Organ-Preserving Surgeries on the Spleen: Evolution of Concepts

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One of the current trends in modern surgery is the study of the spleen injuries and diseases, in particular, its traumatic ruptures which are a fairly common pathology, being the most prevalent among all injuries of the abdominal organs. The improvement of hemostasis options and the choice of tactics in the surgical treatment of the spleen pathologies are crucial. Few recent decades have been dominated by the idea that splenectomy is the major surgical option for the spleen damage and diseases. Currently, as reported in Russia and globally, surgical tactics implying the use of organ-preserving surgeries in case of the spleen injury are being widely developed and applied.
If compared with organ-preserving operations, there are negative changes in the cellular and humoral links of the immunity after splenectomy. A significant number of proposed spleen preserving options are grouped into: conservative treatment, wound tamponades, splenic sutures, segmental resection, ligation of splenic arteries, wound bonding, infrared contact coagulation, autotransplantation of splenic tissue. Currently, surgeons have quite a lot of experimental and clinically tested techniques in their arsenal that allow successfully performing organ-preserving spleen surgery. However, none of them lacks of drawbacks. These drawbacks are quite diverse, ranging from the inability to provide guaranteed reliable hemostasis to technological and economic aspects of the operation, thus, the search for novel organ-preserving techniques remains promising.

