Residency · Residency · General Surgery
Spleen: Indications for Splenectomy and Splenic Preservation
Introduction
The spleen is the largest lymphoid organ in the body and plays critical roles in immune surveillance, hematologic filtration, and reservoir function. The general surgeon must understand the broad indications for splenectomy across hematologic, traumatic, and neoplastic conditions, as well as the principles of splenic preservation when feasible. The introduction of laparoscopic splenectomy has significantly reduced morbidity, and recognition of overwhelming post-splenectomy infection (OPSI) has emphasized the importance of vaccination and splenic conservation strategies.
Splenic Anatomy and Function
The spleen is located in the left upper quadrant and weighs approximately 150 to 200 grams in adults. It is supported by four ligaments: the gastrosplenic, splenorenal, splenocolic, and splenophrenic. Its blood supply comes from the splenic artery, which is the largest branch of the celiac trunk and divides into superior and inferior polar branches. The short gastric arteries arise from the splenic artery or its branches, and the splenic vein joins the superior mesenteric vein to form the portal vein.
The spleen serves several essential functions. Its filtration role involves removing senescent and damaged red blood cells, particulate matter, and encapsulated bacteria from the circulation. Its immune function centers on opsonin production, including IgM, properdin, and tuftsin, as well as antigen processing by splenic macrophages and T-cell and B-cell activation in the white pulp. The spleen also acts as a reservoir, storing approximately 30% of the total platelet mass and a pool of monocytes. In myeloproliferative disorders and severe anemia, the spleen can resume its fetal role in extramedullary hematopoiesis.
<image>Detailed anatomical diagram of the spleen showing the hilar vasculature (splenic artery and vein with segmental branches), supporting ligaments (gastrosplenic, splenorenal, splenocolic, splenophrenic), and internal architecture with the red pulp, white pulp, marginal zone, and trabecular framework labeled</image>
Indications for Splenectomy
Hematologic Indications
Immune thrombocytopenic purpura (ITP) is the most common elective indication for splenectomy. Surgery is considered after failure of corticosteroids and second-line agents such as IVIG, anti-D immunoglobulin, and thrombopoietin receptor agonists, with response rates of 65 to 80%. The laparoscopic approach is preferred, and a careful search for accessory spleens is essential since they are present in 15 to 30% of patients and can be a cause of recurrence.
Hereditary spherocytosis is effectively cured by splenectomy for symptomatic disease. When possible, surgery is delayed until after age 6 years to preserve immune function, and partial splenectomy may be considered in children. Warm-type autoimmune hemolytic anemia (AIHA) may respond to splenectomy when refractory to steroids and rituximab, though cold-type AIHA does not respond. Thrombotic thrombocytopenic purpura (TTP) may warrant splenectomy in relapsing cases refractory to plasma exchange and rituximab.
Among the hemoglobinopathies, sickle cell disease with splenic sequestration crises, hypersplenism, or massive splenomegaly may require splenectomy, as may thalassemia major with transfusion-dependent hypersplenism. In myeloproliferative disorders such as myelofibrosis, splenectomy may be indicated for painful splenomegaly, refractory cytopenias, or portal hypertension, although surgery in these patients carries high morbidity.
Traumatic Indications
Splenic injuries are graded on the AAST scale from I to V. Grades I through III are successfully managed nonoperatively in over 90% of hemodynamically stable patients. Grades IV and V have higher failure rates of nonoperative management and may require angioembolization or splenectomy. Hemodynamic instability with splenic injury is an indication for splenectomy. Nonoperative management failure, including ongoing transfusion requirements, pseudoaneurysm not amenable to embolization, and delayed rupture, also necessitates surgical intervention.
Other Indications
Splenic abscesses, which are often polymicrobial or fungal in immunocompromised patients, may be treated with percutaneous drainage, though splenectomy is often definitive. True splenic cysts (epidermoid or parasitic/hydatid) larger than 5 cm may require surgery, with partial splenectomy or unroofing considered to preserve splenic tissue. Splenic artery aneurysms, the third most common intra-abdominal aneurysm, carry increased rupture risk during pregnancy and are treated when larger than 2 cm or symptomatic. Staging laparotomy for Hodgkin lymphoma was historically performed but is now obsolete with modern imaging and chemotherapy. Felty syndrome, characterized by rheumatoid arthritis with splenomegaly and neutropenia, may warrant splenectomy for severe or recurrent infections.
