Surgery of the Spleen, Adrenal Gland, Pancreas, and Kidney

WHAT IS THE SPLEEN?

The spleen is a blood filled organ located in the upper left abdominal cavity. It is a storage organ for red blood cells and contains many specialized white blood cells called “macrophages” (disease fighting cells) which act to filter blood. The spleen is part of the immune system and also removes old and damaged blood particles from your system. The spleen helps the body identify and kill bacteria. The spleen can affect the platelet count, the red blood cell count and even the white blood count.

HOW DO I KNOW IF MY SPLEEN SHOULD BE REMOVED?

There are several reasons why a spleen might need to be removed, and the following list, though not all inclusive, includes the most common reasons. The most common reason is a condition called idiopathic (unknown cause) thrombocytopenia (low platelets) purpura (ITP). Platelets are blood cells which aid is blood clotting. Hemolytic anemia (a condition that breaks down red blood cells) requires a spleen removal to prevent or decrease the need for transfusion. Also, hereditary (genetic) conditions that affect the shape of red blood cells, conditions known as spherocystosis, sickle cell disease or thallassemia, may require splenectomy. Often patients with cancers of the cells which fight infection, known as lymphoma or certain types of leukemia, require spleen removal. When the spleen gets enlarged, it sometimes removes too many platelets from your blood and has to be removed. Sometimes the spleen is removed to diagnose or treat a tumor. Sometimes the blood supply to the spleen becomes blocked (infarct) or the artery abnormally expands (aneurysm) and the spleen needs to be removed.

HOW ARE THESE PROBLEMS FOUND?

An evaluation typically includes a complete blood count (CBC), a visual look at the blood cells placed on a glass slide called a ‘smear’, and often a bone marrow examination. Sometimes an ultrasound examination of your spleen, a computerized tomography (CT scan), magnetic resonance imaging (MRI) or nuclear scan is needed.

WHAT PREPARATION IS REQUIRED?

After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery. Preoperative preparation includes blood work, medical evaluation, chest x-ray and an EKG depending on your age and medical condition. Immunization with a vaccine to help prevent bacterial infections after the spleen is removed should be given two weeks before surgery, if possible. Blood transfusion and/or blood products such as platelets may be needed depending on your condition. Your surgeon may request that you completely empty your colon and cleanse your intestines prior to surgery. You may be requested to drink clear liquids, only, for one or several days prior to surgery. It is recommended that you shower the night before or morning of the operation. After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery. Drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and Vitamin E will need to be stopped temporarily for several days to a week prior to surgery. Diet medication or St. John’s Wort should not be used for the two weeks prior to surgery. Quit smoking and arrange for any help you may need at home.

HOW IS LAPAROSCOPIC REMOVAL OF THE SPLEEN DONE?

You will be placed under general anesthesia and be completely asleep. A cannula (hollow tube) is placed into the abdomen by your surgeon and your abdomen will be inflated with carbon dioxide gas to create a space to operate. A laparoscope (a tiny telescope connected to a video camera) is put through one of the cannulas which projects a video picture of the internal organs and spleen on a television monitor. Several cannulas are placed in different locations on your abdomen to allow your surgeon to place instruments inside your belly to work and remove your spleen. A search for accessory (additional) spleens and then removal of these extra spleens will be done since 15% of people have small, extra spleens. After the spleen is cut from all that it is connected to, it is placed inside a special bag. The bag with the spleen inside is pulled up into one of the small, but largest incisions on your abdomen. The spleen is broken up into small pieces (morcelated) within the special bag and completely removed.

WHAT CAN I EXPECT AFTER SURGERY?

After surgery you will be given intravenous fluids (IV’s) in your arm. You may have a stomach tube coming up out your nose to prevent vomiting or stomach bleeding because your stomach can fill up with stomach juices and not empty properly after this surgery. Not every surgeon uses this tube. You will be given pain medication to relieve the discomfort you may experience from the small incisions. You will need to let your nurse and surgeon know what your pain medication needs are since everyone has a different pain threshold.

As soon as you can resume oral intake, urinate, and care for your basic needs, you will typically be able to go home. Your surgeon will tell you when it is safe to go home.

AT HOME…

Typically, once you have gone home, you may do the following, but each situation differs and “at home” activities should be discussed with your doctor.

Activity: You can walk and go up stairs. You can shower, but most surgeons prefer that you do not soak in a tub for at least a week or more after surgery. When you feel stronger ask your surgeon about more strenuous activities. Driving: Ask your surgeon. Most people can resume driving 5 to 7 days after surgery. You should not be taking pain medication when you drive. Diet: Unless you have special dietary needs, such as diabetes, you can eat a normal diet at home. Bowel function: It is common to get constipated after surgery, especially when you are taking pain medication. It is important to drink plenty of water and take in enough fiber in your diet. Your surgeon may advise you about means to help your bowel function postoperatively. Ask or call your surgeon before taking a cathartic.