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One of the current trends in modern surgery is the study of injuries and diseases of the spleen, in particular, its traumatic ruptures - a fairly common pathology that ranks first among all injuries of the abdominal organs [1, 2]. The analysis of the structure of surgical interventions suggests that in the first place among the etiological factors acting as indications for operations on the spleen are its injuries – 76%, in the second place – parasitic and solitary cysts – 8% [3]. Turning to the history of the development of methods for the treatment of injuries and diseases of the spleen, it should be noted that the first type of surgical intervention developed is open splenectomy. This operation was first successfully performed for a cyst by the outstanding French surgeon Jules Pean in 1867. In Russia, the first splenectomy for a spleen injury was performed in 1896 by A. A. Troyanov. [4]. In 1911, the Swiss surgeon Theodor Kocher defined splenectomy as the only correct surgical concept that should be implemented in case of damage to the spleen, since he believed that this operation had no side effects and at the same time eliminated the threat of bleeding [5]. In 1916, a splenectomy for idiopathic thrombocytopenic purpura was performed by Schloffer. This event contributed to the beginning of the development of surgical methods for the treatment of blood diseases. Until the mid–60s of the XX century, splenectomy remained the operation of choice for injuries, cysts, tumors and systemic diseases.
In the Soviet Union, A.N. Bakulev, V.R. Braitsev, P.A. Herzen, D.M. Grozdov, V.I. Kazansky were actively engaged in the development of splenectomy issues [6].
In 1952, after H. King and H. B. Shim reported on the development of post-splenectomy sepsis, the doctrine of splenectomy was questioned [7]. The publications describe isolated cases of the use of organ-preserving operations for spleen injuries, starting as early as 1894, when a splenoraphy was first performed by a Tiffany surgeon [8, 9]. Active development of alternative, organ-preserving interventions begins only from the 80s of the XX century [10, 11, 12]. A significant number of spleen preservation options have been proposed, which R.M. In 1981, Seufert and co-authors systematized and grouped into the following groups: conservative treatment, wound tamponades, splenic sutures, segmental resection, ligation of splenic arteries, marsupialization, wound bonding, infrared contact coagulation, autotransplantation of splenic tissue. Methods of local hemostasis in spleen injuries include: physical, chemical, mechanical and biological methods [13].
The topic of organ-preserving operations on the spleen has been repeatedly encountered in the works of domestic and foreign authors [14, 15, 16, 17]. However, despite this, it has not lost its relevance.
The importance of developing methods of organ-preserving surgical treatment of spleen pathologies remains high due to the fact that after performing a traditional splenectomy, negative changes occur in both cellular and humoral links of immunity: the content of monocytes in the blood decreases, there is a decrease in the content of immunoglobulins, various fractions of the compliment system, interleukins [18]. After splenectomy, compared with organ-preserving operations, purulent-septic and thrombotic complications are observed 6.7 times more often. The incidence of acute pancreatitis after splenectomy is also 5 times higher compared to organ-sparing operations [19].
At the same time, up to the present time, the attitude to organ-preserving operations is ambiguous. Thus, according to R.S. Baydulatov (1986), T.H. Ragsdale et al. (1984), organ-preserving operations often turn out to be difficult, not always guaranteeing against a recurrence of bleeding. The frequency of complications in organ–preserving operations – bleeding and septic complications is 4-10% [20]. This is due to the insufficiently developed technique of treating the wound surface of the spleen [21]. Unfortunately, there is no consensus on the reliability of hemostasis during organ-preserving operations on the spleen [22]. In this regard, the proportion of organ-sparing and replacement operations on the spleen is about 25%, which is due to the complexity of their implementation [23, 11, 13].
Therefore, a significant part of surgeons consider splenectomy to be the most rational and radical surgical intervention [24, 25, 26]. However, the concept of preserving the functions of the spleen is generally accepted today [27].
Thus, taking into account the debatable nature of the topic, the question of therapeutic tactics in case of injuries and diseases of the spleen already has several recognized solutions, depending on the age of the patient, the stability of his hemodynamics, the severity, nature and localization of the rupture of the spleen itself. Globally, there are 3 approaches to the surgical treatment of spleen pathologies. The first option applicable to traumatic ruptures of the spleen is conservative management of the patient. It is most relevant in relation to children's patients [28]. The second option is surgical treatment with splenectomy, the latter in turn can be performed through various access options: upper median laparotomy, oblique left subcostal laparotomy, upper median laparotomy with an additional oblique incision in the left subcostal region, transthoracic access with dissection of the diaphragm, and finally, laparoscopic access.
The third option is organ–preserving operational methods. These include providing hemostasis with biological, chemical, physical and mechanical surgical techniques. By mechanical techniques, we can understand two main principal options: splenoraphy and resection of the spleen. Both variants have many modifications, combinations with other methods of hemostasis described above, to include or not to include ligation or endovascular embolization of the arteries feeding the spleen. Next, the issue of resections of the spleen is considered. According to foreign authors, the indication for resection of the spleen, as opposed to splenoraphy or splenectomy, is such damage to the organ when the rupture affected not only the capsule, but also the parenchyma, including in the situation of its spread to the gate area, but the spleen itself was not subjected to total destruction [29, 30]. Classical resections of the spleen pole are divided into anatomical and atypical, depending on whether the resection was performed with or without intraorgan blood supply. To perform anatomical resections of the spleen, an integral stage is the isolation of the splenic artery, and then its lobular and segmental branches. For example, G.S. Ragimov (2010) proposed methods for visualizing the lobe or segment of the spleen. In the first method, a 1% solution of methylene blue was injected into the arterial branch, distal to the compression site. And the second method is that a solution of a magnetized "dye" is injected into the lobular or segmental arterial vessel, after which the corresponding lobe or segment is colored on the surface of the operated organ.
One of the ways to visualize the lobe or segment of the spleen is the clamping or ligation of the lobular or segmental arterial branch, depending on the estimated volume of future resection. However, it is necessary to remember about the possible existence of major intraorgan vessels running under the capsule of the spleen to one of the poles. In these cases, when bleeding from the damaged parenchyma after ligation of the portal vessels, it is necessary to resort to stitching the parenchyma with transverse sutures at the border of the mobilized part of the vascular pedicle. After the appearance of the demarcation line, the removed part of the spleen parenchyma is cut off, distal or proximal to the line, depending on the method of stump treatment [31, 32]. After performing anatomical or atypical resection of the pole of the spleen, the question arises about the method of processing the stump of the remaining part of the organ.
The most technically simple methods are methods involving the use of exclusively suture material to ensure hemostasis and restore the anatomical integrity of the organ. Suturing of the remaining part of the spleen after resection in this case is possible by applying simple nodular sutures, U-shaped, block-shaped sutures, continuous suture, Multanovsky suture, Kuznetsov-Pensky suture, designed specifically to perform the above tasks on parenchymal organs [5].
There is a way to cover the stump of the spleen with an autosalnik, which is then sewn with a continuous seam, a Multanovsky seam or through U-shaped seams. There is also a modification of this method proposed by K.A. Apartsin and V.E. Pak in 1998, which provides for the preliminary imposition of a compressive catgut ligature on the stump of the spleen and fixation of the omentum with threads wound for this ligature [14]. This direction was developed in the work of Dambaev G.Ts., who with co-authors in 2008 developed a method for treating the stump of the spleen, where a titanium clip with memory effect and superelasticity is offered as a ligating agent, which is subsequently removed from the body through a drainage tube [33].
V.N. Bordunovsky (1992) proposed a method for suturing the stump of the spleen, consisting in the imposition of a plate in the form of a cap, a preserved xenogenic peritoneum, which was stitched in a circle with a continuous catgut suture or a through 8-shaped suture. The suture is applied with constant tension of the plastic material on the stump of the organ, which avoids the formation of a near-wound hematoma.

