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Splenectomy

A splenectomy is a surgical procedure involving the complete or partial removal of the spleen, a fist-sized organ located in the upper left quadrant of the abdomen beneath the rib cage, which functions to filter blood, store blood cells, and support immune responses by producing white blood cells and antibodies.^[1] The procedure is typically performed to address conditions that compromise the spleen's function or pose life-threatening risks, such as trauma-induced rupture, and can be conducted via open surgery or minimally invasive laparoscopic techniques.^[2] The spleen plays a critical role in the body's immune system by removing old or damaged red blood cells, detecting and responding to infections, and acting as a reservoir for platelets and white blood cells during emergencies like hemorrhage.^[3] Indications for splenectomy include traumatic injuries causing splenic rupture, benign hematologic disorders such as immune thrombocytopenia (ITP) and hereditary spherocytosis, malignant conditions like lymphomas or leukemias involving the spleen, and certain immunological diseases where the spleen contributes to autoimmune destruction of blood cells.^[4] In cases of hypersplenism, where the spleen overfunctions and destroys excessive blood components, removal can alleviate symptoms like anemia or thrombocytopenia.^[5] Partial splenectomy may be preferred in select scenarios to preserve some splenic function, particularly in children or for benign lesions, reducing the risk of long-term complications while addressing the pathology.^[6] The procedure generally begins with general anesthesia, followed by either a laparoscopic approach involving small incisions and a camera for visualization or an open laparotomy for larger spleens or complex cases.^[3] During surgery, surgeons ligate blood vessels to the spleen, remove the organ, and may perform additional steps like accessory splenectomy to excise remnant splenic tissue.^[2] Postoperative recovery typically involves a hospital stay of 2-7 days, depending on the approach, with patients advised to avoid heavy lifting and monitor for signs of infection.^[1] Despite its benefits, splenectomy carries risks, including intraoperative bleeding, injury to adjacent organs like the pancreas or stomach, and postoperative infections due to the spleen's immune role.^[3] A major long-term concern is overwhelming post-splenectomy infection (OPSI), a potentially fatal condition from encapsulated bacteria like Streptococcus pneumoniae, necessitating lifelong vaccinations against pneumococcus, meningococcus, and Haemophilus influenzae type b, as well as prophylactic antibiotics in high-risk individuals.^[2] Additionally, patients face an elevated risk of thromboembolism, such as portal vein thrombosis, particularly in those with underlying hematologic disorders.^[7] Careful patient selection, preoperative optimization, and vigilant follow-up are essential to mitigate these risks and enhance outcomes.^[3]

Anatomy and Physiology of the Spleen

Gross Anatomy

The spleen is situated in the left upper quadrant of the abdomen, specifically within the left hypochondriac region, positioned posterior to the fundus of the stomach and anterior to the left kidney, with its tail in close proximity to the tail of the pancreas.^[8] It lies protected beneath the ribs 9 through 11 and is partially shielded by the diaphragm, contributing to its relatively mobile position within the peritoneal cavity.^[9] This anatomical arrangement facilitates its interactions with adjacent viscera while maintaining a degree of flexibility.^[10] In adults, the spleen typically measures approximately 11-12 cm in length, 7-8 cm in width, and 3-4 cm in thickness, with an average weight of 150-200 grams, though these dimensions can vary based on factors such as age, sex, body height, and overall health.^[11] For instance, the organ tends to be larger in males and taller individuals, and its size may increase slightly with age up to adulthood before potentially diminishing in the elderly, while conditions like splenomegaly can significantly enlarge it beyond normal ranges.^[12] The spleen's shape is generally ovoid or wedge-like, with a convex superolateral surface conforming to the diaphragm and a concave inferomedial surface facing the kidney.^[8] The spleen is anchored by several peritoneal ligaments, primarily the gastrosplenic ligament, which extends from the splenic hilum to the greater curvature of the stomach and contains the short gastric vessels and left gastroepiploic artery, and the splenorenal ligament, which connects the hilum to the anterior surface of the left kidney and transmits the splenic artery, vein, and tail of the pancreas.^[13] These ligaments, derived from the dorsal mesogastrium, provide structural support while allowing limited mobility.^[10] The organ's vascular supply arises from the splenic artery, the largest branch of the celiac trunk, which courses tortuously along the superior border of the pancreas before entering the hilum; venous drainage occurs via the splenic vein, which joins the superior mesenteric vein to form the portal vein posterior to the pancreas neck.^[14] The hilum, located on the medial surface, serves as the primary entry and exit point for these vessels, as well as lymphatic vessels and nerves.^[13] Externally, the spleen is enveloped by a thin, fibrous capsule composed of dense irregular connective tissue reinforced by elastic and collagen fibers, which provides protection and structural integrity.^[10] From this capsule, numerous trabeculae—septa of fibroelastic tissue—extend inward into the splenic parenchyma, branching to form an incomplete framework that supports blood vessels, nerves, and lymphatics while dividing the organ into smaller compartments.^[13] Developmentally, the spleen originates as a mesenchymal condensation within the cephalic portion of the dorsal mesogastrium during the fifth to sixth week of embryogenesis, progressively separating from the mesentery while retaining ligamentous connections.^[15]