WHAT COMPLICATIONS CAN OCCUR?

Complications following laparoscopic splenectomy are infrequent, but you should consult your doctor regarding possible complications based on your specific case. Possible complications may include cannula site infections, pneumonia, internal bleeding or infection inside the abdomen at the site where the spleen used to be, although these complications are infrequent. The pancreas can become inflamed (pancreatitis). Problems that can occur a few months to years later are hernias at the cannula sites or overwhelming infection throughout the entire body. This complication is also infrequent. Overwhelming infection that occurs after splenectomy is called OPSI or Overwhelming Post-Splenectomy Infection. OPSI is a result of not having a spleen to fight certain bacterial infections. Immunization is usually given before you have your spleen removed and is one method to help the body fight and prevent infection. Antibiotics, like penicillin, can be given if an infection develops because the bacteria that commonly cause this type of infection are very sensitive to antibiotics. It is important that you tell your physician or any physician that is covering for your doctor that you had your spleen removed.

WHEN TO CALL YOUR DOCTOR

Be sure to call your physician or surgeon if you develop any of the following:

• Persistent fever over 101 degrees F (39 C)
• Bleeding
• Increasing abdominal swelling
• Pain that is not relieved by your medications
• Persistent nausea or vomiting
• Chills
• Persistent cough or shortness of breath
• Purulent drainage (pus) from any incision
• Redness surrounding any of your incisions that is worsening or getting bigger
• You are unable to eat or drink liquids

Laparoscopic Adrenal Gland Removal

WHAT ARE THE ADRENAL GLANDS?

The adrenal glands are two small organs, one located above each kidney. They are triangular in shape and about the size of a thumb. The adrenal glands are known as endocrine glands because they produce hormones. These hormones are involved in control of blood pressure, chemical levels in the blood, water use in the body, glucose usage, and the “fight or flight” reaction during times of stress. These adrenal-produced hormones include cortisol, aldosterone, the adrenaline hormones – epinephrine and norepinephrine – and a small fraction of the body’s sex hormones (estrogen and androgens).

WHAT CAUSES ADRENAL GLAND PROBLEMS?

Diseases of the adrenal gland are relatively rare. The most common reason that a patient may need to have the adrenal gland removed is excess hormone production by a tumor located within the adrenal. Most of these tumors are small and not cancers. They are known as benign growths that can usually be removed with laparoscopic techniques. Removal of the adrenal gland may also be required for certain tumors even if they aren’t producing excess hormones, such as very large tumors or if there is a suspicion that the tumor could be a cancer, or sometimes referred to as malignant. Fortunately, malignant adrenal tumors are rare. An adrenal mass or tumor is sometimes found by chance when a patient gets an X-ray study to evaluate another problem.

WHAT ARE THE SYMPTOMS OF ADRENAL GLAND PROBLEMS?

Patients with adrenal gland problems may have a variety of symptoms related to excess hormone production by the abnormal gland. Adrenal tumors associated with excess hormone production include pheochromocytomas, aldosterone-producing tumors, and cortisol-producing tumors. Some of these tumors and their typical features are given below.

• Pheochromocytomas produce excess hormones that can cause very high blood pressure and periodic spells characterized by severe headaches, excessive sweating, anxiety, palpitations, and rapid heart rate that may last from a few seconds to several minutes.
• Aldosterone producing tumors cause high blood pressure and low serum (blood) potassium levels. In some patients this may result in symptoms of weakness, fatigue, and frequent urination.
• Cortisol producing tumors cause a syndrome termed Cushing’s syndrome that can be characterized by obesity (especially of the face and trunk), high blood sugar, high blood pressure, menstrual irregularities, fragile skin, and prominent stretch marks. Most cases of Cushing’s syndrome, however, are caused by small pituitary tumors and are not treated by adrenal gland removal. Overall, adrenal tumors account for about 20% of cases of Cushing’s syndrome.
• An incidentally found mass in the adrenal may be any of the above types of tumors, or may produce no hormones at all. Most incidentally found adrenal masses do not make excess hormones, cause no symptoms, are benign, and do not need to be removed. Surgical removal of incidentally discovered adrenal tumors is indicated only if: The tumor is found to make excess hormones, Is large in size (more than 4-5 centimeters or 2 inches in diameter), or if there is a suspicion that the tumor could be malignant.
• Adrenal gland cancers (adrenal cortical cancer) are rare tumors that are usually very large at the time of diagnosis. Removal of these tumors is usually done by open adrenal surgery.

