Which type of surgeon should operate on a patient with massive splenomegaly (enlargement of the spleen)?

Which Surgeon Should Operate for Massive Splenomegaly

An experienced general surgeon or surgical oncologist with specific expertise in complex abdominal surgery and splenectomy should perform the operation, ideally at a center with critical care support and a multidisciplinary team experienced in managing hematologic disorders. 1

Surgical Expertise Requirements

Splenectomy for massive splenomegaly requires an experienced surgical team and critical care support to minimize risks, with perioperative mortality rates of 5-10% and morbidity rates up to 25% expected even in expert hands 1. The procedure demands:

• Surgeons with specific experience in splenectomy for hematologic malignancies, as these cases involve higher technical complexity due to altered anatomy, friable tissues, and coagulopathy 2, 3
• Capability to perform splenic artery preligation via the lesser peritoneal sac before mobilization, which significantly reduces intraoperative blood loss (P=0.02) and transfusion requirements 2, 3
• Access to critical care support and blood bank resources, as massive splenomegaly cases require mean operative times exceeding standard splenectomy and higher transfusion needs 2

Surgical Approach Selection

The choice between open and laparoscopic approaches depends on spleen size, surgeon experience, and patient factors:

• Laparoscopic splenectomy is feasible for spleens up to 3,200g in experienced hands, with lower morbidity, transfusion rates, and shorter hospital stays compared to open surgery 4
• Hand-assisted laparoscopic technique should be considered for massive splenomegaly to avoid conversion and reduce complications 5
• Open splenectomy remains necessary for spleens >3,200g or when laparoscopic expertise is unavailable 4
• Laparoscopic splenectomy in trauma scenarios with active bleeding is not recommended 1

Center Requirements and Contraindications

Surgery should only be performed at centers meeting specific criteria:

• Portal hypertension and major medical comorbidities are considered contraindications to laparoscopic splenectomy 5
• Centers must have intensive care monitoring capabilities, as operative management should not be performed where intensive monitoring is unavailable 1
• Liver transplant centers or facilities with substantial experience operating in pressurized variceal environments are preferred when portal hypertension is present 1

Critical Pitfalls to Avoid

Common errors that increase morbidity and mortality include:

• Operating without adequate preoperative optimization: Patients require cytoreduction with platelet counts maintained <400×10⁹/L, prophylactic anticoagulation, and correction of coagulopathy before surgery 6
• Failure to ligate splenic artery early: Mobilizing the spleen before splenic artery ligation increases estimated blood loss (P=0.04) and transfusion requirements 2, 3
• Inadequate patient selection: Age >54 years (P=0.047) and prolonged operative time (P=0.01) correlate with major complications in 41% of high-risk patients 2
• Proceeding with surgery when medical management is appropriate: JAK inhibitors should be tried first for myeloproliferative neoplasms, as splenectomy is indicated only when JAK inhibitors are unavailable or ineffective 1

Preoperative Surgical Planning

Essential preoperative measures include:

• Preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B in elective cases 5
• Perioperative anticoagulant prophylaxis with subcutaneous heparin for all patients, with prolonged prophylaxis for high-risk patients 5
• Imaging to determine spleen size and volume, as spleen weight correlates negatively with BMI (P=0.036) and helps predict surgical complexity 7