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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
Splenectomy
Authors
Slee L. Yi1; Jessica L. Buicko Lopez2.
Affiliations
1 Florida Atlantic University
2 Florida Atlantic University/Bethesda Hospital
Last Update: May 6, 2024.
Continuing Education Activity
Splenectomy is a surgical procedure to remove the spleen that is typically performed to treat various clinical
conditions such as hematologic disorders, trauma, and certain cancers. Splenectomy may be performed via open,
laparoscopic, or robotic-assisted techniques. The spleen plays a crucial role in the immune system, filtering blood and
fighting infections, but its removal is sometimes necessary due to disease or injury. Splenectomy carries risks,
including bleeding, infection, and long-term complications such as an increased susceptibility to certain infections.
However, when performed appropriately, splenectomy can significantly improve the quality of life and alleviate
symptoms associated with underlying conditions.
This activity for healthcare professionals reviews the relevant anatomy and physiology, the indications for and
contraindications to, surgical techniques, and complications of splenectomy. The activity also underscores the
importance of the interprofessional team in improving outcomes for patients who require splenectomy.
Objectives:
Identify patients who will benefit from splenectomy based on their clinical history and presentation.
Apply best practices when performing splenectomy via any surgical approach.
Assess and treat the commonly encountered complications of splenectomy using appropriate pharmacological
and nonpharmacological interventions.
Develop and implement effective interprofessional team strategies to improve short- and long-term outcomes
for patients undergoing splenectomy.
Access free multiple choice questions on this topic.
Introduction
Splenectomy is a surgical procedure performed to remove the spleen, an organ located in the upper left side of the
abdomen. Once considered a vestigial organ, the spleen plays important roles in the immune system, including
filtering pathogens from the bloodstream, removing old or damaged red blood cells, and producing antibodies to help
fight infection.[1] Splenectomy is indicated in several clinical scenarios, including benign and malignant processes, as
well as for anatomical reasons and traumatic injuries.[1][2]
Depending on the underlying condition and diagnosis, splenectomy can be performed using open, laparoscopic, or
robotic-assisted techniques.[3] Each approach has advantages and considerations regarding recovery time,
postoperative pain, and complication risks. Although laparoscopic splenectomy is favored in developed nations, open
procedures remain common in the majority of resource-limited countries.[4]
Given the heightened risk of infections and other complications after a splenectomy, monitoring and medical followup are typically recommended to manage potential long-term effects and ensure continued well-being.
Anatomy and Physiology
A comprehensive understanding of the relevant anatomy is essential to effectively performing a splenectomy. The
spleen is situated in the left upper quadrant of the abdomen, positioned beneath the left posterolateral aspects of
the 9th to 11th ribs; its neighboring structures include the stomach, pancreas, colon, and left kidney. Despite
individual variability, the adult spleen measures approximately 12 cm in length, 7 cm in width, and 3 cm in thickness,
with an average weight of 150 grams.
The spleen is tethered to adjacent structures by various ligaments, notably the gastrosplenic and splenorenal
ligaments. The gastrosplenic ligament runs from the greater curvature of the stomach to the hilum of the spleen and
houses the short gastric arteries and the left gastroepiploic artery. The splenorenal ligament spans from the anterior
surface of the left kidney to the splenic hilum, accommodating splenic arteries. These ligaments provide structural
support and vascular connections critical for splenic function.
