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Key Points
The human spleen plays a key immunologic role in defense against a number of organisms, particularly encapsulated bacteria.
The spleen can cause significant morbidity and/or hematologic disturbance if it becomes hyperfunctioning (hypersplenism) or hypertrophied (splenomegaly).
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.
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.
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.
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.
Vaccination of the splenectomized patient remains the most effective prevention strategy against OPSI. Preoperative vaccination before elective splenectomy is most prudent.
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.
Overwhelming postsplenectomy infection (OPSI) is an uncommon but potentially grave disease. Children and those undergoing splenectomy for hematologic malignancy are at elevated risk.
Antibiotic prophylactic strategies against OPSI vary widely. Data regarding their use are lacking.
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HISTORICAL BACKGROUND
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The spleen has been the subject of man’s musings since almost the establishment of the written word. It has been largely misunderstood, often maligned, and certainly underappreciated as a major organ for more than two millennia. The ancients, presumably through patient observation and occasional anatomic exploration, often consigned the spleen to a vestigial role.
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Our current understanding of the central role played by the spleen in regulating the immune system and influencing metabolic and endocrine functions has been built upon knowledge gleaned only over the past few decades. Our early notions of the spleen as a dispensable filter of blood or seat of emotion have been dispelled as our understanding of its structure and function has evolved, informing our surgical approach to this worthy and fascinating organ. Many of the “founding fathers of medicine” have weighed in on the anatomy and function of the spleen over the centuries. Hippocrates in the fourth century BC was one of the first to write on the spleen.1–3 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. ...