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use of an abdominal binder after laparoscopic umbilical and epigastric hernia repair. Hernia

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123. Mayagoitia JC, Suarez D, Arenas JC, et al. Preoperative progressive pneumoperitoneum in patients

with abdominal-wall hernias. Hernia 2006;10(3):213–217.

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Chapter 73

The Spleen

Giorgos C. Karakousis and Douglas L. Fraker

Key Points

1 The spleen relates to the diaphragm both superiorly and laterally, and it generally spans the 9th,

10th, and 11th ribs along the left mid to posterior axillary line.

2 Accessory spleens are small nodules of splenic tissue that are completely separate from the main

body of the spleen. Accessory spleens are important in disease processes in which a complete

removal of all splenic tissue is mandatory for long-term cure such as certain autoimmune disorders.

3 The primary hematologic function of the spleen is removal of senescent erythrocytes or remodeling

of abnormal red blood cells, and the recycling of iron by splenic macrophages.

4 The immunologic function of the spleen is to generate an immune response to antigens that are

identified and cleared from the blood system.

5 The spleen is the most common intra-abdominal organ injured by blunt trauma in the United States.

6 The pathophysiology of immune thrombocytopenic purpura (ITP) is development of an IgG antibody

to a platelet antigen. For patients who have failed medical therapy, an elective splenectomy may be

recommended.

7 Hypersplenism is a physical enlargement of the spleen that can occur because of neoplastic disorders,

hematopoietic disorders of the bone marrow, and metabolic or storage disorders. In neoplastic

disorders, the spleen is infiltrated and enlarged by leukemia or lymphoma cells.

8 The types of organisms that account for infection are typically encapsulated organisms (most

commonly Streptococcus pneumonia).

The spleen has been a mysterious organ throughout surgical and medical history with a clear

understanding and appreciation of its function only emerging in the latter half of the 20th century. The

reasons for this paucity of knowledge on the spleen are multifactorial. The spleen has no obvious

function that can be discerned from its anatomical structures or features; there are no clear relationships

of gross pathology of the spleen to many of the diseases for which it is important; and, even in present

time, it is difficult to obtain a biopsy of the spleen, thereby limiting the amount of tissue available for

pathologic study. The diseases (other than trauma) in which the spleen has importance are generally of

a hematologic or immunologic nature. Understanding of the normal physiology and subsequent

pathophysiology of the spleen is important for surgical decision-making regarding when to recommend

splenectomy and whether a partial splenectomy is possible. The only surgical procedure applied for the

treatment of splenic disorders for the majority of history was splenectomy. Current variations on that

procedure include laparoscopic splenectomy, partial splenectomy, and other spleen-preserving

procedures. The history of surgery for the spleen, its anatomy and physiology, and the relevant disease

processes as well as operative techniques are reviewed.

HISTORY

The spleen has had a colorful history based on the function ascribed to this organ by many of the

prominent scientists throughout the ages (Table 73-1).11 Even the origin of the English term “spleen” is

unclear. It is felt to come from the Greek “splen” which may have been derived from the Greek word

“splancknon,” meaning a viscus, or the Greek word “spaw,” which means to draw.2 The dark purple red

color led ancients to believe that the spleen may draw spoiled or bad parts of the blood to itself which

predates one of the major roles of the spleen as a filtration device for senescent red blood cells. In

ancient Greece, the spleen was felt to be the source of black bile that was one of the four cardinal

humors related to melancholy.2 However, ancient authors wrote in the Talmud that the spleen was the

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seat for laughter and removal of the spleen would limit mirth in that person.2 It was felt that the spleen

was a source of discomfort sometimes felt as “a stitch in the side” for athletes and that by removal or

ablation of the spleen an individual would run faster. Reports of the earliest procedures on the spleen

indicate that runners in ancient Greece may have had their spleens ablated in an effort to improve their

performance. This hypothesis was studied in an experimental model almost 2000 years later in 1922 at

Johns Hopkins University, in which splenectomized mice versus control mice were evaluated for their

ability to run a race and the splenectomized mice were reported to be faster.2

During the Renaissance, scientists began to question the various roles ascribed to splenic function.

Paracelsus rejected the black bile theory and questioned whether the spleen had any meaningful role at

all in the early 16th century. One of his students named Zaccarella reportedly performed the first

splenectomy in the year 1549 in Palermo, Italy, removing the large spleen of a 24-year-old woman

successfully.2 This organ was reportedly displayed in the town square after this landmark but

unsubstantiated procedure. Versalius during that same era performed splenectomy in mice and other

animals and determined that the spleen was not essential to life as there was no clear difference

following removal. Around this time in 1581, Viard performed what is felt to be perhaps the first

splenic-preserving procedures, removing a portion of the spleen in two patients in which the organ had

prolapsed through an abdominal wound. The first authenticated splenectomy was performed in

Germany in 1826 by Carl Frederick Quitterbaum in a patient with secondary hypersplenism due to

cirrhosis. This high-risk patient succumbed 6 hours after the procedure. The first successful operation in

which the patient survived was performed by Jules Pean in France in 1865 for a large splenic cyst. This

patient was operated on for what was thought to be an ovarian cystic mass, but it was found to be

arising from the inferior portion of the spleen and required splenectomy for removal and the patient

survived. In this early period of splenic surgery, there was much pessimism due to the high operative

mortality rate primarily from hemorrhage. A collective series published in 1877 reported 50

splenectomies with a 70% overall mortality rate. By 1900, Bessel-Hagen reported 360 splenectomies

with a 40% mortality rate. An in-depth discussion of the spleen in literature, art, and history was

recently published by Morgenstern.3

Table 73-1 Historical Milestones in Surgery of the Spleen

The 20th century brought technical advances in terms of hemostasis and blood transfusion as well as

an understanding of the pathophysiology of splenic function.4 The spleen was identified as the site of

red cell destruction in autoimmune hemolytic anemia by Micheli in 1911. Paul Kaznelson, who was a

Czech medical student, postulated that the removal of the spleen in patients with idiopathic

thrombocytopenic purpura would be of benefit and, in 1916, he reported the successful treatment of a

patient with that disease with splenectomy. Throughout the 20th century, as the understanding the

pathophysiology of hematologic and immune disorders associated with the spleen increased, it became

clearer the roles for splenectomy that are pertinent to modern-day practice.

EMBRYOLOGY AND ANATOMY

1 The spleen develops from the mesoderm as an outpouching from the mesogastrium during the 5th

week of gestation4–6 with the natural rotation of the gut during subsequent development placing the

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