The splenic artery is the primary arterial supply to the spleen. Originating from the celiac trunk, the splenic artery
traverses along the upper margin of the pancreatic body and tail. Upon reaching the splenic hilum, the artery divides
into the short gastric artery, supplying the gastric fundus, and the left gastroepiploic artery, which runs along the
greater curvature of the stomach. These branches ensure adequate blood flow to the spleen and adjacent gastric
regions. Venous drainage occurs through tributaries that converge to form the splenic vein at the hilum. This vein
courses posterior to the pancreas and merges with the superior mesenteric vein, ultimately contributing to the
formation of the portal vein behind the pancreatic neck. The lymphatics of the spleen drain into the splenic hilar
lymph nodes and the retropancreatic lymph nodes.[5]
Accessory spleens occur in 10% to 30% of individuals; most are located at the splenic hilum.[6] However, accessory
spleens may be located near the pancreatic tail, gastrosplenic or splenorenal ligaments, and occasionally within the
mesentery.[7] Instances of accessory spleens located below the peritoneal reflection are exceptionally rare.[8]
Indications
The most common indications for splenectomy include:
Congenital hemolytic anemias and hemoglobinopathies
Hereditary spherocytosis
Hereditary elliptocytosis
Pyruvate kinase deficiency
Drepanocytosis or sickle cell disease [1]
Thalassemia
Acquired immunological disorders
Immune thrombocytopenic purpura
Autoimmune hemolytic anemia
Hematologic malignancies and myeloproliferative disorders
Various leukemias
Lymphoma [9]
Polycythemia vera
Myelofibrosis [10]
Hypersplenism
Metabolic storage disorders such as Gaucher or Niemann-Pick disease [11]
Infectious diseases including abscesses, schistosomiasis, malaria, and hydatid disease
Inflammatory disorders including Felty syndrome
Intrinsic splenic disorders such as cysts, hemangiomas, neoplasms, and splenic arterial aneurysms
Congestive disorders secondary to splenic or portal venous thrombosis or cirrhosis
Anatomical necessity
En bloc with the distal pancreas for pancreatic disease involving the body and tail of the pancreas [2]
En bloc with the stomach in a radical gastrectomy [12]
Trauma
The spleen is the most frequently affected organ in blunt abdominal trauma (35%–45% of cases) [13]
Splenic injury is a rare complication of colonoscopy [14][15]
Spontaneous rupture
Contraindications
While there are no absolute contraindications to splenectomy, certain factors warrant careful consideration,
particularly in patients with splenomegaly or portal hypertension. When the spleen exceeds 1000 g to 2000 g,
laparoscopic splenectomy may be challenging due to operative space restrictions, complicating dissection and
specimen extraction. Research indicates prolonged operative times, increased blood loss, and a higher likelihood of
conversion to open surgery in cases of splenomegaly compared to normal-sized spleens.[16] In such scenarios, if time
allows, splenic artery embolization may be considered to reduce spleen size and facilitate laparoscopic intervention.
[17]
Similarly, patients with portal hypertension face heightened bleeding risks attributable to esophagogastric varices and
thrombocytopenia. Consequently, these individuals may experience prolonged operative times, elevated blood loss,
and increased likelihood of requiring conversion to open surgery.[18]
Equipment
The equipment needed to perform a splenectomy varies depending on the surgical technique: open, laparoscopic, or
robotic-assisted.
For an open splenectomy, the following equipment is typically required:
Scalpel
Electrocautery device
For an open splenectomy, the patient is supine; the positioning of patients during laparoscopic splenectomy is a topic
of ongoing debate. Two approaches (using 3 patient positions) are commonly described: medial (anterior) and lateral
(hemilateral and lateral). The superiority of one technique over the other is debatable since both approaches have
well-known limitations.[24] The anterior position offers good visualization of the omental pouch and splenic hilum,
facilitating concurrent procedures and potential conversion to open laparotomy if needed. However, dissection of
ligament structures and dorsal vessels may be challenging, especially near the pancreatic tail. In contrast, the
hemilateral position, where the patient is placed in the right lateral decubitus position, provides easier access to the
posterior surface of the spleen and perisplenic ligaments, with simpler dissection and ligation of hilar vessels due to
sparing the pancreatic tail. This position is favored by many surgeons for its adjustability and improved access to
anatomic landmarks. The lateral position, with the abdomen vertical to the operating table, offers even easier
dissection of ligaments and hilar landmarks, potentially reducing the risk of pancreatic injury. Comparative studies
have shown the advantages of the lateral position, including shorter operative times, fewer complications, and shorter
hospital stays.[25] However, repositioning for conversion to open laparotomy is required. Ultimately, the choice of
patient position depends on the surgeon's preference.
