Indications for Splenectomy

To better describe and understand operative indications in surgery of the spleen, one could categorize

splenectomy or procedures of the spleen into eight general areas:

1. Trauma or injury to the spleen.

2. Autoimmune/erythrocyte disorders. In this category of disease, there are specific cytopenias related to

antibodies targeting platelets, erythrocytes, or neutrophils with the second category of diseases

related to intrinsic structural changes within the erythrocyte. For these disorders, total splenectomy is

typically indicated for cure.

3. Hypersplenism results in decreased circulating blood cells often including all subtypes of platelets and

red blood cells. Hypersplenism may be related to neoplastic infiltration of the spleen or infiltration

with lipids and other stored products that lead to massive spleen. Hypersplenism may cause

symptoms due to the splenic size.

4. Incidental splenectomy. The spleen may be removed as part of a standard operation to remove the

distal pancreas most commonly, and also for proximal gastric cancers due to the direct or nodal

involvement. Other enlarged tumors of the left upper quadrant and retroperitoneum such as sarcoma

and adrenal tumor, and left-sided renal cell cancers, may require splenectomy because of association

of these tumors with the spleen or its vessels.

5. Iatrogenic splenectomy. This is a category that may be underreported but includes splenectomy or

splenic preservation procedures due to inadvertent injury to the spleen during surgery for other

reasons within the general abdominal cavity or, specifically, the left upper quadrant.

6. Diagnostic procedures. This category of splenectomy includes cases when the spleen is removed

primarily to make a clinical diagnosis when none is available.24 A subcategory of this would be

staging laparotomy for Hodgkin disease that is rapidly becoming more of a historical footnote as the

treatment of this lymphoma now rarely requires splenectomy.

7. Vascular abnormalities. Splenectomy for vascular events or abnormalities includes patients with splenic

vein thrombosis or less commonly splenic artery aneurysms.

8. Miscellaneous procedures. This would include treatment of simple and neoplastic cysts, echinococcal

cysts of the spleen, and treatment of the symptomatic “wandering spleen,” a congenital anomaly.

An estimated 22,000 splenectomies are performed annually in the United States.25 Two recent reports

have been published describing 10-year experiences for all splenectomies done in their respective

institutions. The first report is the combined series of 1,280 splenectomies over a 10-year interval from

the Barnes Hospital in St. Louis and the Brigham and Women’s Hospital in Boston.24 The second report

is a single institution over the identical time period from Vanderbilt University.26 In the

Barnes/Brigham series, there were 1,280 splenectomies, and in the Vanderbilt series there were 896

splenectomies (see Table 73-6). One can see that dependent on the type of institution and referral

patterns, the indications for splenectomy vary to some degree. In the Vanderbilt series, the majority of

splenectomies are done for trauma, which account for 41.5% of all operations done in that institution.

In the Barnes/Brigham & Women’s series, the most common indication was incidental splenectomy in

which the spleen was removed as part of an excision of another organ, typically large tumor somewhere

in the left upper quadrant of the abdomen. The second most frequent indication for splenectomy was

staging laparotomy for Hodgkin disease. This is likely to be different in the ensuing decade as both

treatment indications and diagnostic techniques have significantly eliminated this practice after 1990.

These differences highlight that indications for splenectomy can vary dramatically among centers, in

part related to trauma volume at the centers and cancer case referrals. It also should be noted that if

one eliminates the traumatic, incidental, and staging procedures, the most common indication in both

series relates to autoimmune or erythrocyte disorder.

Table 73-6 Indications for Splenectomy in Two Large Series From Academic

Medical Centers

1992

Table 73-7 Grading of Splenic Injuries

The details of the indications for splenectomy in each of these categories are discussed. The specific

indications for splenectomy (whether total or partial), the alternative treatments that are available, and

the results from surgical removal of the spleen are also reviewed.

