Chapter 34

1. The human spleen plays a key immunologic role in defense against a number of organisms, particularly encapsulated bacteria.

2. The spleen can cause significant morbidity and/or hematologic disturbance if it becomes hyperfunctioning (hypersplenism) or hypertrophied (splenomegaly).

3. There is a broad spectrum of nontraumatic diseases for which elective splenectomy can be curative or palliative. They can be broadly categorized as red blood cell disorders and hemoglobinopathies, white blood cell disorders, platelet disorders, bone marrow disorders, infections and abscesses, cysts and tumors, storage diseases and infiltrative disorders, and miscellaneous conditions.

4. Partial splenectomy may be a suitable alternative to total splenectomy for certain conditions of hypersplenism or splenomegaly, particularly in children in whom preservation of splenic immunologic function is especially important.

5. Preoperative splenic artery embolization for elective splenectomy has benefits and disadvantages. It may be most suitable in cases of enlarged spleen. Conclusive evidence is lacking.

6. Overwhelming postsplenectomy infection (OPSI) is an uncommon but potentially grave disease. Children and those undergoing splenectomy for hematologic malignancy are at elevated risk.

7. Vaccination of the splenectomized patient remains the most effective prevention strategy against OPSI. Preoperative vaccination before elective splenectomy is most prudent.

8. Antibiotic prophylactic strategies against OPSI vary widely. Data regarding their use are lacking.

9. Laparoscopic splenectomy provides equal hematologic outcomes with decreased morbidity compared with the open operation. The laparoscopic approach has emerged as the standard for elective, nontraumatic splenectomy.

10. Inadvertent intraoperative splenic injury is a scenario for which every abdominal surgeon should be prepared. Availability of a predetermined algorithm, with emphasis on the patientâs condition, facilitates intraoperative decision making.

The spleen has had a remarkable number of attributes and functions ascribed to it throughout history. In 350 b.c. Aristotle described how the “hot character” of the spleen aided in digestion. Writings dating back to the first century variously describe the spleen as the seat of laughter and also as the source of black bile giving rise to melancholy. Thus the term spleen came to be associated with the derivative meaning of “ill temper.” Historically, credence was given to the idea of the spleen as a locus of conflicting emotions. In the midseventeenth century Blackmore characterized the spleen as the organ to which “Hypochondrial and Hysterical Affections” could be attributed. Throughout the centuries the spleen also has been considered an impediment to fleetness of foot for both man and beast. Until modern times, however, removal of the spleen usually resulted in the death of the patient.

Anecdotal reports of splenic surgery began to emerge in the sixteenth century. By the end of the eighteenth century, the vast majority of splenectomies performed were partial, with the majority of patients requiring surgical attention for left upper quadrant stab wounds resulting in partial or total splenic prolapse. By 1877 only 50 ...

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