Open Splenectomy
The patient is placed supine, and a time-out is conducted to verify the correct patient, procedure, site, and any
additional information. Endotracheal intubation is performed, and adequate lines and tubes, including arterial lines,
foley catheter, nasogastric or orogastric tube, and sequential compression devices, are placed. The abdomen is
prepped and draped in a sterile fashion. A vertical midline incision is made extending from the xiphoid process to the
pubic symphysis, or a left subcostal incision is made approximately 2 fingerbreadths below the costal margin
extending from midline to the anterior axillary line and deepened through the skin, subcutaneous tissue, fascia layers,
into the peritoneal cavity. All 4 quadrants of the abdomen are inspected, and a retractor is placed to aid in
visualization.
Adhesiolysis is performed as needed, and the gastrocolic ligament is incised to enter the lesser sac. The gastrosplenic
and splenocolic ligaments are divided and ligated, and the spleen is mobilized medially to expose the retroperitoneal
attachments. The splenorenal and splenophrenic ligaments are divided and ligated, followed by ligation of the splenic
artery and vein near the hilum using suture ligation or a vascular load stapler, with care taken to avoid injuries to the
pancreatic tail. The spleen is carefully passed off the field to prevent spillage, and hemostasis is obtained. If pancreatic
injuries are noted, a closed-suction drain may be placed. The abdomen is examined for accessory spleens, with the
most common location being in the hilum, and any accessory spleens are resected. Finally, the fascia is closed, and the
skin edges are reapproximated with staples or running subcuticular sutures.[25]
Laparoscopic Splenectomy
The patient is placed supine, and a time-out is conducted to verify the correct patient, procedure, site, and additional
information. General anesthesia induction follows, and the patient can be positioned in either the supine or right
lateral decubitus position, ensuring proper padding of all pressure points. Lines and tubes, including arterial lines,
foley catheter, nasogastric or orogastric tube, and sequential compression devices, are correctly placed, and the
abdomen is prepped and draped in a sterile fashion. The splenectomy procedure typically begins with obtaining
abdominal access, commonly using an open cutdown technique, an optical trochar system, or a Veress needle.
However, open cutdown is preferred in cases of massive splenomegaly, where the risk of injury is high.
Diagnostic laparoscopy is recommended before splenic mobilization to check for accessory spleens. Trocars are
placed based on surgeon preference, typically 1 in the left subcostal position just off the midline/subxiphoid region,
another in the left subcostal region in the anterior axillary line, and potentially an additional trocar laterally off the tip
of the eleventh rib for cases of splenomegaly. Posterior avascular attachments and short gastric vessels are divided to
retract the spleen and obtain access to the splenic hilum and pancreatic tail. The splenic hilum is then divided using an
endoscopic stapler with a vascular load, ensuring hemostasis and controlling staple line bleeding with clips or
hemostatic agents. In cases where the stapler is deemed unsafe, alternative methods such as electrothermal bipolar
vessel sealers or ultrasonic coagulating shears can be used to divide the hilar vessels safely. The spleen is grasped and
placed into a bag to avoid spillage of splenic tissue, especially in cases of malignancy. Morcellation is typically used
for spleen removal, except in cases where intact removal is necessary. Drainage is generally not recommended except
in cases of obvious or suspected pancreatic injury. The pneumoperitoneum is evacuated, and all trocars are removed.
The fascial port sites are closed to prevent incisional hernias, and the skin incisions are reapproximated.[25]
Hand-Assisted Laparoscopic Splenectomy
This laparoscopic variation is an alternative to standard laparoscopic splenectomy, particularly in cases of massive
splenomegaly where a conversion to open surgery may otherwise be necessary. Hand-assisted laparoscopic
splenectomy (HALS) combines the advantages of both open and laparoscopic techniques, enabling the surgeon's
nondominant hand to be inserted through hand-assist devices to maintain pneumoperitoneum and facilitate
intraoperative maneuvers. An additional incision, typically no more than 7 cm to 8 cm in length and strategically
positioned near the inferior pole of the enlarged spleen, allows for easier manipulation and removal of the spleen.