Functions and Pathophysiology

The spleen serves as a critical organ in hematopoietic processes, primarily through its role in filtering and processing blood cells within the red pulp. It removes aged or damaged red blood cells (RBCs) via phagocytosis by resident macrophages, preventing their circulation and contributing to the maintenance of erythrocyte homeostasis.^[16] This filtration process also facilitates iron recycling, as macrophages in the spleen break down hemoglobin from senescent RBCs, extracting and storing iron for reuse in erythropoiesis while excreting excess via heme oxygenase pathways.^[17] In certain pathological conditions, such as severe anemia or bone marrow failure, the spleen can engage in extramedullary hematopoiesis, producing blood cells outside the bone marrow to compensate for hematopoietic stress, though this is not a primary function in healthy individuals.^[18] Immunologically, the spleen acts as a sentinel for blood-borne antigens, with its architecture divided into white pulp and red pulp compartments that support distinct but complementary roles. The white pulp, comprising lymphoid tissue organized into periarteriolar lymphoid sheaths and follicles, facilitates adaptive immune responses by serving as a site for B and T lymphocyte activation, proliferation, and differentiation upon antigen encounter.^[19] Marginal zone B cells in this region initiate rapid antibody production against T-independent antigens, while T cells coordinate humoral and cellular immunity. In contrast, the red pulp's venous sinuses and cords harbor macrophages that perform phagocytosis of opsonized pathogens and debris, clearing them from circulation and linking innate immunity to adaptive responses.^[20] Additionally, the spleen produces opsonins such as tuftsin and properdin, which enhance phagocytosis and complement activation, thereby amplifying antibody-mediated clearance of encapsulated bacteria.^[21] Pathophysiological alterations in splenic function often manifest as splenomegaly, hypersplenism, or infarction, disrupting normal hematopoiesis and immunity. Splenomegaly frequently arises in portal hypertension, where increased venous pressure from conditions like cirrhosis leads to congestion and enlargement of the spleen, impairing its filtration capacity.^[22] Hypersplenism ensues when this enlarged spleen hyperactively sequesters and destroys blood cells, resulting in cytopenias such as thrombocytopenia, anemia, and leukopenia due to accelerated phagocytosis and pooling within the splenic cords.^[23] Splenic infarction, conversely, occurs when arterial or venous blood flow is compromised, often by emboli from cardiac sources or in situ thrombosis, leading to localized ischemia, tissue necrosis, and potential abscess formation if untreated.^[24] Asplenia, the absence of splenic function, profoundly impacts homeostasis and increases susceptibility to severe infections. Without the spleen's filtration, patients face heightened risk of overwhelming post-splenectomy infection (OPSI) from encapsulated bacteria like Streptococcus pneumoniae, as the organ's macrophages and opsonins are essential for clearing poorly opsonized pathogens via the marginal zone.^[25] This vulnerability stems from impaired IgM memory B cell responses and reduced phagocytosis, with S. pneumoniae accounting for 57–87% of cases of OPSI, particularly in studies from the late 1990s and early 2000s.^[26] Hematologically, asplenia causes thrombocytosis due to loss of the spleen's platelet sequestration role, elevating thrombosis risk, alongside persistent Howell-Jolly bodies on blood smears indicating defective RBC pitting.^[27]

Indications for Splenectomy

Splenic rupture is a frequent consequence of blunt abdominal trauma, most commonly resulting from high-impact events such as motor vehicle collisions, falls from height, or sports-related injuries.^[28] The spleen's vascular vulnerability, owing to its thin capsule and rich blood supply, predisposes it to laceration or fragmentation upon deceleration forces that shear its attachments.^[28] In blunt trauma scenarios, the spleen accounts for approximately 30-40% of solid organ injuries, making it the most commonly affected intra-abdominal organ.^[29] Diagnosis relies on rapid imaging to assess injury severity and guide management. The Focused Assessment with Sonography for Trauma (FAST) ultrasound serves as an initial bedside tool to detect free intraperitoneal fluid, indicative of hemoperitoneum, with high sensitivity in unstable patients.^[30] For hemodynamically stable individuals, contrast-enhanced computed tomography (CT) angiography is the gold standard, providing detailed grading of the injury and identifying active extravasation or vascular injuries.^[31] Injuries are classified using the American Association for the Surgery of Trauma (AAST) Organ Injury Scale, ranging from Grade I (minor capsular tear) to Grade V (shattered spleen or complete devascularization), with Grades IV and V associated with higher risks of failure in non-operative approaches.^[32] Indications for splenectomy in trauma arise primarily from acute life-threatening conditions, including hemodynamic instability unresponsive to resuscitation, ongoing hemorrhage evidenced by persistent hypotension or transfusion requirements exceeding 4-6 units of blood, or failure of non-operative management such as embolization.^[33] Peritonitis from associated hollow viscus injury or high-grade lesions (AAST IV-V) with active bleeding on CT also necessitate emergent surgery.^[34] Historically, splenectomy was the standard treatment for most splenic injuries until the 1970s, when recognition of the spleen's immunological role prompted a paradigm shift toward spleen-preserving strategies like observation and angioembolization for stable patients, reserving splenectomy for severe cases where preservation is infeasible.^[35] This evolution has reduced splenectomy rates to under 10% in modern trauma centers for blunt injuries.^[36]

Non-Traumatic Medical Indications

Non-traumatic medical indications for splenectomy encompass elective or semi-elective procedures performed to address underlying hematologic, oncologic, or other systemic conditions where the spleen contributes to disease progression or symptoms. These indications are typically evaluated based on diagnostic criteria such as persistent cytopenias, organ dysfunction, or structural abnormalities unresponsive to conservative management. Hypersplenism, characterized by splenic sequestration causing cytopenias, often underlies many of these cases, linking to broader pathophysiology of splenic overactivity.^[3] In hematologic disorders, splenectomy is indicated for idiopathic thrombocytopenic purpura (ITP) refractory to medical therapy, including corticosteroids, thrombopoietin receptor agonists, or rituximab. According to the American Society of Hematology (ASH) 2019 guidelines, splenectomy is recommended as a second-line option for adults with ITP lasting at least 3 months who remain corticosteroid-dependent or unresponsive, particularly those at high risk of bleeding. Long-term remission rates following splenectomy for ITP range from 60% to 80%, with approximately two-thirds of responses being durable beyond 5 years.^[37]^[38]^[39] Splenectomy is also a standard intervention for hereditary spherocytosis causing severe hemolysis, particularly in moderate to severe cases with significant anemia, reticulocytosis, or symptomatic complications like gallstones. Guidelines from the International Working Group on Hereditary Spherocytosis recommend splenectomy for patients with hemoglobin levels below 8-9 g/dL or transfusion dependence, as it effectively halts hemolysis and improves quality of life in most cases. The procedure is generally deferred until after age 5 in children to mitigate infection risks, though it remains curative for the hemolytic component.^[40]^[41] Oncologic indications include primary splenic tumors, which are rare but often malignant, such as angiosarcoma, necessitating splenectomy for both diagnosis and treatment. Splenectomy is the primary curative approach for these lesions, recommended upon confirmation via imaging or biopsy to prevent rupture and metastasis, with early intervention improving outcomes in resectable cases. For lymphomas, splenectomy was historically used for staging, particularly in Hodgkin lymphoma, but current practice favors non-invasive imaging like PET/CT, limiting its role to symptomatic hypersplenism or diagnostic uncertainty in splenic marginal zone lymphoma.^[42]^[3]^[43] Other indications involve hypersplenism secondary to cirrhosis, where splenectomy addresses severe thrombocytopenia or anemia impeding antiviral therapy or causing recurrent bleeding. In cirrhotic patients with portal hypertension, splenectomy is considered when platelet counts fall below 30,000/μL despite medical optimization, often improving hepatic function and reducing transfusion needs, though it carries risks of postoperative complications. Splenectomy is also indicated for splenic abscesses unresponsive to prolonged antibiotics and percutaneous drainage, particularly in immunocompromised hosts, as surgical removal controls infection in up to 90% of refractory cases. For nonparasitic splenic cysts larger than 5 cm or symptomatic aneurysms, splenectomy is performed to avert rupture, with aneurysms over 2 cm in diameter warranting intervention due to a 10% rupture risk in pregnancy or high-pressure states.^[44]^[45]^[46] While splenectomy effectively manages these conditions, alternatives such as medical therapies are prioritized in young patients to preserve splenic immunity and reduce lifelong infection risks, with surgery reserved for cases where benefits outweigh potential immunosuppression. The ASH guidelines emphasize this balanced approach, noting splenectomy's role only after exhausting less invasive options.^[47]^[37]

