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

I. Spleen: Anatomy, Function and Indications for Surgery

Surgical Anatomy

Spleen = intraperitoneal lymphoid organ in left upper quadrant
Relations:

Diaphragm and ribs IX-XI laterally/posteriorly
Stomach medially via gastrosplenic ligament
Tail of pancreas at splenic hilum
Splenic flexure inferiorly
Left kidney/adrenal posteriorly

Ligaments:

Gastrosplenic ligament → short gastric vessels
Splenorenal ligament → splenic vessels + pancreatic tail nearby
Splenocolic and phrenicosplenic attachments

Blood supply:

Splenic artery from celiac trunk
Splenic vein joins SMV → portal vein
Segmental arterial branches allow partial splenectomy in selected cases

Functions Relevant to Surgery

Filters aged/abnormal RBCs and platelets
Immune response against encapsulated bacteria
IgM memory B-cell function
Reservoir/destruction site for platelets
Loss of spleen → lifelong risk of overwhelming post-splenectomy infection (OPSI)

Indications for Splenic Surgery

Trauma

Blunt abdominal trauma most common acute surgical context
Unstable patient with splenic bleeding → emergency laparotomy/splenectomy or splenic salvage if possible
Stable high-grade injury → non-operative management with monitoring and possible splenic artery embolization

Hematologic diseases

Immune thrombocytopenia (ITP) refractory to medical therapy
Hereditary spherocytosis
Autoimmune hemolytic anemia in selected refractory cases
Thalassemia major/intermedia in selected cases with hypersplenism/transfusion burden

Hypersplenism

Splenomegaly + cytopenias + compensatory bone marrow response
May cause anemia, leukopenia, thrombocytopenia

Focal splenic pathology

Splenic cyst: large/symptomatic or uncertain diagnosis
Splenic tumor: rare; lymphoma/metastasis/vascular tumors
Splenic abscess not controlled by antibiotics/drainage
Symptomatic infarct/complication rarely

Portal-hypertension-related selected cases

Sinistral/left-sided portal hypertension from splenic vein thrombosis
Gastric varices due to splenic vein obstruction: splenectomy can be definitive in selected cases
General portal hypertension is not a routine indication for splenectomy

Contraindications / Cautions

Elective splenectomy should be avoided if medical treatment is adequate
Massive splenomegaly increases bleeding and conversion risk
Severe portal hypertension/cirrhosis → high bleeding risk
Children: preserve splenic tissue whenever possible because infection risk is higher

II. Splenectomy, Perioperative Care and Complications

Types of Splenic Surgery

Total splenectomy

Complete removal of spleen
Used for trauma with uncontrolled bleeding, many hematologic indications, large tumors or abscess

Partial splenectomy

Preserves splenic tissue and immune function
Possible because spleen has segmental vascular supply
Used for selected polar lesions/cysts, children, benign focal disease

Splenic preservation / non-operative trauma management

Observation, serial vitals and hemoglobin
CT grading and follow-up imaging in selected high-grade cases
Splenic artery embolization for stable patients with contrast blush/vascular injury or selected high-grade injury

Open splenectomy

Trauma, hemodynamic instability
Massive splenomegaly
Complex adhesions or malignancy
Allows rapid vascular control and inspection of abdomen

Laparoscopic splenectomy

Standard for many elective benign hematologic diseases
Less pain, shorter stay, faster recovery
Needs careful hilar control and pancreatic tail protection
Conversion if uncontrolled bleeding, massive spleen, dense adhesions

Preoperative Considerations

Vaccination against encapsulated organisms:

Streptococcus pneumoniae: pneumococcal vaccination according to current schedule
Neisseria meningitidis: MenACWY + MenB with boosters
Haemophilus influenzae type b: Hib if not previously vaccinated / indicated
Give ideally at least 14 days before elective splenectomy
If emergency splenectomy → vaccinate after operation when clinically stable

Blood type and crossmatch because bleeding risk can be high
Correct coagulopathy if possible
Review anticoagulants/antiplatelets
Treat active infection before elective operation if possible
Imaging: US/CT to assess spleen size, focal lesion, vessels, accessory spleens
Hematology consultation for ITP/hemolytic disease
Patient education: fever after splenectomy is urgent

