The surgery of the spleen

One of the few things you can do to a spleen surgically is to remove it. The indications for doing so (apart from trauma, 66.6) must be good, because the spleen of a tropical patient is commonly large, and is so firmly stuck to his diaphragm that: (1) Exposing it is difficult. (2) If he has portal hypertension he is likely to bleed from the vascular adhesions that join it to his diaphragm, and through which high pressure venous blood will be escaping into his systemic circulation. A further danger is the increased risk of subsequent infection (see below).

A Splenic abscess occurs occasionally. It starts acutely, it may become chronic, and it shows up radiologically as a fluid level in an irregular space. The pus is sterile, and he may have sickle cell disease. Drain it, don't try to remove his spleen.

Torsion of the spleen occurs when it has an exceptionally long pedicle, and is one of the rare indications for splenectomy. You are unlikely to make the diagnosis before you operate.

The tropical splenomegaly syndrome, which is an immune response to recurrent attacks of malaria, is responsible for nearly all large spleens in malarious areas. It responds to long courses of antimalarials[md]pyrimethamine or chloroquine weekly, or paludrine daily. Don't remove such spleens. This is only indicated if hypersplenism is a complication.

Sickle-cell anaemia in children sometimes benefits from splenectomy. This is rarely necessary, it is not urgent, and it is dangerous in an SS patient. If you really think it is indicated refer him.

KASHY (20 years) complained of a swelling in his right iliac fossa. Ordinarily, it was painless but during attacks of ''fever' it became painful and tender. At laparotomy, his whole spleen was found to be in his right iliac fossa, but his splenic vessels crossed his abdomen to their normal position. His ''wandering spleen' was removed easily. LESSON Some rare conditions have easy solutions.

SPLENECTOMY [s7]OTHER THAN FOR TRAUMA INDICATIONS. The strong indications are conditions in a patient's spleen itself, as: (1) Spontaneous rupture. (2) Torsion. (3) Wandering spleen. (4) Hydatid disease (31.13). (5) Tumours (very rare).

Splenectomy may also be indicated in: (6) Hypersplenism. (7) Idiopathic thrombocytopenia. (8) Myeloid leukaemia. (9) Congenital spherocytosis. (10) Sickle-cell disease (rarely). (11) As part of surgical operations which you are unlikely to do.

CAUTION ! (1) Don't operate lightly, your only definite indications for doing so are the first four. (2) If a patient's spleen is huge, think seriously about referring him: it may need a thoracoabdominal approach.

METHOD. Follow the method for the removal of the spleen for trauma in Section 66.6.

SPLENIC IMPLANTATION. Depending on the indications for splenectomy, consider the advisability of a splenic implant. Unless, there is: (1) an obvious accessory spleen, (2) malignant disease, or (3) hypersplenism. Keep some slices of spleen, say 5[mu]3[mu]0.5 cm, and implant them under the peritoneum in the side wall of his abdomen, or in his anterior abdominal wall (66.6). Or, place some 1 cm cubes of spleen on his omentum. They will usually take, and will reduce the severity of attacks of malaria and the danger of septicaemia, especially that due to pneumococci. In a malarious area, he must take prophylaxis against malaria for the rest of his life.