Surgical Procedure

Preoperative Preparation

Preoperative preparation for splenectomy involves a comprehensive patient evaluation to optimize outcomes and minimize perioperative risks, particularly given the spleen's role in immune function and hematopoiesis. A detailed medical history and physical examination are essential to identify potential coagulopathies, such as thrombocytopenia in immune thrombocytopenic purpura (ITP) or other hematologic disorders, and to assess infection risks from underlying conditions like portal hypertension or malignancy. Vaccination status is reviewed, as asplenia increases susceptibility to encapsulated bacterial infections; if not previously administered, vaccines against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type b (Hib) should be given at least 14 days prior to elective surgery to allow adequate immune response.^[3]^[48]^[49] Diagnostic imaging and laboratory studies are critical for surgical planning and transfusion readiness. Computed tomography (CT) or magnetic resonance imaging (MRI) of the abdomen is performed to evaluate splenic anatomy, size, vascular supply, and any accessory spleens or adhesions that could complicate the procedure. Blood tests include a complete blood count (CBC) to assess for anemia or thrombocytopenia, a coagulation profile (prothrombin time, activated partial thromboplastin time, and international normalized ratio) to detect bleeding risks, and blood typing with crossmatch to prepare for potential intraoperative hemorrhage, which can be significant due to the spleen's rich vascularity.^[3]^[48]^[50] Risk stratification guides perioperative management, incorporating the American Society of Anesthesiologists (ASA) physical status classification and frailty assessments to predict complications like thrombosis or infection in high-risk patients, such as those with massive splenomegaly or comorbidities. Antibiotic prophylaxis, typically with intravenous cefazolin, is administered within 60 minutes of incision to prevent surgical site infections, following guidelines for clean-contaminated procedures. Patient counseling is a key component, involving informed consent that details asplenia risks, including a 50- to 100-fold increased lifetime incidence of overwhelming post-splenectomy infection (OPSI) from encapsulated organisms, and emphasizes post-discharge strategies like antibiotic prophylaxis for febrile illnesses and annual influenza vaccination.^[3] Special considerations include the planned surgical approach, which influences preparation; for spleens exceeding 20 cm in craniocaudal dimension, open or hand-assisted laparoscopic techniques are often preferred over pure laparoscopy due to increased operative difficulty and bleeding risk, necessitating additional imaging for precise sizing and potential preoperative embolization in select cases. Patients may need to discontinue antiplatelet agents or anticoagulants 5-7 days prior under medical guidance to balance bleeding and thrombotic risks.^[51]^[1]

Operative Techniques

Splenectomy techniques have evolved significantly since the mid-20th century, when open surgery was the standard approach, particularly for trauma cases following World War II, to the dominance of minimally invasive methods by the 2020s, driven by advancements in laparoscopy introduced in the early 1990s.^[52]^[3] Laparoscopic splenectomy was first reported in 1991 and has since become the preferred method for most elective cases due to reduced recovery time and morbidity compared to open procedures.^[53] Open splenectomy involves a midline incision for cases with highly enlarged spleens or staging laparotomies, or a left subcostal incision otherwise, allowing access to the spleen located in the left upper quadrant beneath the diaphragm and adjacent to the stomach and pancreas.^[54] The spleen is mobilized by dividing the splenocolic, lienorenal, and lienophrenic ligaments, followed by ligation and division of the short gastric vessels.^[54] Vascular control is achieved by identifying and ligating the splenic artery and vein close to the hilum, after which the spleen is removed and hemostasis is secured through careful inspection and additional ties if necessary.^[54]^[1] Laparoscopic splenectomy, established as standard since the 1990s, typically uses 3 to 5 ports placed in the umbilicus, left upper quadrant, and midline, with the patient in the right lateral decubitus position for optimal exposure.^[4] Access is obtained via open cutdown or Veress needle, followed by mobilization of the spleen using energy devices like the harmonic scalpel to divide the splenocolic and lienophrenic ligaments, and ligation of short gastric vessels.^[4] Retraction is facilitated by a fan retractor, while the splenic hilum is dissected for ligation of the artery and vein using clips or a vascular stapler; the spleen is then placed in an endobag for morcellation and extraction to minimize spillage.^[4] Conversion to open surgery occurs in approximately 5-10% of cases, often due to bleeding or adhesions.^[52]^[55] Emerging techniques include hand-assisted laparoscopic splenectomy for large spleens greater than 20 cm, which incorporates a hand port for tactile feedback and facilitates manipulation and intact specimen removal, and robotic-assisted approaches for complex cases involving adhesions or splenomegaly, offering enhanced visualization and precision at the cost of longer setup times.^[56]^[57]^[58] Operative duration generally ranges from 1 to 3 hours, with blood loss managed through preoperative embolization if indicated or intraoperative cell saver use in high-risk scenarios.^[59]^[60]

