPSI and Long-Term Care

• OPSI: overwhelming post-splenectomy infection
• Typical pathogens: pneumococcus, meningococcus, Hib
• Risk: highest in children and early after splenectomy, but lifelong risk exists
• Lifelong vaccination updates/boosters according to local schedule
• Prompt antibiotics for fever or suspected infection
• Medical alert card/bracelet for asplenia
• Long-term follow-up: platelet count, thrombotic risk, hematologic outcome

III. Retroperitoneal Space and Diseases Requiring Surgery

Retroperitoneal Space

• Retroperitoneum: space behind parietal peritoneum
• Contains:

• Kidneys, ureters, adrenal glands
• Pancreas part, duodenum parts II-IV, ascending/descending colon
• Aorta, IVC, iliac vessels
• Lymph nodes, lymphatics, nerves, retroperitoneal fat

• Clinical point: large hidden space → tumors/hematomas/abscesses may become large before symptoms

Diseases Requiring Surgery / Intervention

1. Tumors

• Retroperitoneal sarcoma: liposarcoma, leiomyosarcoma
• Adrenal tumors: pheochromocytoma, adenoma, carcinoma
• Pancreatic tail lesions
• Lymphadenopathy → diagnostic biopsy or therapeutic dissection

2. Inflammatory / infectious disease

• Retroperitoneal fibrosis → ureteric obstruction
• Retroperitoneal abscess / psoas abscess
• Infected pancreatic necrosis extending retroperitoneally

3. Vascular disease and trauma

• Abdominal aortic aneurysm (AAA)
• Major vessel injury / retroperitoneal hemorrhage
• Trauma to kidney, pancreas, duodenum, colon or major vessels

Diagnostics and Planning

• Contrast CT abdomen/pelvis: main mapping test
• MRI: soft-tissue/pelvic tumors and neurovascular involvement
• CTA: aneurysm, bleeding, vascular invasion
• Percutaneous core biopsy: suspected retroperitoneal sarcoma before treatment planning when appropriate
• Hormonal workup before adrenal surgery, especially pheochromocytoma
• MDT planning: surgery, vascular/urology/HPB, radiology, oncology, pathology

IV. Surgical / Interventional Methods for Retroperitoneal Diseases

1. Open Retroperitoneal Surgery

• Traditional approach with large flank, midline or abdominal incision
• Used for large tumors, complex vascular repair, trauma, uncontrolled bleeding
• Allows wide exposure and multiorgan resection if needed

2. Laparoscopic / Robotic Surgery

• Minimally invasive approach: transperitoneal or retroperitoneoscopic
• Common for adrenalectomy
• Useful for selected nephrectomy, lymph node biopsy/dissection and small benign retroperitoneal tumors
• Advantages: less pain, shorter stay, faster recovery in selected cases
• Not ideal for very large invasive retroperitoneal sarcoma needing intact en bloc resection

3. Endovascular and Image-Guided Interventions

• EVAR: endovascular aneurysm repair for suitable AAA
• Embolization/stent graft: selected vascular bleeding or injury
• CT-guided drainage: retroperitoneal abscess
• Percutaneous biopsy: retroperitoneal mass diagnosis
• Nephrostomy/ureteric stent: obstructive uropathy from fibrosis or tumor compression

Principles of Retroperitoneal Tumor Surgery

• Preoperative CT/MRI planning is essential
• Suspected sarcoma → sarcoma MDT / high-volume center
• Goal: wide complete en bloc excision with clear/macroscopically complete margins
• Often requires multiorgan resection because tumors present late and large
• Avoid tumor rupture and piecemeal excision
• Lymph node dissection: diagnostic/therapeutic when indicated, not routine for most sarcomas