Chapter 30: Spleen

INTRODUCTION

Splenic injuries demonstrate themselves clinically more often than do hepatic injuries, making it the most commonly injured solid viscus requiring laparotomy. During the past 50 years, there has been increasing interest in the notion that not all splenic injuries require splenectomy. Nonoperative management (NOM) with close observation is safe in appropriately identified patients. There is also increasing evidence supporting the safety of selective angioembolization; however, optimal patient selection is still debated. Although evolution has steadily moved us away from routine aggressive operative management, it is important to always keep in mind that patients with splenic injury can bleed to death.

HISTORICAL PERSPECTIVE

The spleen has been subject to injury for as long as man has suffered trauma. In ancient India, where malaria was endemic and large and fragile spleens were commonplace, intentional injury of the spleen was a method of assassination (F. William Blaisdell, MD, Sacramento, CA, 1985, personal communication). Paid assassins called thuggee carried out their mission by delivering a blow to the left upper quadrant of the intended victim. They hoped to cause splenic rupture and, if this was severe enough, the victim would bleed to death. As we know from our current imaging capabilities and management protocols, the thuggees must have been frustrated on occasion by the lack of success of their attempted assassinations.

The spleen was felt by the ancient Greeks and Romans to play a significant role in human physiology. Aristotle thought that the spleen was on the left side of the body as a counterweight to the right-sided liver.¹ He believed that the spleen was important in drawing off “residual humors” from the stomach. The close relation of the stomach and spleen and the presence of the short gastric vessels so important in present-day splenic mobilization likely encouraged this belief. The spleen was also felt to “hinder a man’s running,” and Pliny reportedly claimed that “professed runners in the race that bee troubled with the splene, have a devise to burne and waste it with a hot yron.”² The exceptional speed of giraffes was felt to be related to the erroneous belief that giraffes were asplenic. Early references to removal of the spleen to increase speed make it apparent that it has long been known that the spleen is not absolutely necessary to sustain life. Paracelsus believed that the spleen could be removed and rejected the notion that it was important for the storage of “black bile.”³

In 1738, John Ferguson of Scotland removed a portion of the spleen through an open wound in the left side (Fig. 30-1).³ Once the era of abdominal surgery had begun, it was discovered that the spleen could be removed with what seemed like relative impunity. Mayo reported in 1910 that “the internal secretion of the spleen is not important, as splenectomy does not produce serious results.”⁴ Although some suggested ...