Complications and Side Effects

Short-Term Complications

Short-term complications of splenectomy primarily encompass perioperative events occurring within the first 30 days post-procedure, with risks varying based on surgical approach (laparoscopic versus open) and underlying indication such as trauma or elective hematologic conditions. These complications can significantly impact patient outcomes, necessitating prompt recognition and intervention.^[3] Bleeding, or postoperative hemorrhage, represents one of the most immediate concerns, often arising from incomplete ligation of short gastric vessels during splenic mobilization. The incidence is estimated at approximately 1-3% in reported series, particularly in emergency splenectomies where vascular control may be challenging; management typically involves relaparotomy for hemostasis, with transfusion requirements in severe cases.^[3]^[61] Infection, including wound infections and intra-abdominal abscesses, occurs in 1-5% of patients, with higher rates (up to 7%) observed in open procedures due to greater tissue trauma and exposure. Pancreatic injury, a consequence of the spleen's anatomical proximity to the pancreatic tail, manifests as pancreatic fistula or acute pancreatitis in 0.2-4.5% of laparoscopic cases, often requiring drainage or supportive care; this risk is elevated during hilar dissection.^[3]^[62] Pulmonary complications, such as atelectasis and pneumonia, arise from diaphragmatic irritation and reduced mobility post-surgery, affecting approximately 5-10% of patients, and are more prevalent in open splenectomies. Venous thromboembolism, including portal vein thrombosis, occurs in 6-11% of cases early postoperatively.^[63] Overall perioperative mortality remains low at less than 1% for elective splenectomies but can reach 5-20% in trauma settings, influenced by factors including patient age over 65 years, comorbidities, and intraoperative blood loss.^[64]^[65]

Long-Term Risks

One of the primary long-term risks following splenectomy is overwhelming post-splenectomy infection (OPSI), a fulminant sepsis syndrome resulting from the spleen's lost role in filtering encapsulated bacteria from the bloodstream. The lifetime risk of OPSI is estimated at 1-5%, with the highest incidence in the first two years post-procedure, and a fatality rate of up to 50% even with treatment.^[26]^[66] Postsplenectomy reactive thrombocytosis affects 75-82% of patients, often leading to platelet counts exceeding 1 million per microliter due to reduced splenic sequestration, which elevates the risk of thromboembolism including deep vein thrombosis (DVT) and pulmonary embolism (PE). This hypercoagulable state persists in some cases and is typically managed with low-dose aspirin prophylaxis.^[67]^[68] Hyposplenism, the functional equivalent of asplenia, manifests as the presence of Howell-Jolly bodies—nuclear remnants in erythrocytes—visible on peripheral blood smears, indicating impaired splenic clearance of defective red blood cells. Additionally, red blood cell lifespan increases post-splenectomy due to diminished hemolysis from splenic destruction, though this can contribute to other complications.^[69]^[70] Other risks include gallstone formation from altered hemolysis patterns, particularly in patients with underlying hemolytic disorders, and rare development of pulmonary hypertension, potentially linked to vascular changes or residual disease effects.^[71] To mitigate these risks, patients require ongoing monitoring, including annual complete blood counts (CBC) to track persistent leukocytosis, thrombocytosis, and hyposplenic markers, alongside prompt initiation of broad-spectrum antibiotics at the onset of fever to prevent OPSI progression.^[72]^[73]

Recovery and Aftercare

Immediate Postoperative Management

Following splenectomy, patients are closely monitored in the immediate postoperative period to ensure hemodynamic stability and detect early complications. For cases involving trauma, admission to the intensive care unit (ICU) is often required to provide advanced monitoring and support, particularly given the higher risk of associated injuries.^[74] Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, are continuously assessed to identify signs of hemorrhage or instability. If surgical drains are placed, output is meticulously monitored for excessive volume or bloody drainage, which could indicate intra-abdominal bleeding—a potentially life-threatening short-term complication.^[61] Pain management typically involves patient-controlled analgesia (PCA) with opioids to provide effective, titratable relief while minimizing oversedation.^[75] Nutritional support begins with patients kept nil per os (NPO) immediately after surgery to reduce the risk of ileus, progressing to clear liquids and then a regular diet as bowel function returns, usually within 1-2 days for laparoscopic procedures.^[2] Early ambulation is encouraged within 24 hours postoperatively to promote circulation, prevent deep vein thrombosis (DVT), and facilitate pulmonary toilet, with the aid of sequential compression devices or prophylactic anticoagulation as indicated.^[2] If vaccinations were not administered preoperatively—particularly in emergent or traumatic cases— they should be given as soon as possible postoperatively, ideally within 2 weeks, to mitigate the risk of overwhelming post-splenectomy infection (OPSI). Recommended vaccines include pneumococcal (PCV20 or PCV21, or PCV15 followed by PPSV23 at least 8 weeks later if PCV15 used), meningococcal (MenACWY and MenB series), and Haemophilus influenzae type b (Hib).^[76]^[3] Wound care involves keeping the incision site clean and dry, with staples or sutures typically removed 7-10 days postoperatively. Patients are monitored for signs of seroma or hematoma formation at the surgical site, which may require aspiration if symptomatic.^[2] Discharge from the hospital generally occurs 3-7 days after laparoscopic splenectomy or 5-7 days after open surgery, once vital signs are stable, the patient is tolerating oral intake without nausea, pain is controlled with oral medications, and mobility is adequate.^[1]^[2]

