SPLENECTOMY

Splenectomy patients can present in very different ways. If they have a torsion or an active bleed from a rupture or tumour, then they may present very flat, pale, and in shock. If the have a pre-planned surgery to remove a tumour that is not bleeding, then they may present as otherwise bright and alert. Depending on the situation, ensure that the patient is stabilised as much as possible prior to anaesthetic. Bloods including PCV should be taken pre-operatively and the patient should be started on fluid therapy before surgery begins.

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Ensure the patient is on a heat pad with blankets and is pre-oxygenated prior to intubation. If it is a cat, make sure that they are given a full 30-90 seconds between giving Intubeaze and intubating to avoid risk of trachaeal irritation. If they have an active bleed or torsion, be mindful of handling and the positions the patient is in whilst preparing for surgery too.

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If the patient is critical, the priority will be to get them into surgery as fast as possible to remove the spleen and secure and bleeding, fluids and stabilisation can be done whilst prepping the patient.

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Be mindful of the medications the patient recieves pre-anaesthetic as well. Medications such as acepromazine can cause splenomegaly and hypotension so should ideally be avoided in these cases.  

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Have the patient on their back for clipping - sometimes they need sandbags to keep them steady. I'd recommend placing a wedge under the chest to keep the thorax elevated and reduce any pressure on the lungs. Full visualisation is required in the surgery, especially if there are bleeds, so clip fur up to the 10th/11th rib and down to the very base of the pubis. The edges will need to be clipped far back too, to reduce risk of any fur entering the abdomen. Clip away the fur using size 40 blade clippers and clean the surgical site with your scrub of choice. Sometimes it is useful to have a dedicated vacuum to remove fur from the surgical site prior to scrubbing. 

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At this stage, if time and patient stability allows, it is recommended to place a urinary catheter and drain the bladder so that it isn't full whilst the surgeon is in the abdomen. For male dogs this procedure is straightforward enough, but this can prove more difficult in bitches. I will leave the urinary catheter in place throughout surgery and, for male dogs, secure it to the left thigh to keep it out of the way. (Often the incision will run along the right-hand side of the penis).

 

I recommend performing a local line block along the incision area at this stage using a 1-2mg/kg dose of bupivicaine (1mg/kg MAXIMUM for feline patients). Any bupivicaine left in the syringe can be kept for a splash block at the point of closing the surgical site.

 

Move the patient to the surgical table and postion on their back, keeping the wedge in place to keep the chest elevated. If you have use of a vacuum mat, then these can be great to keep patients warm, supported, and stable throughout the surgery. There can be a fair amount of heat during splenectomies due to the large clipped patch and the opened abdomen, so I would always recommend using active warming devices such as Bair Huggers to keep them warm. Wait until the patient is fully draped before turning on forced air warming devices. Then give another scrub and prep the area using a final cleaning stage e.g. ChloraPrep. I also like to place several incontinence sheets around the patient and the floor to help keep the theatre as clean and dry as possible - especially when it comes to lavaging the abdomen.

 

The surgeon can then perform the splenectomy. When setting up for surgery, make sure to get extra clamps as there are lots of vessels that will need ligating, and if you have access to one, make use of a vessel sealer to speed the surgery along. If you have abdominal retractors such as Balfours then I would have this ready too.

 

The spleen obviously contains a large volume of blood so if there is a rupture or bleed from a mass, then the patient can lose a large amount of blood very quickly. The same goes for when the surgeon is ligating vessels, bleeds may occur. Ensure that your patient is on IV fluids throughout the surgery (surgical maintenance rate is 5ml/kg/hr in canines and 3ml/kg/hr in felines) to help with blood pressure and have bolus rates prepared and written down in case of a bleed. Monitor gum colour carefully and pulse oximetry can be useful too. If there is severe blood loss, then a blood transfusion is likely warranted, either via packed red blood cell transfusion if you have a bag and have blood typed your patient, or by autotransfusion. 

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Ideally the patient will have recieved sufficient analgesia with their premedication as well as an adjuvant analgesia prior to surgery. However, abdominal surgery can prove more painful for some patients than others. Watch out for changes in heart rate, respiration rate, or blood pressure at this point. Paracetamol can be given to canine patients only if it hasn't been given already (at a dose of 10-20mg/kg slow IV) or, if very severe pain response is seen, a one off dose of ketamine can be used (0.5mg/kg IM or slow IV) or fentanyl (5μg/kg slow IV). Be mindful for signs of apnoea if giving ketamine or fentanyl. Fentanyl can also slow heart rate too so be aware of this if giving. Avoid NSAIDs until post-operative ideally as splenectomies can have sudden changes in blood pressure which could compromise renal function.

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During the surgery, handling of the spleen can cause heart arrythmias such as VPCs so consider lidocaine to reduce these if needed - a loading dose of 1-2mg/kg slow IV (10-15 mins) followed by CRI of 20-100ug/kg/min in canines only.

In feline patients, if ventricular arrythmias occur, then a maximum dose of 0.25mg/kg can be given slowly IV. 

AVOID CRI LIDOCAINE IN FELINES.

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When the spleen is due to be removed, especially in the case of large tumours, the lifting and removal can cause a sudden hypotension to occur. I'd recommend communicating with the surgeon and getting them to slowly remove the mass to allow the patient time to adjust to sudden reperfusion of any organs or vessels that may have been occluded under the tumour/spleen.

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In the case of splenic tumours such as haemangiosarcomas, it can be worthwhile flushing the abdomen to remove as much contaminant as possible. If doing so, then it is recommended to flush through with up to 200ml/kg of sterile saline. Ensure any flush is warmed before using it (I like to have a bucket of warm water that the irrigating fluids can sit in to stay warm during surgery). 

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Remember to lubricate the eyes during surgery and on recovery to reduce risks of corneal ulcers forming and keep the patient wrapped up warm. 

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In recovery, monitor ECG traces closely to watch for any arrythmias and monitor the patient's mucous membrane colour and blood pressure. Any sudden changes should be reported. If possible, AFAST scans should be done to check for any bleeding, and repeat PCV checks should be done to assess anaemia, especially if there was a bleed during surgery and if transfusions occurred.