Among the methods of hemostasis using xenogenic materials for resection of the spleen, there is a method using compressor nets [34]. Methods are also described where, as a plastic material, a proprietary muscular-aponeurotic flap on the feeding leg obtained from the muscles of the anterior abdominal wall or a serous-muscular flap cut out of the area of the large curvature of the stomach is similarly used [15, 20, 31]. Ragimov G.S. (2010) a method was proposed using a hemostatic pulp developed by him for resection of the spleen, providing for the preliminary application of this instrument along the line of the intended resection, after which a continuous hemostatic suture was applied along the instrument through a lining of plastic material, the removed part of the organ was cut off along the outer edge of the pulp, the stump of the spleen was additionally covered with plastic material, which can be an omentum, parietal peritoneum, or absorbable hemostatic gauze was used [35].
Methods of resection have also been developed, similar in technique to the above-described method of Ragimov G.S., but involving the imposition of a hemostatic suture using a special device [36, 37].
One of the variants of anatomical resection can be performed with an extensive rupture of the spleen affecting the gate of the organ, but preserving the integrity of the upper pole of the spleen and the short gastric arteries feeding it, passing through the thickness of the gastrointestinal ligament. During the operation, the spleen was mobilized, the vascular pedicle was clamped, the lower part of the organ was resected, and then the wound surface was sutured with separate nodular sutures [8, 38]. A modification of this method is the method proposed by L.I. Kazimirov, A.M. Gorokhov and N.B. Stavitskaya, providing for the ligation of the main vessels of the spleen with the preservation of short gastric arteries supplying blood to the upper pole of the spleen. The wound surface of the spleen stump after ligation and coagulation of the largest vessels was covered with separate U-shaped sutures [23].
Currently, anatomically robot-assisted and laparoscopic resection of the spleen is also used, during which the patient is placed on the right side on the operating table, the head end of the table is raised by 15-20 °. At the first stage of the operation, the spleen is mobilized, starting from its lower pole. The splenic-colonic and colonic-diaphragmatic ligaments intersect, small vessels coagulate throughout, after which the splenic bend of the colon shifts downwards. The gastro-splenic ligament is dissected with scissors, the short vessels of the stomach are clipped or crossed by a stitching device. Lobular and segmental vessels of the resected part of the spleen are clipped, intersected or stitched by the device. After the appearance of the demarcation line, the parenchyma of the spleen is crossed by a scalpel using ultrasonic vibrations at a distance of 0.5 cm laterally to the edge of the demarcation line. The final hemostasis is created by bipolar coagulation. A drainage tube is connected to the resection surface of the organ. The drug in the container is removed from the abdominal cavity [39, 40, 41].
In contrast to planar anatomical and atypical resections, the method of longitudinal wedge-shaped resection, proposed in 1987 by E.A. Wagner and M.G. Urman, is somewhat isolated, during which the mobilized spleen is removed into the wound. Then a longitudinal subtotal resection of the spleen is performed with the preservation of tissue along the attachment of the gastrointestinal ligament. The wound surface of the remaining part of the spleen has a cone-shaped shape. Hemostasis is provided by applying a continuous enveloping catgut suture with an atraumatic needle [42]. In 2010, S.V. Tarasenko and co-authors proposed a method of atypical resection in the treatment of patients with nonparasitic spleen cysts. This method differs from planar pole resections in that after enucleation of the cyst, the wound surface of the remaining part of the organ acquires, according to the description of the authors themselves, the shape of an "oyster". A capsule incision is made along the border of the pathological formation and the parenchyma of the spleen. Dissection is carried out, forming a strongly concave wound surface, the largest vessels are ligated. Then they begin to suture the wound surface "from the bottom". To do this, several rows of continuous hemostatic stitches are applied, and the direction of the stitches is perpendicular to the course of the trabeculae or at an angle to them. After that, the wound surfaces are brought together according to the type of oyster flaps. Then, in the projection of the "flaps", a second group of hemostatic sutures is applied in the form of wide through U-shaped sutures passing through both flaps of the "oyster". When using the proposed method, almost the entire functionally active parenchyma of the spleen with the main blood supply is preserved [43]. A method of bloodless resection of the spleen was also developed using the physical method of hemostasis, during which it is necessary to isolate and intersect the vessels feeding the removed part of the spleen, perform radiofrequency ablation (RF) along the border of the upcoming resection by immersing the electrode into the parenchyma of the spleen, followed by dissection of the parenchyma with a cutting tool [44]. In addition to the above methods of hemostasis, spleen resections use coagulation by infrared radiation, laser, hot air, as well as methods of biological hemostasis using gelatin sponge, oxycellulose, collagen fibrils, acrylates and combined techniques [45, 46]. In order to ensure reliable hemostasis during operations on the spleen, methods have been proposed, the use of which leads to a stop of bleeding, but at the same time a pronounced adhesive process develops in the abdominal cavity [47]. Therefore, surgeons increasingly prefer local applicative means that affect the main stages of the coagulation cascade of hemostasis. For this purpose, various hemostatic sponges based on collagen and gelatin, blood components, fibrin and cyancrylate adhesives and varnishes are used. New adhesive compositions are being created and tested. Currently, biological and synthetic adhesives are used in medicine. Biological adhesives include lyophilized plasma, fibrin adhesives, polysaccharide adhesives. There are several types of synthetic adhesive compositions: epoxy, acrylate, polyethylene glycol, polyurethane, latex fabric adhesive [45].