Long-Term Lifestyle and Monitoring

Patients who have undergone splenectomy, rendering them asplenic, require lifelong strategies to mitigate the heightened risk of severe infections, particularly overwhelming post-splenectomy infection (OPSI).^[77] Infection prophylaxis typically involves daily antibiotic therapy, such as penicillin V, for high-risk individuals including children under 5 years and those with additional immunocompromising conditions; this is recommended indefinitely to reduce the incidence of encapsulated bacterial infections like pneumococcal disease.^[78] Adults without high-risk factors may receive prophylaxis for at least the first 2 years post-surgery, with options to continue based on patient preference and clinician assessment.^[79] A critical component of this prophylaxis is an emergency fever protocol: asplenic patients should seek immediate medical evaluation for any fever exceeding 38.5°C (101.3°F), accompanied by symptoms such as chills or rigors, and carry standby antibiotics like amoxicillin for prompt self-administration if care is delayed.^[80] Vaccination is a cornerstone of long-term management to bolster immunity against common pathogens. Asplenic patients should receive the pneumococcal conjugate vaccine (PCV15, PCV20, or PCV21) followed by the pneumococcal polysaccharide vaccine (PPSV23) if PCV15 is used, with PPSV23 boosters administered every 5 years thereafter to maintain protection against Streptococcus pneumoniae.^[49] Meningococcal vaccines, including MenACWY (with boosters every 5 years) and MenB (with boosters 1 year after primary series and every 2-3 years), are essential, as are Haemophilus influenzae type b (Hib) and annual influenza vaccinations for all ages ≥6 months.^[49] For travel to malaria-endemic areas, chemoprophylaxis with antimalarials such as atovaquone-proguanil is advised due to impaired splenic clearance of Plasmodium parasites.^[78] Lifestyle modifications focus on minimizing exposure to infections while promoting overall health. Asplenic individuals should avoid high-risk activities, such as consuming unpasteurized dairy products, undercooked meats, or untreated water, and limit close contact with ill persons or animals that may carry zoonotic infections like babesiosis.^[80] Prompt wound care is vital, including immediate cleaning and medical attention for any cuts or injuries to prevent bacterial entry, and wearing medical alert jewelry identifying asplenia is recommended to ensure appropriate care in emergencies.^[77] A balanced diet, regular exercise, and avoidance of smoking support immune function and cardiovascular health, as splenectomy may elevate risks for thrombosis and pulmonary issues.^[80] Routine follow-up care involves periodic hematology consultations every 6 to 12 months to monitor blood counts for persistent thrombocytosis or other hematologic changes, and to reinforce education on infection prevention.^[79] In select high-risk cases, such as those with underlying hemolytic anemias, periodic echocardiography may be warranted to screen for rare cardiac complications like pulmonary hypertension.^[81] Patient education emphasizes recognizing OPSI symptoms—rapidly progressing high fever, confusion, or hypotension—and the importance of immediate intervention, as early treatment can be lifesaving.^[77] Most asplenic patients experience a high quality of life with few symptoms attributable to spleen absence, resuming normal activities once recovered, though vigilance against infections remains essential for long-term well-being.^[80] Comprehensive counseling at follow-up visits empowers patients to adhere to these measures, reducing morbidity and supporting an active lifestyle.^[78]

Partial Splenectomy

Indications and Advantages

Partial splenectomy is indicated in cases of splenic trauma, particularly for grades I-III injuries where splenic salvage is feasible to avoid total removal and preserve organ function.^[82] It is also recommended for benign splenic lesions such as cysts and non-malignant tumors like hemangiomas, lymphangiomas, or hamartomas, allowing targeted resection while maintaining residual splenic tissue.^[6] In pediatric patients with early-stage hereditary spherocytosis, partial splenectomy helps alleviate hemolytic symptoms while preserving splenic immunity against encapsulated bacteria.^[83] The primary advantages of partial splenectomy over total splenectomy include the preservation of at least 25-30% of splenic volume, which is sufficient to sustain immunological functions such as phagocytosis and antibody production.^[6] This approach substantially reduces the lifetime risk of overwhelming post-splenectomy infection (OPSI), a severe complication associated with asplenia, by maintaining partial splenic filtration capacity.^[83] It is particularly beneficial in pediatric cases, where conserving splenic tissue minimizes long-term susceptibility to infections and supports growth-related hematologic stability.^[84] Studies demonstrate lower overall infection rates following partial splenectomy compared to total removal, with systematic reviews reporting reduced postsplenectomy sepsis incidence in preserved spleen cohorts, though short-term technical challenges like conversion to total splenectomy occur in up to 3.5% of cases.^[85] Partial splenectomy is contraindicated in splenic malignancies, where total resection is required for oncologic staging and complete tumor removal.^[1] It is also unsuitable for severe hypersplenism, such as in advanced portal hypertension or refractory cytopenias, where insufficient remnant tissue may fail to control excessive blood cell destruction, necessitating full splenectomy. The procedure gained popularity in the 1990s following advancements in laparoscopic techniques, which enabled safer partial resections with minimal invasiveness and improved visualization of splenic vasculature.^[87]

Surgical Methods

Partial splenectomy techniques have evolved significantly since the 1990s, transitioning from experimental procedures to a standard option for splenic salvage in select trauma and benign lesion cases. This shift was driven by advances in imaging and hemostatic tools, enabling safer parenchyma division while maintaining immunologic function.^[88] In open partial splenectomy, surgeons prioritize vessel-preserving strategies to ensure remnant viability, such as selective ligation of segmental arteries supplying the targeted area, which allows ischemic demarcation for precise resection.^[89] For benign cysts, radiofrequency ablation is commonly employed to coagulate and resect the cyst wall along with a margin of parenchyma, minimizing blood loss through thermal sealing without extensive dissection.^[90] These approaches rely on the spleen's anatomical segmentation into superior and inferior poles, facilitating localized resections.^[91] Laparoscopic partial splenectomy utilizes advanced energy devices for parenchyma transection, including the harmonic scalpel for ultrasonic coagulation and cutting, or LigaSure for bipolar vessel sealing, which reduce thermal spread and operative bleeding.^[92] Intraoperative ultrasound guides resection margins by delineating lesion boundaries and vascular structures in real time, enhancing precision in minimally invasive settings.^[93] This technique is particularly suited for peripheral lesions, with mobilization of the spleen via ligament division preceding division. Outcomes of partial splenectomy include operative times typically ranging from 2 to 4 hours, longer than total splenectomy due to meticulous hemostasis, but with shorter hospital stays averaging 4-7 days compared to open total procedures.^[94] In trauma salvage scenarios, success rates exceed 80%, with low conversion to total splenectomy when at least one-third of splenic volume is preserved.^[95] Key challenges include achieving hemostasis in the vascular splenic parenchyma, often managed with topical agents like fibrin sealants, and confirming adequate perfusion of the remnant spleen using indocyanine green fluorescence imaging to visualize real-time blood flow and avoid ischemia.^[96]

