The spleen was regarded by Galen as “an organ of mystery,” by Aristotle as unnecessary, and by Pliny as an organ that might hinder the speed of runners.1 In many societies, the spleen was also thought to be affiliated with mood. The word spleen comes from a Greek word that has idiomatic equivalent of the heart in English, that is, to be good-spleened means to be good-hearted or compassionate. In contrast, the spleen has also been associated with melancholy, and in 19th-century England, women in bad humor were said to be afflicted by the spleen or the vapors of the spleen.
Until relatively recently, the spleen was considered expendable. The gradual realization of the valuable role of the spleen in host defense, beginning with reports of fulminant sepsis in children after splenectomy for hematologic disease, has increased interest in splenic conservation techniques.2,3 The indications for splenectomy in both the emergency and elective settings continue to evolve. The introduction of laparoscopic approaches has decreased the morbidity of surgery, but a balance between the indications for splenectomy and the long-term consequences of splenectomy, particularly sepsis, must always be considered.
In this chapter, we review the anatomy, physiology, and pathology of splenic diseases, before addressing operative techniques and strategies, focusing on the laparoscopic approach.
The spleen arises by mesenchymal differentiation along the left side of the dorsal mesogastrium in juxtaposition to the anlage of the left gonad in the 8-mm embryo. The organ ultimately migrates to the left upper quadrant.
In the healthy adult, the spleen weighs 150 g (range, 75-250 g), although there are variations based on sex, age, and racial background.4 Although the ultrasonographic upper limit of normal for spleen size is 12 cm, it is larger in men and taller or heavier people, and sex- and size-corrected normal values are available.5 The spleen is not normally palpable in adults. When the spleen tip can be felt below the left costal margin, splenomegaly should be assumed and further investigated.
The spleen resides in the posterior portion of the left upper quadrant lying deep to the 9th, 10th, and 11th ribs, with its long axis corresponding to that of the 10th rib. Its convex superior and lateral surfaces are immediately adjacent to the undersurface of the left leaf of the diaphragm. The configuration of the concave medial surface of the spleen is a consequence of impressions made by the stomach, pancreas, kidneys, and splenic flexure of the colon (Fig. 77-1).
Gross anatomy of the spleen.
The position of the spleen is maintained by several suspensory ligaments, which need to be divided during a splenectomy to allow full mobilization of ...