Laparoscopic Splenectomy

Anesthesia Implications

Position: Supine, airplaned right, arms at side on armboards
Time: 1-2 hours (average)
Blood Loss: Moderate (50 – 200 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Yes
Blocks: Quadratus Lumborum, TAP

Immunizations – For non-emergent cases, make sure patient has had vaccinations for streptococcus pneumonia, haemophilus influenza type B, and meningococcus infections 2 weeks prior to surgery.

Pulmonary function – watch for left lower lobe atelectasis if the patient has splenomegaly or postoperatively if there will only be a partial splenectomy.

Immune thrombocytopenic purpura (ITP) – If patient has ITP with a low platelet count, do not infuse platelets until the spleen has been removed from the blood circulation (splenic artery and vein have been ligated). Otherwise the spleen will consume all the platelets before circulating in the body.

Arterial Line – If the case is NOT emergent, you probably do not need an A-line, unless there are high concerns for hemodynamic stability (eg. bleeding, heart conditions, etc).

High blood loss risk – Though these cases do not typically result in high blood loss, there is a high risk. Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available. A cell saver may be employed if there is increased bleeding.

Chemotherapy Patients – It’s relatively common to have patients that are on chemotherapy drugs. Bleomycin, Methotrexate, and cytarabine can cause pulmonary fibrosis. Doxorubicin can cause pleural effusion, CHF, or cardiotoxicity (obtain an ECHO to assess heart function in these patients).

Laparoscopic cases (general considerations): The patient’s peritoneum is insufflated (which is called a pneumoperitoneum), and instrumentation will be inserted into the abdomen. General anesthesia, ETT tube, and paralytics are necessary. Some of the procedures are rather short, so make sure the timing is right to reverse the paralytic. The pressure in peritoneum affects the organs of that space. Anything more than 10 mmHg will begin to alter hemodynamics. Cardiac output is decreased and SVR is increased. Peak inspiratory pressures rise. Renal vessels will be compressed, which reduces flow to the kidneys, and activates the renin angiotensin aldosterone system (RAAS). Reduced blood to the kidney means reduced urine output. Peak inspiratory and plateau pressures will also increase. The gas used to insufflate the peritoneum is CO2 – so, as you might guess, hypercarbia can develop – and with it, acidosis. You’ll see this sometimes reflected in the end-tidal CO2. This is all adding to the stress response we try to avoid in anesthesia.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.

Typical indications for a splenectomy include leukemia (Hodgkins, non-hodgkins), Idiopathic Thrombocytopenia purpura (ITP), tumors, and cysts.

Emergent – typically due to trauma/bleeding, usually will be a midline incision for quick access to the spleen.

Non-emergent/elective – usually laparoscopic, sometimes open if spleen is enlarged.