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Sep 1, 2019 · The physical organization of the spleen allows it to filter blood of pathogens and abnormal cells and facilitate low probability interactions ...
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Splenic Macrophage Subsets and Their Function during Blood ... - NIH
The spleen is one of the major immunological sites for maintaining blood homeostasis. Previous studies showed that heterogeneous splenic macrophage populations ...
[21]
Functional hyposplenism - PMC - NIH
The spleen is also an important site of production of opsonins (like tuftsin and properdin) which are protein particles derived by enzymatic fragmentation of ...<|separator|>
[22]
Splenomegaly - StatPearls - NCBI Bookshelf - NIH
Venous thrombosis (portal or hepatic vein thrombosis): This leads to an increase in vascular pressure leading to splenomegaly. Splenic congestion (venous ...
[23]
Hypersplenism: History and current status - PMC - NIH
Sep 7, 2016 · Hypersplenism is a common disorder characterized by an enlarged spleen which causes rapid and premature destruction of blood cells.
[24]
Splenic Infarcts - StatPearls - NCBI Bookshelf - NIH
Splenic infarction occurs when the blood supply to the spleen is compromised, resulting in tissue ischemia and eventual necrosis. It may be the result of ...
[25]
Functional Asplenism - StatPearls - NCBI Bookshelf
Apr 20, 2024 · Functional asplenism can increase the risk of certain infections, particularly those caused by polysaccharide-encapsulated bacteria, such as ...
[26]
Post-splenectomy Sepsis: A Review of the Literature - PubMed Central
Feb 6, 2020 · Sepsis in asplenic patients is more likely to be caused by encapsulated organisms as they are more resilient to phagocytosis. The most dreadful ...
[27]
PERIPHERAL BLOOD FILM - A REVIEW - PMC - PubMed Central
Myeloblasts are the earliest recognizable granulocyte precursors and may spill over into the periphery in situations that cause marked left shift.Red Cell Morphology · White Cell Morphology · Platelet MorphologyMissing: activation | Show results with:activation
[28]
Splenic Trauma - StatPearls - NCBI Bookshelf
Jun 2, 2025 · General indications for splenectomy include hemodynamic instability ... AAST Organ Injury Scale is commonly used to grade splenic injuries.
[29]
Abdominal pain is a main manifestation of delayed bleeding after ...
Nov 18, 2022 · Approximately a quarter of blunt abdominal traumas result in splenic injury, the most frequently encountered solid organ injury. Over the past ...
[30]
Splenic trauma | Radiology Reference Article - Radiopaedia.org
Oct 13, 2025 · FAST scanning may be performed to determine the presence of free fluid. particularly in the upper abdomen. fresh blood is usually characterized ...AAST spleen injury scale · Splenic injury - grade 5 · Seurat spleen · Question 2653
[31]
Splenic trauma: WSES classification and guidelines for adult and ...
Aug 18, 2017 · WSES class III includes hemodynamically stable AAST-OIS grade IV–V blunt and penetrating lesions. Severe spleen injuries: WSES class IV includes ...
[32]
AAST spleen injury scale | Radiology Reference Article
Oct 20, 2025 · The American Association for the Surgery of Trauma (AAST) splenic injury scale, revised in 2018, is the most widely used grading system for splenic trauma.
[33]
Splenic Injury, Blunt, Selective Nonoperative Management of
Angiography with embolization should be considered for patients with AAST Grade greater than III injuries, presence of a contrast blush, moderate hemoperitoneum ...
[34]
Grade IV splenic injury: When to consult interventional radiology-a ...
Apr 30, 2024 · Splenectomy is often indicated for high-grade post-traumatic injuries and in patients who are hemodynamically unstable, while non-operative ...
[35]
An update on nonoperative management of the spleen in adults
Jun 9, 2017 · The indications for emergent splenectomy have remained consistent for years, that is, hemodynamic instability from hemorrhage and peritonitis. ...Spleen Anatomy And Its... · Splenic Injury Grades And... · Monitoring The Patient
[36]
Splenic trauma, the way forward in reducing splenectomy - RCSEng
Jan 7, 2020 · It has been suggested that patients with low-grade splenic injuries (AAST grade I–II) can safely be discharged following a period of clinical ...
[37]
American Society of Hematology 2019 guidelines for immune ...
Dec 3, 2019 · Long-term outcome following splenectomy for chronic and persistent immune thrombocytopenia (ITP) in adults and children: splenectomy in ITP.
[38]
Splenectomy for immune thrombocytopenia: down but not out | Blood
We try to avoid splenectomy within the first 12 months after ITP diagnosis for most patients to allow for spontaneous or therapy-induced remissions, ...Efficacy of splenectomy for ITP · Safety of splenectomy · Safety of splenectomy in...
[39]
Long-term outcomes in adults with chronic ITP after splenectomy ...
Aug 15, 2004 · Multiple studies show that corticosteroid treatment and splenectomy, alone or together, increase platelet counts to safe levels in 60% to 70% ...
[40]
Recommendations regarding splenectomy in hereditary hemolytic ...
- Indications for splenectomy in the intermediate forms of HS should be individually tailored based on spleen size and quality of life parameters (agreed by 95% ...
[41]
[PDF] Recommendations regarding splenectomy in hereditary hemolytic ...
Indications for splenectomy in hereditary spherocytosis based on severity of disease*. Disease. Hemoglobin Reticulocyte. Bilirubin. Indication for splenectomy.
[42]
Primary angiosarcoma of the spleen, a rare indication for splenectomy
In summary, angiosarcoma of the spleen is a rare tumor with a nonspecific presentation. Early diagnosis and splenectomy avoid splenic rupture and associated ...
[43]
Diagnostic and therapeutic splenectomy for splenic lymphomas
To examine the use of splenectomy, chemotherapy, and subsequent overall survival (OS) in contemporary patients with splenic lymphomas.
[44]
Splenectomy in cirrhosis with hypersplenism - Elsevier
