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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, 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, spleen has been typically 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. Although over the last century the functions of spleen have become clearer, an element of mystery remains around the organ.
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Surgeons often have a love–hate relationship with the spleen. A surgeon's experience with the spleen is often tainted as most of his or her experience with the organ comes from emergent settings, when the patient is often unstable and the spleen is the source of significant bleeding. Even when dealing with elective cases, the increased complexity of medical indications for splenectomy has made the role of surgery often confusing. Despite these drawbacks, surgery on the spleen remains an enticing procedure for most surgeons, one that is wonderfully challenging and often memorable.
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In this chapter we review the anatomy, physiology, and pathology of splenic diseases, before focusing on techniques of splenectomy, focusing on the laparoscopic approach.
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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.
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In the healthy adult, the spleen weights 150 g (range 75–250 g), although there are variations based on sex, age, and racial background.2 It 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, and measures about 11 cm. On ultrasound imaging, 13 cm is regarded as the upper limit of normal size for spleen. It's 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. 62-1).
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The position of the spleen is maintained by several suspensory ligaments, which need to be divided during a splenectomy to allow full mobilization of the organ. These are the gastrosplenic, splenophrenic, splenocolic, and splenorenal ligaments (Figs. 62-2 and 62-3). The gastrosplenic ligament contains the short gastric vessels that course to the splenic hilum from the greater ...