Operative Considerations
Laparoscopic Splenectomy
Laparoscopic splenectomy is the standard approach for normal-sized to moderately enlarged spleens measuring less than 20 cm. The patient is positioned in the right lateral decubitus position, which allows gravity retraction of the abdominal organs. The key steps include dividing the splenocolic ligament, mobilizing the splenic flexure, dividing the short gastric vessels, dissecting the splenic hilum, dividing the splenic artery and vein separately using a vascular stapler or clips, dividing the remaining attachments, and extracting the spleen in a retrieval bag. A systematic search for accessory spleens should include inspection of the splenic hilum, gastrosplenic ligament, splenocolic ligament, greater omentum, mesentery, and pelvis. The hand-assisted technique is useful for massive splenomegaly exceeding 20 cm or when open conversion seems likely.
Open Splenectomy
Open splenectomy is indicated for massive splenomegaly, trauma with hemodynamic instability, or when the laparoscopic approach cannot be safely performed. It is approached through a left subcostal or midline incision. A key technique is early splenic artery control by ligating the splenic artery at the superior border of the pancreas through the lesser sac, which reduces blood loss and facilitates splenic handling by allowing the spleen to autotransfuse its blood volume.
<image>Laparoscopic splenectomy in right lateral decubitus position showing port placement, stepwise division of the splenocolic ligament, short gastric vessels, and hilar vessels with a vascular stapler, and the completed mobilization with the spleen in a retrieval bag</image>
Splenic Preservation Strategies
Nonoperative management of splenic trauma involves observation with serial examinations and hemoglobin monitoring in hemodynamically stable patients, with angioembolization available for active extravasation or pseudoaneurysm. Splenorrhaphy techniques include direct suture repair, topical hemostatic agents, and mesh wrapping for minor capsular injuries encountered at operation. Partial splenectomy preserves at least 25% of splenic tissue to maintain immune function and is based on the segmental blood supply; it is most applicable for focal lesions such as cysts and benign tumors, and for hereditary spherocytosis in children. Autotransplantation, or intentional splenosis, involves implanting splenic fragments into an omental pouch after splenectomy. This approach partially restores filtrative function but provides incomplete immune protection, and its efficacy remains debated.
Overwhelming Post-Splenectomy Infection (OPSI)
OPSI carries a lifetime incidence of 0.5 to 1% and a mortality rate of 50 to 70% if untreated. The greatest risk occurs in the first two years after splenectomy, but the risk persists for life. The most common causative organism is Streptococcus pneumoniae, responsible for 50 to 90% of cases, followed by Haemophilus influenzae type b and Neisseria meningitidis. Other organisms include Capnocytophaga canimorsus from dog bites, Babesia, and malaria parasites.
The vaccination protocol includes pneumococcal vaccination with PCV13 followed by PPSV23 at least 8 weeks later, ideally administered 2 weeks before elective splenectomy. Meningococcal vaccines include both MenACWY and MenB series. A single dose of Haemophilus influenzae type b vaccine is given if not previously vaccinated, and annual influenza vaccination is recommended.
Patient education is critical and should cover wearing medical alert identification, initiating early antibiotics such as amoxicillin-clavulanate for any febrile illness, and understanding the increased risk associated with animal bites and travel to regions endemic for malaria or babesiosis. Prophylactic oral penicillin V is recommended for at least 2 years after splenectomy in children and may be considered in high-risk adults.
<image>Infographic of the post-splenectomy vaccination schedule showing recommended vaccines (PCV13, PPSV23, MenACWY, MenB, Hib), optimal timing relative to splenectomy, and interval between doses, along with key patient education points for preventing OPSI</image>
Clinical Pearls
ITP is the most common elective indication for splenectomy, and a thorough search for accessory spleens is essential since they can cause recurrence if left in place. Early splenic artery ligation at the superior border of the pancreas reduces splenic engorgement and blood loss during open splenectomy. Nonoperative management of blunt splenic injury is successful in over 90% of hemodynamically stable patients. Vaccination should be administered at least 2 weeks before elective splenectomy; when splenectomy is emergent, vaccines are given 2 weeks postoperatively. OPSI is a lifelong risk after splenectomy, and patient education about early antibiotic use for febrile illness is a critical component of post-splenectomy care.
References
- Kojouri K, Vesely SK, Terrell DR, George JN. Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systematic review to assess long-term platelet count responses, prediction of response, and surgical complications. Blood. 2004;104(9):2623-2634.
- Coccolini F, Montori G, Catena F, et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg. 2017;12:40.
- Di Sabatino A, Carsetti R, Corazza GR. Post-splenectomy and hyposplenic states. Lancet. 2011;378(9785):86-97.
- Habermalz B, Sauerland S, Decker G, et al. Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc. 2008;22(4):821-848.