Common indications were inability to treat with interferon, transfusion-dependent anemia, recurrent mucosal bleeds, and large spleen compromising quality of ...
[45]
Splenic Abscess - StatPearls - NCBI Bookshelf
Mar 20, 2025 · A splenic abscess is a localized infection within the splenic capsule, typically presenting with fever and leukocytosis.
[46]
Splenic Artery Aneurysm - StatPearls - NCBI Bookshelf
Preservation of the spleen is encouraged when possible, but splenectomy should be performed if adequate hemostasis is impossible to achieve otherwise.
[47]
[PDF] Management of Immune Thrombocytopenia (ITP)
In adults with newly diagnosed ITP, the ASH guideline panel recommends against a prolonged course (>6 weeks) of prednisone in favor of a short course (≤6 ...
[48]
Laparoscopic Spleen Removal (Splenectomy) Patient ... - SAGES
Preoperative preparation includes blood work, medical evaluation, chest x-ray and an EKG depending on your age and medical condition. Immunization with a ...
[49]
Altered Immunocompetence | Vaccines & Immunizations - CDC
Jun 26, 2024 · Pneumococcal, meningococcal, and Hib vaccinations should be administered at least 14 days before elective splenectomy, if possible. If the ...
[50]
http://www.surgicalcore.org/Search.aspx?q=blood%2Bcoagulation
[51]
Hand-assisted laparoscopic splenectomy versus open ... - NIH
Hand-assisted laparoscopic splenectomy is a safe and effective technique for the management of spleens larger than 20 cm. The technique results in shorter ...
[52]
Laparoscopic vs Open Splenectomy - JAMA Surgery
Laparoscopic splenectomy was attempted in 147 patients and completed successfully in 143. Four patients (2.7%) were converted to laparotomy for completion of ...
[53]
Laparoscopic splenectomy is emerging 'gold standard' treatment ...
Jun 24, 2015 · Since its first description by Delaitre and Maignien in 1991, laparoscopic splenectomy (LS) has evolved as treatment of choice for ...
[54]
Splenectomy for hematological disorders - Surgical Treatment - NCBI
A partial resection of the spleen may be necessary as a diagnostic procedure in suspected hematological disorders with inconclusive hematologic findings, or in ...Missing: complications | Show results with:complications
[55]
20 years' experience with laparoscopic splenectomy. Single center ...
The overall conversion rate was 3%, and the intraoperative complications rate was 5%. Postoperative morbidity was 8.6% and we noted mortality of 0.4% (2 ...
[56]
Hand-assisted laparoscopic splenectomy is a useful surgical ... - NIH
The advantages of LS over open splenectomy (OS) include less trauma, quicker recovery, and less postoperative pain[9-11]. However, patients with splenomegaly ...
[57]
Laparoscopic Splenectomy Technique - Medscape Reference
Nov 7, 2023 · ... splenectomy, a hand-assisted technique may reduce conversion rates and operating time. Single-port approaches to laparoscopic splenectomy ...
[58]
Minimally invasive splenectomy: an update and review - PMC - NIH
The present article is an update and review of current procedures and controversies regarding minimally invasive splenectomy.
[59]
How Long Does Splenectomy Surgery Take? - YouTube
Aug 7, 2025 · splinctomy surgery generally takes between 1 to 3 hours with laparoscopic procedures being on the shorter side and open surgeries taking longer.<|separator|>
[60]
Hand-Assisted Laparoscopic Splenectomy vs Conventional ...
This group noted favorable results with the hand-assisted technique, with a mean operative time of 177 minutes, an EBL of 463 mL, no conversions to open ...
[61]
Management of Postoperative Complications Following Splenectomy
Complications of post-splenectomy, especially intra-abdominal hemorrhage can be fatal, with delayed or inadequate treatment having a high mortality rate.
[62]
Short- and long-term outcomes of 486 consecutive laparoscopic ...
Apr 2, 2021 · The aim of the present study was to analyze the short- and long-term outcomes of LS in a single institution over 16 years, and to compare the ...
[63]
Medical complications following splenectomy - ScienceDirect.com
Splenectomy is attended by medical complications, principally infectious and thromboembolic; the frequency of complications varies with the conditions that led ...
[64]
Splenectomy for adult patients with idiopathic thrombocytopenic ...
Splenectomy has been a standard treatment for adult patients with idiopathic thrombocytopenic purpura (ITP) for more than 50 years.Methods · Results · Surgical ComplicationsMissing: physical | Show results with:physical<|separator|>
[65]
Splenectomy results from an 18-year single centre experience - PMC
Following emergency splenectomy, the operative morbidity and mortality rates were 13.5% (5 cases) and 21.6% (8 cases) respectively. This compares with 25.0% ( ...
[66]
Overwhelming post splenectomy infection syndrome – Review study
The same study showed a lifetime risk to be 5%. Asplenic patients have different ... risk of developing OPSI in the first two years after Splenectomy [11].
[67]
Postsplenectomy reactive thrombocytosis - PMC - NIH
Postsplenectomy reactive thrombocytosis has an incidence of about 75% to 82%. Thrombosis in association with elevated platelet count after splenectomy is well ...
[68]
Splenectomy and the incidence of venous thromboembolism and ...
Jun 6, 2013 · After splenectomy, patients with ITP have a higher risk of venous thrombosis and sepsis than patients with ITP who do not undergo ...
[69]
Histology, Howell Jolly Bodies - StatPearls - NCBI Bookshelf
Jul 27, 2024 · Although Howell-Jolly bodies are sensitive markers for asplenia, they are less effective for detecting mild forms of hyposplenism. Pitted ...
[70]
Long-term evaluation of the beneficial effect of subtotal splenectomy ...
Jan 15, 2001 · 9 Recent studies have also raised additional concerns regarding long-term complications after splenectomy, such as atherosclerotic events and ...
[71]
Post splenectomy related pulmonary hypertension - PMC - NIH
Splenectomy predisposes patients to a slew of infectious and non-infectious complications including pulmonary vascular disease. Patients are at increased risk ...
[72]
Persistent changes in circulating white blood cell populations after ...
