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KEY POINTS

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  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. 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.

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

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

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

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

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HISTORICAL BACKGROUND

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For more than two millennia, the spleen has perhaps been the least understood and most underappreciated major organ. The central role played by the spleen in regulating the immune system as well as influencing metabolic and endocrine functions has only become clear over the past few decades. Our previous notion of the spleen as an utterly dispensable filter of the blood has been dispelled, enlightening our surgical approach to this fascinating organ.

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Many of the “founding fathers of medicine” have weighed in on the anatomy and function of the spleen over the centuries. Hippocrates1,2,3 in the fourth century bc was one of the first to write on the spleen. He taught broadly on the need for balance and equilibrium between the patient and his environment. Illness arose from disharmony in nature, particularly among the patient’s four humors: blood, phlegm, black bile (melancholia), and yellow bile. Hippocrates wrote of a direct connection between the brain and spleen and its particular association with the black bile. These ideas would influence thinking about the role of the spleen for more than 1000 years.2

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Aristotle, later in the same era, famously stated that, “Nature makes nothing in vain,” yet held the spleen to be an organ of minor importance whose main role was to counterbalance the liver.4 He ...

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