Why Is a Spleen Removed in a Distal Pancreatectomy?

A distal pancreatectomy involves surgical resection of the body and tail of the pancreas.

A pancreatosplenectomy (pancreaticosplenectomy) or spleen-preserving distal pancreatectomy is performed to surgically treat the pancreatic disease of the tail and body. A distal pancreatectomy involves surgical resection of the body and tail of the pancreas with or without splenectomy.

There are various surgical techniques, and the choice of procedure depends upon the disease process, characteristics of the lesion, and surgeon’s experience. 

A spleen-preserving distal pancreatectomy is reserved for chronic pancreatitis, proven benign pancreatic lesions and cysts, and pancreatic trauma. Lesions in the body and tail of the pancreas become symptomatic because they enlarge and invade surrounding structures.

Anatomy and functions of the pancreas and spleen

• The pancreas: It is about 6 inches long and located behind the stomach. The head of the pancreas is on the right side of the abdomen and is connected to the duodenum (the first section of the small intestine) through a small tube called the pancreatic duct. The narrow end of the pancreas, called the tail, extends to the left side of the body. The pancreas produces digestive enzymes and insulin, a hormone that regulates blood sugar.
• The spleen: It is an organ located in the upper left of the abdomen and left of the stomach. The spleen varies in size and shape, but it is typically fist-shaped, purple, and about 4 inches long. The spleen is protected by the rib cage; hence, it cannot be felt unless it is abnormally enlarged. The spleen acts as a filter. It helps to fight infection and removes damaged red blood cells.

Some common indications for surgery are as follows:

• Chronic pancreatitis (chronic and recurrent inflammation of the pancreas)
• Pancreatic tumors
• Stenosis (narrowing) the pancreatic duct
• Pancreatolithiasis (calculi/stones in the pancreas)
• Stenosis of the blood vessels supplying the pancreas
• Pancreatic cysts
• Pancreatic trauma

The surgery is performed under general anesthesia.

Staging laparotomy is usually performed before proceeding to resection. During a staging laparotomy, the surgeon inserts a scope (a camera with a light source) through a small incision (a surgical cut) on the abdomen. 

A staging laparotomy helps to examine the structures in the abdominal cavity and staging the cancer of the pancreas. The surgery may be performed via an open approach or laparoscopically or via a robotic-assisted surgery. 

There are also various surgical techniques. The approach and technique depend upon the disease, extent of surgery, and surgeon’s experience. A surgical drain may be inserted during the surgery.

• Open distal pancreatectomy and splenectomy: In this technique, the spleen is separated and mobilized first, and the resection of the pancreas is the final step. The tumor is resected completely along with a margin of healthy tissues. Surrounding lymph nodes may be removed.
• Radical antegrade modular pancreatosplenectomy (RAMPS): In this technique, the neck of the pancreas is divided first, and mobilization of the spleen is the final step. The tumor is resected completely along with a margin of healthy tissues. Surrounding lymph nodes may be removed.
• Robot-assisted RAMPS may be done.
• In laparoscopic surgery, multiple small incisions are made through which the scope and surgical instruments are inserted.
• A spleen-preserving distal pancreatectomy may be done if there is no indication for spleen removal.

After the surgery

Patients are administered with painkillers and antibiotics during the postoperative period. Patients are usually discharged five to seven days after the surgery. Although the surgery is complex, most patients recover well from the surgery.

A spleen may be removed during the surgery because the artery supplying the spleen lies along the body and tail of the pancreas. Because of this, the blood vessel can get blocked, and infection or tumor can spread to the spleen. 

Because the spleen helps the body fight infection, a splenectomy (spleen removal) would reduce the patient’s immunity. Hence, the doctor would recommend certain vaccines before the surgery and precautions to be taken after the surgery.

Some common complications that may be encountered during the surgery are

• pancreatic leak,
• pancreatic fistula,
• abdominal abscess,
• infection,
• bleeding,
• small bowel obstruction,
• new-onset insulin-dependent diabetes,
• problems with digestion,
• change in bowel habits and
• loss of appetite and weight.