Despite the additional incision, HALS has been associated with fewer intraoperative complications, lower conversion
rates, shorter operative times, and, consequently, shorter hospital stays compared to open splenectomy. Notably,
patients with smaller spleen sizes are not typically candidates for HALS, while those with massive splenomegaly (>22
cm) can benefit greatly from this approach, which combines the benefits of minimally invasive surgery with the
technical advantages of hand assistance.[25]
Single-Incision Laparoscopic Splenectomy
The quest for minimally invasive and scarless surgical techniques has led to the development of single-incision
laparoscopic procedures, including single-incision laparoscopic splenectomy (SILS). In SILS, a single port is utilized
to insert working trocars into the abdominal cavity, typically through an umbilical or periumbilical incision. While
SILS follows the basic principles of laparoscopy, it poses technical challenges due to the proximity of surgical tools,
which are not specifically designed for SILS. Studies comparing SILS to standard laparoscopy have shown longer
operative times and increased blood loss with SILS, which are attributed to these technical difficulties. However,
SILS has comparable conversion, morbidity, and mortality rates to standard laparoscopy, with the added benefit of
potentially less postoperative pain for patients. With further technological advancements and increased experience,
SILS may become a more popular option for laparoscopic splenectomy.[25]
Robotic-Assisted Splenectomy
Since its introduction, robotic-assisted surgery has been hailed as an advanced iteration of laparoscopy, offering
inherent benefits that have garnered widespread acceptance across various surgical specialties. This extends to
splenectomy, where the robotic surgery platform is increasingly employed.[26] The reported advantages of robotics in
splenectomy stem from its enhanced magnification and maneuverability. Traditionally, much importance is given to
opening the lesser sac widely and dissecting the splenic vessels thoroughly. However, one study described a total
lateral approach via robotic-assisted splenectomy using lateral ports with a technical modification where entering the
lesser sac is wholly avoided.[27] Both techniques are described below:
Robotic-assisted technique with opening of the lesser sac
In a robotic-assisted splenectomy, when the lesser sac is opened, the patient is typically positioned in a
modified lithotomy position to allow optimal access to the abdomen. Following general anesthesia
induction and proper positioning, the abdomen is prepped and draped in a sterile fashion. The surgeon
makes small incisions for the robotic ports, typically placed in a configuration similar to laparoscopic
splenectomy. The robotic arms and camera are inserted through these ports. Using the robotic system, the
surgeon carefully dissects the peritoneal attachments to enter the lesser sac. The short gastric vessels are
divided, allowing access to the spleen and hilum. The splenic artery and vein are meticulously dissected
and ligated using robotic instruments. Care is taken to avoid injury to surrounding structures, including
the pancreas. Once the splenic vessels are secured, the remaining attachments to the spleen are dissected
using the robotic arms. The spleen is placed in an endoscopic retrieval bag and removed from the
abdomen through one of the ports. If necessary, morcellation techniques may be employed to facilitate
the extraction of the spleen. After confirming hemostasis and inspecting the surgical field, the robotic
arms are removed, and port sites are closed in the traditional fashion.
Robotic-assisted technique without opening of the lesser sac
Patients are positioned in the right lateral decubitus position with the left arm abducted to expose the
surgical field adequately. A flank cushion or bean bag is positioned beneath the right flank to elevate it
from the iliac crest, creating adequate working space within the abdominal cavity. Ports are meticulously
placed using the robotic system to ensure optimal access and visualization. The infraumbilical port is
inserted first, with additional ports following in a diagonal line parallel to the splenic axis. The robot is
then docked from the left side of the patient, targeting the splenic hilum for dissection. Dissection
commences with the division of the splenocolic ligament, facilitated by the suspended spleen providing
traction. Robotic instruments mobilize the inferior pole of the spleen, creating a window near the splenic
capsule for the division of the short gastric vessels. Unlike traditional methods, the gastrocolic omentum
remains intact. The splenic hilum is divided using a vascular endostapler, leaving the spleen free in the
abdomen for retrieval. A retrieval bag introduced through the assistant port or lateral robotic arm port
contains the spleen, which may be morcellated if necessary. Routine abdominal drainage is typically not
required.[27]
Complications
Splenectomy has associated intra- and postoperative complications; postoperative complications may occur early, in
the initial 3 postoperative months, or later.
