There is in this day and age almost never a valid excuse for performing an open splenectomy in a child as a planned procedure. The open incision is invariably large, painful, and potentially morbid, whereas the instrumentation and expertise to perform the procedure safely using the laparoscopic approach are widely available. The patient can be supine or slightly tilted with a bump. A line should be drawn where an open incision would be made should it become necessary to do so in a hurry. For reasons of exposure, postoperative comfort, and cosmesis, this incision should be transverse or oblique, rather than subcostal. Three or four ports are used, all 5 mm except for the umbilical port which should be a 10/12-mm port. For total splenectomy, I prefer to completely mobilize the spleen, leaving the hilum for last. The hilar vessels can be easily controlled with an endoscopic stapling device maneuvered through the umbilical incision, being careful not to transect the tail of the pancreas (which is actually generally well-tolerated). A 15-mm endo-bag device will fit through the periumbilical incision after removal of the port and slight enlargement by stretching with a large hemostat. A safe, effective, and inexpensive morcellator has yet to be developed; however morcellation by hand using curved sponge clamps and a large plastic Yankhauer suction tip works quite well.
Partial splenectomy can also be performed laparoscopically, but parents should be warned about the slightly higher risk of conversion to open. The upper-most short gastric vessels should be preserved until it is clear that suitable branches of the hilar vessels can been preserved. Division of the appropriate hilar vessels causes the spleen to demarcate. Transection of the splenic parenchyma is challenging and often rather daunting. The devascularized portion of the spleen is a reservoir for a large amount of blood and release of this blood while coming across the spleen can be difficult to distinguish from active bleeding. Also, although the harmonic scalpel is probably the best energy source to use to come across the spleen, it is not perfect, and adjuncts, such as clips, electrocautery, fibrin sealants, or stapling devices, are often needed. The argon-beam coagulator can be used on the raw surface of the cut spleen with good effect.
The clearest and perhaps most common indication for partial splenectomy is the splenic cyst. Some surgeons have advocated partial excision of the cyst, using the argon-beam coagulator to “destroy the remaining epithelium” on the back wall that remains. This is impossible, of course, especially since the epithelial surface of the splenic cyst is usually trabeculated. The recurrence rate for cysts managed in this fashion approaches 100%. Partial splenectomy for hematologic conditions makes sense and certainly should be studied in a formal way to be certain that the recurrence rate is low and that splenic function can indeed be adequately preserved.
There are sometimes requests for splenectomy for unusual indications. The wandering spleen syndrome is presumably due to intermittent volvulus of the spleen because of inadequate peritoneal attachments. The diagnosis is suggested in patients with intermittent abdominal pain or by imaging studies that reveal a spleen with an unusual lie or tilted axis of orientation. The diagnosis is confirmed at laparoscopy and best treated by creating a peritoneal pocket within which the spleen can be placed and secured. Rarely, the pediatric surgeon will be asked to remove a spleen simply because it is too big, due to a perceived risk of traumatic or “spontaneous” rupture. This is a difficult predicament as there are no accepted parameters whereby the risk of rupture can be predicted simply on the basis of size of the spleen. Unless the spleen is truly massive, reassurance and the use of a spleen guard are probably the best recommendations. Pediatric surgeons are still sometimes asked to remove the spleen in the child with portal hypertension and secondary hypersplenism. The preferred management of these children is treatment directed at the underlying cause, namely portosystemic shunt or liver transplantation. Finally, we are occasionally asked to biopsy the spleen, which is not as difficult or dangerous as it sounds. It can be done safely as a core-needle biopsy under image guidance and with surgery “on standby,” or laparoscopically with electrocautery or sutures used on the capsule to stop the bleeding after tru-cut needle biopsy.