Trauma of the Spleen

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

and in many institutions splenectomy remains the most common operative procedure performed on the

spleen.27 The history of splenic surgery mirrors the history of surgery for trauma. In the ancient medical

literature, there have been reports of resection of portions of the spleen that had herniated through a

flank wound.28 The first documented splenectomy for penetrating trauma occurred in San Francisco by a

British naval surgeon named O’Brien in 1816 when a spleen protruded out the side of a knife wound.12

In the late 19th century, Theodor Billroth observed during an autopsy of a patient who died of head

trauma 5 days earlier that there was minimal blood in the peritoneum from the fracture of the splenic

capsule and predicted that these injuries might be managed operatively. Although in the earlier part of

the 20th century, splenic trauma was uniformly managed by a complete splenectomy, Dr. Campos

Christo of Brazil reported partial splenectomy and splenic salvage for both penetrating and blunt trauma

in 1962 (Table 73-1).4 This initial report, combined with the ability to obtain repeated cross-sectional

imaging and with the understanding of splenic function, has led to the current management guidelines

of nonoperative management for lower-grade splenic injuries and operative management centered

around splenic preservation when possible.29

The most common modes of blunt injuries leading to splenic rupture are motor vehicle accidents as

well as bicycle accidents in which upper abdominal trauma may occur. The signs and symptoms of

isolated splenic injury include tenderness in the left upper quadrant of the abdomen. Attention must be

directed towards the lower lateral left ribs; focal tenderness over ribs 9 through 11 in that region should

raise suspicion of possible splenic injury. Approximately 20% of cases of rib fracture can be

demonstrated on radiographs. Patients may have referred pain to the left shoulder (Kehr sign)

particularly when placed in the Trendelenburg position with palpation of the upper abdomen. The

spleen itself is rarely palpable but when a left upper quadrant mass is palpable, it likely represents a

contained hematoma or a subcapsular hematoma (Ballance sign). Depending on the severity of the

injury, patients may have no hemodynamic instability or may be in frank hypovolemic shock. The

grading system for splenic trauma is summarized in Table 73-7.

The diagnostic studies associated with splenic rupture would potentially include a decrease in

hematocrit and hemoglobin although initial assessment before volume resuscitation may show normal

1993

levels. After a short period of time there is often a leukocytosis in the range of 15,000 to 20,000. Plain

abdominal x-ray films, in addition to possibly showing left rib fractures, may show displacement or a

corrugated appearance along the greater curvature of the stomach due to a hematoma infiltrating the

gastrosplenic ligament (Fig. 73-6). Peritoneal lavage will reveal the presence of blood in the abdomen.

The most important current tool for diagnosis particularly in patients who are hemodynamic stable

enough to be managed conservatively is the CT scan. Contrast CT scan will show the splenic contour

and will also show the amount of extrasplenic blood (Fig. 73-7).30

Overall blunt injuries comprise the majority of splenic trauma, but the spleen is susceptible to

penetrating trauma in the retroperitoneum, lower thoracic penetrating trauma, or upper abdominal

penetrating trauma. A 15-year state review of splenic trauma in Pennsylvania reported 10,652 (92%)

blunt injuries and 893 (8%) penetrating.29 The management and diagnosis of penetrating injuries

trauma of the thorax and upper abdomen are less of a diagnostic dilemma as a majority of these patients

undergo abdominal exploration because of associated injuries. In some series, there are additional

injuries in 90% to 100% of patients with penetrating trauma to the spleen and 40% to 60% associated

injuries in cases of blunt trauma.

Figure 73-6. Abdominal film in a patient with a splenic rupture from blunt trauma with a perisplenic hematoma displacing the

greater curvature of the stomach medially. The scalloped appearance is indicative of blood in the gastrosplenic ligament

(radiograph courtesy of Dr. C. William Schwab).

Figure 73-7. A contrast CT scan on a patient with splenic rupture near the hilum. There is considerable blood in the perisplenic

fossa as well as free blood in the peritoneal cavity around the liver (radiograph courtesy of Dr. C. William Schwab).

1994

Management of splenic injuries historically has been a laparotomy with splenectomy. Since Christo

introduced the ability to do either partial splenectomy or splenorrhaphy, there has been an increased

trend with surgical procedures to try to repair or preserve part, if not all, of the spleen. The current

trend in management is a nonoperative approach with observation in serial CT scans.31 The presence of

peritonitis, associated injuries requiring surgery, overall injury severity, evidence of hypovolemic shock

with ongoing bleeding, and the patient’s age are the primary factors that are taken into consideration

while deciding on nonoperative versus operative management of blunt splenic injuries.29 If patients

have diffuse peritonitis or if patients have hypotension related to hypovolemic shock, urgent

laparotomy is indicated (Fig. 73-8). There have been increasing reports of splenectomy successfully

performed laparoscopically for blunt splenic trauma32; however, a minimally invasive approach is

typically used very selectively in this setting, given the frequent hemodynamic instability and

concurrent injuries that may be better addressed via laparotomy. For patients who are hemodynamically

stable and do not have other injuries that require surgical management, the recommendation is to

attempt nonoperative observation of these patients.