In splenectomised patients (> 4 years), platelet counts and lymphocyte subsets are increased which persist over time.
[73]
Post-splenectomy sepsis: preventative strategies, challenges, and ...
Poorly opsonized bacteria such as encapsulated bacteria, in particular, Streptococcus pneumoniae, are often implicated in sepsis. The spleen is a ...
[74]
Variation in ICU Utilization and Mortality After Blunt Splenic Injury
Risk-adjusted ICU utilization rates for splenic trauma varied widely among trauma centers, with no clear relationship to mortality.
[75]
Patient-Controlled Analgesia - StatPearls - NCBI Bookshelf - NIH
Jan 29, 2023 · PCA has been proven to be more effective at pain control than non-patient-controlled opioid injections and results in higher patient ...Missing: splenectomy | Show results with:splenectomy
[76]
Adult Immunization Schedule Notes | Vaccines & Immunizations - CDC
Oct 7, 2025 · Elective splenectomy: 1 dose preferably at least 14 days before splenectomy. Hematopoietic stem cell transplant (HSCT): 3–dose series 4 weeks ...Missing: preoperative | Show results with:preoperative
[77]
Detection, Education and Management of the Asplenic or ... - AAFP
Feb 1, 2001 · Fulminant, potentially life-threatening infection is a major long-term risk after splenectomy or in persons who are functionally hyposplenic ...Missing: thrombocytosis | Show results with:thrombocytosis
[78]
Preventing infections in children and adults with asplenia
Dec 4, 2020 · In nonimmunocompromised populations, US and Australian guidelines recommend prophylaxis for 1 to 3 years after splenectomy or until a certain ...Prevention: vaccines · Prevention: patient and family... · Asplenia and coronavirus...
[79]
British Journal of Haematology | Wiley Online Library
Apr 10, 2024 · Vaccines should ideally be administered 2 weeks before or 2 weeks after splenectomy (Grade 1B), but they can be given at any time before or ...
[80]
No spleen? What you need to know to stay healthy - Harvard Health
Apr 24, 2020 · Additionally, it is usually recommended that people without a spleen have antibiotics that they carry with them (often referred to as “pill in ...
[81]
Cardiovascular effects of splenomegaly and splenectomy in beta ...
Assessment was performed before and 6 months after splenectomy and included hematological profile and resting echocardiography; total blood volume was also ...
[82]
Introduction of a Simple Technique for Partial Splenectomy in ...
Dec 5, 2013 · Patients with splenic injuries of up to stage IV and grade 3 shocks underwent partial splenectomy. The operations were performed without ...
[83]
Role of Partial Splenectomy in Hematologic Childhood Disorders
Nov 5, 2021 · The main advantage of partial splenectomy is the preservation of residual splenic tissue that can maintain the immune function of the spleen, ...
[84]
Laparoscopic partial splenectomy: indications and results ... - PubMed
Partial splenectomy is a good way to prevent postsplenectomy infections by preservation of the immune role of spleen in children with haematological diseases.
[85]
Partial splenectomy: Who, when and how. A systematic review of the ...
Results: Among 2130 PSs, indications for resection were hematological disease in 1013 cases and nonhematological conditions in 1078, including various tumors in ...
[86]
Splenectomy is contraindicated for thrombocytopenia secondary to ...
We believe that splenectomy is contraindicated in patients with portal hypertension and secondary hypersplenism.
[87]
Laparoscopic Partial Splenectomy for Splenic Hemangioma - NIH
After the partial splenectomy was firstly performed in 1980s, the first case of laparoscopic partial splenectomy was reported in the literature in 1990s.[2] ...
[88]
[PDF] livspleen.pdf - The Eastern Association for the Surgery of Trauma
Nonoperative management in children with splenic injuries rapidly gained currency because of the significant incidence and seriousness of post-splenectomy ...
[89]
Splenic trauma in the twenty-first century: changing trends in ... - NIH
A partial splenectomy or splenorrhaphy requires at least one-third of viable splenic tissue. Essential steps are atraumatic mobilisation of spleen ...
[90]
Partial splenectomy using a laparoscopic bipolar radiofrequency ...
Laparoscopic partial splenectomy is a safe, minimally invasive technique for the treatment of solitary splenic lymphangiomas in the splenic pole. We performed ...Case Report · Figure 1 · Discussion<|control11|><|separator|>
[91]
Partial Splenectomy for Splenic Cyst using a Bipolar ... - NIH
Partial splenectomy has been described using a unipolar “cool tip” radiofrequency (RF) [10] device or unipolar RF technology combined with adequate irrigation ...
[92]
Partial Splenectomy | SpringerLink
Partial splenectomy figures prominently in the early history of splenic surgery. As described in “The History of Splenectomy” (Morgenstern, this volume), ...
[93]
Laparoscopic partial splenectomy using the harmonic scalpel ... - NIH
Elective splenectomy is indicated in several conditions, including cysts, abscess and neoplasms of the spleen. In the asplenic patient, thrombocytosis and ...<|separator|>
[94]
Application of Laparoscopic Partial Splenectomy with Total Blood ...
Dec 20, 2024 · Subsequently, we employ intraoperative ultrasound to identify the boundary of the lesion and resect the corresponding portion of the spleen ...Missing: harmonic | Show results with:harmonic
[95]
Laparoscopic Partial Splenectomy: A Critical Appraisal of an ...
Although there is the obvious advantage of spleen partial preservation, PS has only slowly spread through the 1990s, and it is still not recognized as an option ...
[96]
Clinical analysis on comparison of outcomes between partial splenic ...
Aug 5, 2025 · Data from a study of 14 trauma centres showed that the non-surgical success rate of grade IV injuries in the AAST was 65.5%, and that the grade ...
[97]
A novel three-block method for laparoscopic partial splenectomy
Oct 21, 2025 · This emphasizes the need for surgical options that allow benign splenic lesion removal with splenic function preservation.