If an adrenal tumor is suspected based on symptoms or has been identified by X-ray, the patient should undergo blood and urine tests to determine if the tumor is over-producing hormones. Special X-ray tests, such as a CT scan, nuclear medicine scan; an MRI or selective venous sampling is commonly used to locate the suspected adrenal tumor.

Surgical removal of the adrenal gland is the preferred treatment for patients with adrenal tumors that secrete excess hormones and for primary adrenal tumors that appear malignant.

WHAT PREPARATION IS REQUIRED?

Prior to the operation, some patients may need medications to control the symptoms of the tumor, such as high blood pressure.

• Patients with a pheochromocytoma (see previous page) will need to be started on special medications several days prior to surgery to control their blood pressure and heart rate.
• Patients with an aldosterone-producing tumor (see previous page) may need to have their serum potassium checked and take extra potassium if the level is low.
• Patients with Cushing’s syndrome (see previous page) will need to receive extra doses of cortisone medication on the day of surgery and for a few months afterwards until the remaining adrenal gland has resumed normal function.
• Preoperative preparation includes blood work, medical evaluation, chest x-ray and an EKG depending on your age and medical condition.
• After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery.
• Blood transfusion and/or blood products may be needed depending on your condition.
• Your surgeon may request that you completely empty your colon and cleanse your intestines prior to surgery. You may be requested to drink clear liquids, only, for one or several days prior to surgery.
• It is recommended that you shower the night before or morning of the operation.
• After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.
• Drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and large doses of Vitamin E will need to be stopped temporarily for several days to a week prior to surgery.
• Diet medication or St. John’s Wort should not be used for the two weeks prior to surgery.
• Quit smoking and arrange for any help you may need at home.

HOW IS LAPAROSCOPIC ADRENAL GLAND REMOVAL PERFORMED?

The surgery is performed under a complete general anesthesia, so that the patient is asleep during the procedure. A cannula (a narrow tube-like instrument) is placed into the abdominal cavity in the upper abdomen or flank just below the ribs. A laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula. This gives the surgeon a magnified view of the patient’s internal organs on a television screen. Other cannulas are inserted which allow your surgeon to delicately separate the adrenal gland from its attachments. Once the adrenal gland has been dissected free, it is placed in a small bag and is then removed through one of the incisions. It is almost always necessary to remove the entire adrenal gland in order to safely remove the tumor. After the surgeon removes the adrenal gland, the small incisions are closed.

WHAT SHOULD I EXPECT AFTER SURGERY?

After the operation, it is important to follow your doctor’s instructions. Although many people feel better in just a few days, remember that your body needs time to heal.

• After laparoscopic adrenal gland removal, most patients can be cared for on a regular surgical nursing unit. Occasionally, a patient with a pheochromocytoma may require admission to an intensive care unit after surgery to monitor their blood pressure. Most patients can de discharged from the hospital within one or two days after surgery.
• Patients with an aldosterone-producing tumor will need to have their serum potassium level checked after surgery and may need to continue to take medications to control their blood pressure.
• Patients with cortisol-producing tumors and Cushing’s syndrome will need to take prednisone or cortisol pills after surgery. The dose is then tapered over time as the remaining normal adrenal gland resumes adequate production of cortisol hormone.
• Patients are encouraged to engage in light activity while at home after surgery. Patients can remove any dressings and shower the day after the operation.
• Post-operative pain is generally mild and patients may require a pain pill or pain medication.
• Most patients can resume normal activities within one week, including driving, walking up stairs, light lifting, and work.
• You should call and schedule a follow-up appointment within 2 weeks after your operation.

 

WHAT COMPLICATIONS CAN OCCUR?

As with any operation, there is a risk of a complication. Complications during the operation may include:

• Adverse reaction to general anesthesia
• High blood pressure
• Bleeding
• Injury to other organs
• Wound problems, blood clots, heart attacks, and other serious complications are uncommon after laparoscopic adrenalectomy

WHEN TO CALL YOUR DOCTOR

Be sure to call your physician or surgeon if you develop any of the following:

• Persistent fever over 101 degrees F (39 C)
• Bleeding
• Increasing abdominal swelling
• Pain that is not relieved by your medications
• Persistent nausea or vomiting
• Chills
• Persistent cough or shortness of breath
• Purulent drainage (pus) from any incision
• Redness surrounding any of your incisions that is worsening or getting bigger
• You are unable to eat or drink liquids

Patient Information for Laparoscopic Adrenal Gland Removal (Adrenalectomy) from SAGES Patient Information published on: 03/2004
by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)