The standard nonoperative management protocol would include very close observation in an intensive

care unit or a similar monitored environment. Patients would have serial abdominal examinations as

well as serial hemoglobin and hematocrit assessments. Any change in status in which patients remain

otherwise relatively stable would be evaluated with a follow-up CT scan to see if there is progressive or

ongoing bleeding demonstrated by increased hemoperitoneum or expansion of splenic hematoma. A

recent report noted that routine follow-up CT scans did not alter management in patients treated

nonoperatively.33 Only patients with changes in hemodynamic parameters had a change in

management. With this conservative management, the majority of patients would avoid laparotomy for

isolated splenic blunt trauma.34 If patients are older, have associated injuries, or have ongoing blood

loss, a laparotomy is appropriate for blunt splenic trauma.28,35 Again, the nature of the splenic injury is

graded relative to the degree of damage to the splenic parenchyma and the proximity to the splenic

hilum and major blood vessels (Table 73-7). The principles of operative management would include

stopping ongoing hemorrhage while preserving the maximal amount of viable splenic parenchyma.

Nonviable or devascularized tissue must be debrided.36 Partial splenectomy has been popularized on the

basis of the concept of segmental blood supply via the trabecular arteries. A variety of approaches can

be taken to more minor peripheral splenic trauma including primary repair or mesh repair (Fig. 73-9).

Utilization of multiple material that are available for hemostasis including microfibrillar collagen,

thrombins of gelfoam, or fibrin glue sealants have been utilized to obtain control of splenic hemorrhage.

The argon beam coagulator is a very useful instrument for capsular tear or evulsions. Of note, all of

these techniques that have been applied to patients with blunt trauma can be similarly applied to

patients who have inadvertent trauma to the spleen during operations for other reasons (surgeries

involving dissection of the splenic flexure of the colon or the left kidney, adrenal gland, or stomach).

1995

Figure 73-8. A,B: Rapid mobilization of a bleeding spleen can be accomplished in most patients by blunt dissection of the lateral

attachments. C: The splenic hilum can then be quickly controlled.

1996

Figure 73-9. A: Techniques to suture superficial splenic lacerations. B: Technique to control bleeding after hemisplenectomy. The

sutures can be interlocked. C: Polyglycolic acid mesh sheets or mesh bags can be applied to spleens that have had the capsule

stripped away.

Over the past decade, this trend towards non-surgical management has expanded, with increasing

success rates noted with conservative management. A recent study of more than 625 patients with blunt

trauma over the past decade compared with the prior decade showed that there was an increase in

initial nonoperative management from 61% to 85%.37 The success rate of nonoperative management

increased as well from 77% to 96% and the splenic salvage rate from 57% to 88%.37 This may be partly

due to a decreased distribution of more severe splenic injuries and partly the result of an increasing

trend toward the use of embolization of splenic arteries as part of the nonoperative management of

blunt trauma. A recent systematic review of 16,490 patients with blunt splenic trauma reported that for

severe splenic trauma, nonoperative management was associated with a decreased mortality rate as

compared with operative management (4.8% vs. 13.5%).38 However, the higher mortality rate observed

in the group managed operatively appeared could be explained by the presence of other concurrent

injuries in that group. The authors concluded that, while nonoperative management remains the

recommended approach by the American Association for the Surgery of Trauma for grade I and II

injuries, the data for managing more severe splenic injuries are very heterogeneous with multiple

potential confounders, making it more difficult to interpret.

Since its introduction in the early 1992 as a potential maneuver to improve the nonoperative

management of blunt splenic injury, embolization with either coils or gelfoam of either proximal or

distal splenic vessels has had increased utilization,39 extending into the management of selected grade 3

or 4 injuries. In the study comparing the outcome of blunt trauma over the past two decades, the use of

embolization increased from 2.7% to 22.6%.37 The majority of studies provide similar data that the

overall success rate for nonoperative management with splenic artery embolization is improved and

could decrease the use of blood products.40 There have been some recent studies stating that this may

be overutilized and a report of a failure rate of 27% in patients with embolization failed and needed

surgical exploration.41 Again, these comparative studies are not matched in terms of severity of injury

1997