Intraoperative Complications
Bleeding: most commonly secondary to injury of the splenic capsule or short gastric vessels during
mobilization. Conversion to laparotomy should be considered if adequate hemostasis cannot be achieved in a
timely fashion.
Injury to surrounding structures: the structures most commonly injured during splenectomy include the
stomach, colon, and pancreas. Pancreatic injuries can lead to acute pancreatitis, pancreatic fluid collection, and
possible pancreatic fistula.[28] Approximately 15% of laparoscopic splenectomies are complicated
by pancreatic injuries. A drain should be placed when a pancreatic injury is suspected.
Missed accessory spleen
Splenic rupture and splenosis
Early Postoperative Complications in the Three Months Following Splenectomy
OPSI: suspected when a patient exhibits a sudden systemic infection characterized by a rapid and
overwhelming onset following splenectomy, often accompanied by dermatorrhagia and disseminated
intravascular coagulation, despite the absence of an identifiable infection site.[25] OPSI may begin as a simple
respiratory infection that rapidly progresses to hyperpyrexia, headache, shivering, jaundice, anuria, septic
shock, acute respiratory distress syndrome, multiple organ dysfunction syndrome, coma, and death.[25]
Bleeding
Intrabdominal abscess: most commonly in the subphrenic space and secondary to an infected hematoma or
gastrointestinal tract injury. Drainage and antibiotics are typically required. These abscesses are more common
in patients with immune thrombocytopenic purpura for reasons that are not well understood.[9]
Venous thromboembolism (VTE): abdominal VTE is reported in 6% to 11% of patients following splenectomy.
[1] Portal vein thrombosis is a common and severe complication following splenectomy. The incidence is
reported to be 5% to 55%, but a recent meta-analysis published in 2018 suggests an incidence of 8.1%.[29]
[30] Portosplenomesenteric venous thrombosis represents one of the most severe complications of this
procedure.[10]
Pneumonia and atelectasis
Pancreatitis
Ileus
Abdominal wall infections
Abdominal wall hematomas
Abdominal wall hernias
Late Postoperative Complications
Infections: the lifetime risk of OPSI is approximately 1% to 3%.[1] Patients without a spleen have a 200-fold
increased risk of death from septicemia compared to patients with a normally functioning spleen.[2] Asplenic
patients are at risk for other bacterial and viral infections due to immunosuppression.[2]
Cancer: splenectomized patients have an increased risk of cancer, as well as increased cancer-related mortality.
The risk for cancer development is greatest during the first 2 to 5 years after splenectomy. However, a persistent
risk beyond 10 years after a splenectomy has been described.[1]
Abdominal wall hernias
Clinical Significance
The clinical significance of splenectomy lies in its therapeutic role in various medical conditions and its implications
for long-term health and well-being. Splenectomy is performed for a range of indications, including both benign and
malignant conditions such as hematologic disorders, splenic trauma, splenic cysts, and certain solid tumors. While
splenectomy can alleviate symptoms, prevent complications, and improve overall patient outcomes, there are potential
risks and long-term implications.
Patients undergoing splenectomy are at increased risk of infections, particularly from encapsulated bacteria, due to
compromised immune defenses. Therefore, lifelong monitoring and preventive measures, such as vaccinations and
antibiotic prophylaxis, are often necessary to mitigate these risks. Additionally, splenectomy may impact hematologic
parameters, changing blood cell counts and potentially increasing the risk of thrombotic events.
Overall, while splenectomy can offer therapeutic benefits for certain medical conditions, clinicians must carefully
weigh the potential risks and benefits and provide comprehensive postoperative care to optimize patient outcomes and
minimize complications.