Operative Steps: Laparoscopic Splenectomy

Patient right lateral/semilateral position
Port placement and abdominal inspection
Divide splenocolic and inferior attachments
Open gastrosplenic ligament and control short gastric vessels
Mobilize spleen medially, protect pancreatic tail
Control splenic hilum with stapler/clips/energy device
Remove spleen in retrieval bag, morcellation only if benign disease
Check hemostasis and pancreatic tail region

Complications of Splenic Surgery

Intraoperative:

Bleeding from splenic hilum/short gastric vessels
Pancreatic tail injury → pancreatic fistula
Gastric/colon/diaphragm injury

Early postoperative:

Hemorrhage
Subphrenic abscess
Atelectasis/left pleural effusion
Wound infection
Portal/splenic/mesenteric venous thrombosis
Reactive thrombocytosis; aspirin/anticoagulation considered according to platelet count and risk

Late:

OPSI: overwhelming sepsis, classically pneumococcus/meningococcus/Hib
Lifelong infection risk, highest in children and early years after splenectomy
Accessory spleen causing recurrence of hematologic disease, e.g. ITP

Long-Term Post-Splenectomy Care

Lifelong vaccination updates/boosters according to local schedule
Medical alert card/bracelet for asplenia
Urgent medical review for fever or rigors
Early antibiotics for suspected infection; some high-risk patients need standby or prophylactic antibiotics depending on local practice
Malaria/babesia/capnocytophaga risk counseling for travel and animal bites
Follow platelet count after surgery; treat marked thrombocytosis/thrombotic risk individually

III. Retroperitoneal Space and Diseases Requiring Surgery

Retroperitoneal Anatomy

Retroperitoneum = space behind parietal peritoneum and anterior to posterior abdominal wall
Contains:

Kidneys, ureters, adrenal glands
Pancreas except tail, duodenum parts II-IV, ascending/descending colon
Aorta, IVC, iliac vessels
Lymph nodes and lymphatic channels
Sympathetic chain, nerves
Retroperitoneal fat/fascia

Clinical feature: large potential space → tumors/hematomas/abscesses can become large before symptoms

Common Retroperitoneal Diseases

Retroperitoneal tumors

Sarcoma: liposarcoma, leiomyosarcoma, undifferentiated pleomorphic sarcoma
Germ cell tumor metastases
Lymphoma/lymphadenopathy
Neurogenic tumors

Endocrine/urologic disease

Adrenal adenoma, pheochromocytoma, adrenocortical carcinoma
Renal tumors/trauma
Ureteric obstruction/stricture

Inflammatory/infectious disease

Retroperitoneal abscess
Infected pancreatic necrosis extending retroperitoneally
Psoas abscess
Retroperitoneal fibrosis causing ureteric obstruction

Vascular disease

Abdominal aortic aneurysm (AAA)
Iliac aneurysm
Retroperitoneal hemorrhage
Major vessel trauma

Trauma

Kidney, duodenum, pancreas, colon, major vessels
Retroperitoneal hematoma may hide major bleeding

Clinical Features

Often nonspecific and late
Abdominal/flank/back pain
Palpable abdominal mass
Weight loss, early satiety
Venous compression → leg edema, DVT
Ureter compression → hydronephrosis, renal dysfunction
Nerve compression → radicular pain/weakness
Fever/sepsis in abscess
Shock in bleeding/ruptured AAA/major vascular trauma

Diagnostics and Preoperative Planning

Contrast-enhanced CT abdomen/pelvis = main mapping test
MRI useful for pelvic tumors, neurovascular involvement and soft tissue characterization
CTA for aneurysm/vascular invasion/bleeding
Chest CT for sarcoma staging because lung metastases are important
Core needle biopsy before retroperitoneal sarcoma treatment unless sarcoma MDT says otherwise
Avoid unplanned excision or tumor rupture
Assess renal function and contralateral kidney if nephrectomy possible
Hormonal workup before adrenal surgery, especially pheochromocytoma
MDT planning: surgical oncology, vascular, urology, HPB, radiology, oncology, pathology

IV. Surgical Methods for Retroperitoneal Diseases

1. Open Retroperitoneal Surgery

Traditional and still essential for large/complex disease
Incisions:

Midline laparotomy: wide access to abdomen/retroperitoneum
Transverse/chevron incision for upper abdominal retroperitoneal tumors
Flank/lumbotomy incision for kidney/adrenal/lumbar retroperitoneal access
Thoracoabdominal approach for very large upper retroperitoneal lesions rarely

Used for:

Large retroperitoneal sarcoma
Multivisceral resection
Open AAA repair
Major trauma and uncontrolled bleeding
Complex infected necrosis/abscess not treatable percutaneously

2. Laparoscopic / Robotic Retroperitoneal Surgery

Minimally invasive access, transperitoneal or retroperitoneoscopic
Advantages: less pain, shorter stay, faster recovery in selected cases
Used for:

Adrenalectomy
Nephrectomy / partial nephrectomy in selected renal disease
Retroperitoneal lymph node biopsy/dissection in selected cases
Selected small benign retroperitoneal tumors
Distal pancreatectomy for pancreatic body/tail lesions where appropriate

Not ideal for very large invasive sarcoma where intact en bloc resection is needed

3. Endovascular and Image-Guided Interventions

Endovascular aneurysm repair (EVAR) for suitable AAA anatomy
Stent grafting or embolization for selected vascular injury/bleeding
CT- or US-guided drainage of retroperitoneal abscess
Percutaneous biopsy of retroperitoneal mass
Percutaneous nephrostomy/ureteric stent for obstructive uropathy
Often bridge to definitive surgery or definitive treatment in high-risk patients

Principles of Retroperitoneal Tumor/Sarcoma Surgery

Refer suspected retroperitoneal sarcoma to high-volume sarcoma center
Preoperative CT/MRI mapping is essential
Biopsy before treatment planning in most suspected sarcomas
Goal: complete macroscopic en bloc resection
Avoid tumor rupture and piecemeal excision
Resect adherent/involved organs en bloc if needed:

Colon
Kidney
Pancreatic tail/spleen
Psoas/fascia
Vascular reconstruction if major vessels involved and resection justified

Lymph node dissection is not routine for most sarcomas, but done for suspicious nodes or other tumor types
Neoadjuvant radiotherapy/chemotherapy considered only by MDT in selected histology/resectability settings
Grossly incomplete resection is usually avoided unless palliative intent is clear

Treatment by Disease Type

Disease	Main surgical/interventional method
Retroperitoneal sarcoma	En bloc complete resection, often multivisceral, in sarcoma center
Adrenal tumor	Laparoscopic adrenalectomy if benign/small; open en bloc surgery for suspected carcinoma/invasion
Pheochromocytoma	Alpha-blockade first, then adrenalectomy with careful hemodynamic control
Retroperitoneal fibrosis	Medical therapy often first; ureteric stent/nephrostomy; ureterolysis if obstruction persists
AAA	EVAR if anatomy suitable; open repair for unsuitable anatomy/rupture depending on context
Abscess	Antibiotics + CT-guided drainage; open/laparoscopic drainage if failed or source control needed
Trauma	Observation/embolization/stenting in stable selected cases; laparotomy for instability/peritonitis/major bleeding

Exam-Focused Summary

Spleen surgery is mainly trauma, hematologic disease, hypersplenism, focal lesions and selected sinistral portal hypertension
Stable splenic trauma is treated organ-sparing when possible; unstable bleeding → emergency operation
Elective splenectomy requires pneumococcal, meningococcal and Hib vaccination ideally at least 14 days preoperatively
After splenectomy: lifelong OPSI risk, fever = emergency
Retroperitoneum contains kidneys/adrenals/pancreas part/aorta/IVC/lymph nodes; disease presents late because space is large
Retroperitoneal sarcoma surgery = planned en bloc resection with clear/macroscopically complete margins, often multivisceral, in MDT sarcoma center
Retroperitoneal abscess/vascular disease increasingly treated with image-guided/endovascular methods when appropriate

Exam focus: For spleen, always mention immune function, vaccination and OPSI. For retroperitoneal disease, always mention anatomy, CT/MRI planning, biopsy for suspected sarcoma, MDT decision-making and en bloc surgery without tumor rupture.