Why is left lower-lobe atelectasis the most common post-splenectomy complication and what is a prehab/ERAS-style prevention protocol?

Left Lower-Lobe Atelectasis After Splenectomy: Causes and Prevention Protocol

Left lower-lobe atelectasis is the most common post-splenectomy complication due to the anatomical proximity of the left lower lobe to the surgical site, diaphragmatic dysfunction, and pain-induced hypoventilation, requiring a comprehensive ERAS protocol including multimodal analgesia, early mobilization, and structured respiratory therapy to prevent it.

Why Left Lower-Lobe Atelectasis Occurs After Splenectomy

• The spleen's anatomical location adjacent to the left lower lobe of the lung creates direct mechanical effects on pulmonary function during and after surgery 1
• Post-surgical pain leads to shallow breathing and reduced deep inspiration, particularly affecting the left lower lobe due to splinting (guarding against pain) 2
• Diaphragmatic dysfunction occurs following upper abdominal surgery, with the left hemidiaphragm being particularly affected after splenectomy 1
• General anesthesia causes decreased functional residual capacity and promotes airway closure, especially in dependent lung regions 3
• Surgical manipulation and inflammation in the left upper quadrant directly impacts adjacent pulmonary tissue 4

Comprehensive ERAS-Style Prevention Protocol

Preoperative Phase

• Preoperative education and counseling:

  • Teach proper deep breathing techniques, incentive spirometry use, and early mobilization expectations 3
  • Smoking cessation at least 4 weeks before surgery to improve pulmonary function 3
  • Baseline pulmonary function assessment for high-risk patients 3

• Preoperative vaccination:

  • Administer pneumococcal, meningococcal, and H. influenzae vaccines at least 4 weeks before elective splenectomy 3
  • This not only prevents post-splenectomy infections but also reduces risk of post-operative pneumonia 3

Intraoperative Phase

• Anesthetic management:

  • Use of thoracic epidural anesthesia for open procedures to attenuate stress response and provide superior postoperative pain control 3
  • If epidural contraindicated, consider intravenous lidocaine (1.5 mg/kg at induction followed by 2 mg/kg/h infusion) for its anti-inflammatory and opioid-sparing properties 3
  • Maintain adequate muscle relaxation during surgery but ensure complete reversal before extubation 3
  • Use low tidal volumes with adequate PEEP to prevent atelectasis 3
  • Maintain inspired oxygen concentration >80% to decrease surgical site infections 3

• Surgical technique:

  • Laparoscopic approach when feasible to reduce postoperative pain and pulmonary complications 3
  • Careful handling of the left hemidiaphragm to minimize dysfunction 1

Postoperative Phase

• Multimodal analgesia protocol:

  • Thoracic epidural analgesia for 48-72 hours post-operation with local anesthetic and low-dose opioid 3
  • If no epidural, patient-controlled analgesia (PCA) for first 24-48 hours 3
  • Transition to oral analgesics with scheduled acetaminophen (1g q6h) and NSAIDs (if not contraindicated) 3
  • Consider regional blocks such as transversus abdominis plane (TAP) block as adjunct 3
  • Pain goal: maintain pain scores ≤4/10 to allow effective deep breathing and early mobilization 3

• Respiratory therapy:

  • Incentive spirometry: 10 deep breaths every hour while awake, with 3-second inspiratory hold at maximum inspiration 3
  • Deep breathing exercises with coached coughing every 2 hours 3
  • Early removal of nasogastric tubes to facilitate deep breathing 3
  • Consider high-flow oxygen therapy or non-invasive ventilation for patients at high risk of pulmonary complications 3

• Early mobilization protocol:

  • Out of bed to chair within 6 hours post-surgery 3
  • Ambulation within 24 hours post-surgery 3
  • Progressive increase in ambulation distance daily (minimum 3 times/day) 3
  • Structured physiotherapy program combining early mobilization, breathing exercises, and pain management 3

• CPAP criteria and implementation:

  • Consider CPAP for patients with:
    • Pre-existing obstructive sleep apnea 3
    • BMI >35 kg/m² 3
    • Oxygen saturation <92% despite supplemental oxygen 3
    • Presence of atelectasis on chest imaging despite standard respiratory therapy 3
  • Initial settings: CPAP 5-10 cmH₂O, titrate to effect 3
  • Duration: minimum 1 hour every 4 hours while awake for first 48 hours 3

• Fluid management:

  • Goal-directed fluid therapy to avoid overhydration, which can worsen pulmonary function 3
  • Early resumption of oral intake to reduce IV fluid requirements 3

Special Considerations and Pitfalls

• High-risk patients (elderly, obese, COPD, smokers) require more aggressive prophylactic measures and closer monitoring 3
• Pain control failures can rapidly lead to atelectasis development; have rescue analgesia protocols ready 3
• Monitor for post-splenectomy thrombocytosis, which may increase thromboembolic risk including pulmonary embolism that can mimic or exacerbate atelectasis 4
• Infection prevention is critical as post-splenectomy patients are at increased risk for respiratory infections that can complicate atelectasis 3, 5
• Avoid oversedation in the immediate postoperative period as it impairs respiratory effort and coughing 3

By implementing this comprehensive protocol, the incidence of left lower-lobe atelectasis following splenectomy can be significantly reduced, leading to improved outcomes, shorter hospital stays, and enhanced recovery 3.