Enhancing Healthcare Team Outcomes
Regarding splenectomy, a multidisciplinary healthcare team collaborates to ensure comprehensive patient care,
optimal outcomes, and safety. Physicians, advanced practitioners, nurses, pharmacists, and other healthcare
professionals play distinct yet interconnected roles. Physicians and surgeons utilize their surgical expertise to perform
the procedure effectively, employing the latest techniques, such as laparoscopic or robotic-assisted approaches, to
minimize patient trauma and enhance recovery. Advanced practitioners, including physician assistants and nurse
practitioners, contribute to patient care through preoperative evaluations, postoperative monitoring, and assisting in
surgical procedures. Nurses are pivotal in patient advocacy, providing preoperative education, postoperative care, and
monitoring for complications, including vigilance for signs of postsplenectomy infections. Pharmacists ensure
appropriate medication management, including prophylactic antibiotics to reduce infection risk postoperatively,
vaccinations to prevent infection, and educating patients about medication adherence and potential side effects.
Interprofessional communication and care coordination are essential components of patient-centered care in
splenectomy. Effective communication among team members facilitates seamless care transitions, ensures timely
interventions, and reduces the risk of errors. Care coordination involves integrating services across disciplines,
ensuring patients receive holistic care from diagnosis to postoperative follow-up. Regular multidisciplinary team
meetings allow for discussion of complex cases, shared decision-making, and coordination of care plans tailored to
individual patient needs. By fostering collaboration and communication among healthcare professionals, splenectomy
patients benefit from a cohesive, patient-centered approach that optimizes outcomes, enhances patient safety, and
improves overall team performance.
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References
1. Abduljalil M, Saunders J, Doherty D, Dicks M, Maher C, Mehigan B, Flavin R, Flynn CM. Evaluation of the risk
factors for venous thromboembolism post splenectomy - A ten year retrospective cohort study in St James's
hospital. Ann Med Surg (Lond). 2021 Jun;66:102381. [PMC free article: PMC8131975] [PubMed: 34026114]
2. Camejo L, Nandeesha N, Phan K, Chharath K, Tran T, Ciesla D, Velanovich V. Infectious outcomes after
splenectomy for trauma, splenectomy for disease and splenectomy with distal pancreatectomy. Langenbecks Arch
Surg. 2022 Jun;407(4):1685-1691. [PMC free article: PMC8786199] [PubMed: 35075620]
3. Mazzola M, Crippa J, Bertoglio CL, Andreani S, Morini L, Sfondrini S, Ferrari G. Postoperative risk of pancreatic
fistula after distal pancreatectomy with or without spleen preservation. Tumori. 2021 Apr;107(2):160-165.
[PubMed: 32635820]
4. Khan MA, Kamran H, Ullah R, Zarin M. Laparoscopic Splenectomy; Single Surgeon, Single Centre Initial
Experience At Tertiary Level Hospital In Peshawar. J Ayub Med Coll Abbottabad. 2021 Jul-Sep;33(3):488-491.
[PubMed: 34487663]
5. Skandalakis PN, Colborn GL, Skandalakis LJ, Richardson DD, Mitchell WE, Skandalakis JE. The surgical
anatomy of the spleen. Surg Clin North Am. 1993 Aug;73(4):747-68. [PubMed: 8378819]
6. Mohammadi S, Hedjazi A, Sajjadian M, Ghrobi N, Moghadam MD, Mohammadi M. Accessory Spleen in the
Splenic Hilum: a Cadaveric Study with Clinical Significance. Med Arch. 2016 Oct;70(5):389-391. [PMC free
article: PMC5136441] [PubMed: 27994303]
7. Yildiz AE, Ariyurek MO, Karcaaltincaba M. Splenic anomalies of shape, size, and location: pictorial essay.
ScientificWorldJournal. 2013;2013:321810. [PMC free article: PMC3654276] [PubMed: 23710135]
8. Liu X, Li W, Qu J. Accessory spleen below the peritoneal reflection masquerading as metastatic rectal cancer: A
case study. Asian J Surg. 2024 Jun;47(6):2880-2881. [PubMed: 38383194]
9. Weledji EP. Benefits and risks of splenectomy. Int J Surg. 2014;12(2):113-9. [PubMed: 24316283]