The modern development of medicine involves the use of high-tech equipment in surgery and the introduction of new methods of surgical treatment. Currently, the issues of the technical plan remain debatable to a greater extent in the surgery of the spleen and require improvement: improvement of methodological techniques and techniques of the operation.
To date, there are quite a lot of experimental and clinically tested techniques in the arsenal of surgeons that make it possible to successfully perform organ-sparing surgery on the spleen. However, none of them is without drawbacks. The latter, in turn, are quite diverse, starting with the inability to provide guaranteed reliable hemostasis, ending with the technological and economic aspects of the operation. Therefore, the issue of searching for new organ-preserving techniques remains promising.


About the authors

Ilya Iosifovich Kagan

Orenburg State Medical University

ORCID iD: 0000-0002-7723-7300
SPIN-code: 5756-7732

Doctor of Medical Sciences, Professor, Honored Scientist of the Russian Federation, Professor of the Department of Operative Surgery and Clinical Anatomy named after S.S. Mikhailov

Russian Federation, 460000, Russian Federation, Orenburg region, Orenburg, Sovetskaya str./M.Gorky str./lane. Dmitrievsky, 6/45/7.

Olga Borisovna Nuzova

Orenburg State Medical University

ORCID iD: 0000-0003-4803-4157
SPIN-code: 3016-5085

Doctor of Medical Sciences, Professor of the Department of Faculty Surgery

Russian Federation, 460000, Russian Federation, Orenburg region, Orenburg, Sovetskaya str./M.Gorky str./lane. Dmitrievsky, 6/45/7.

Ilya YUr'evich Pikin

Orenburg State Medical University

Author for correspondence.
ORCID iD: 0000-0002-2845-4747
SPIN-code: 8886-8683

Assistant of the Department of Faculty Surgery

Russian Federation, 460000, Russian Federation, Orenburg region, Orenburg, Sovetskaya str./M.Gorky str./lane. Dmitrievsky, 6/45/7.


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