Surgery chapters
Spleen: splenic injury, splenectomy and OPSI
Anatomy and functions of the spleen, splenic trauma and its non-operative management, the indications, technique and complications of splenectomy, and how to prevent overwhelming post-splenectomy infection.
- The spleen is the commonest organ injured in blunt abdominal trauma; haemodynamically stable patients (especially children) are managed non-operatively with CT, observation and angioembolisation if needed; unstable patients go for splenectomy (or repair).
- Commonest indication for splenectomy is trauma; elective indications include ITP, hereditary spherocytosis, hypersplenism and en bloc cancer resection; the tail of the pancreas and the stomach (short gastrics) are at risk at operation.
- OPSI is caused mainly by encapsulated bacteria (Strep. pneumoniae first, H. influenzae b, N. meningitidis); prevent with vaccines (2 weeks before elective surgery, or before discharge after emergency splenectomy), penicillin prophylaxis and patient education.
On this page
Overview
The spleen is a soft, very vascular organ that filters blood and fights encapsulated bacteria. It is the organ most often injured in blunt abdominal trauma. Modern management tries to save the spleen when safe, because losing it leaves a lifelong risk of overwhelming post-splenectomy infection (OPSI).
Anatomy
- Normal adult weight is about 75-250 g (size up to roughly 10 by 7 by 3 cm). It sits under the 9th to 11th ribs on the left, with its long axis along the 10th rib.
- Notch on the inferolateral (anterior) border helps identify an enlarged spleen on examination.
- It must enlarge to about three times its normal size before it can be felt; it enlarges towards the right iliac fossa.
- Ligaments:
- Gastrosplenic ligament: carries the short gastric and left gastroepiploic vessels.
- Splenorenal (lienorenal) ligament: carries the splenic vessels and the tail of the pancreas.
- Splenocolic and phrenicocolic ligaments.
- Splenic artery: tortuous branch of the coeliac trunk, runs along the upper border of the pancreas, divides into segmental end arteries (this segmental supply allows partial splenectomy).
- Splenic vein runs behind the pancreas and unites with the SMV (behind the pancreatic neck), forming the portal vein.
- Splenunculi (accessory spleens): found in about 10-30% of people, mostly near the hilum or in the tail of the pancreas and omentum; must be removed at splenectomy for ITP or haemolytic anaemia, or the disease recurs.
Functions
| Function | What it means clinically |
|---|---|
| Filtering and culling | Removes old or abnormal red cells and platelets |
| Pitting | Removes inclusions from red cells: Howell-Jolly bodies (nuclear remnants), Heinz bodies |
| Immune | Makes opsonins (tuftsin, properdin) and IgM; macrophages clear encapsulated bacteria not well coated with antibody |
| Reservoir | Holds a small fraction of red cells and a pool of platelets |
| Haemopoiesis | Fetal life; again in myelofibrosis (extramedullary) |
Splenic injury
Causes
- Blunt trauma (road accidents, falls), especially to the left upper quadrant; often with left lower rib fractures.
- Penetrating trauma.
- Iatrogenic during left upper quadrant surgery (mobilising the splenic flexure, stomach, oesophagus or distal pancreas).
- Rupture of a diseased, enlarged spleen after trivial trauma: malaria, infectious mononucleosis, typhoid, leukaemia. Common in tropical countries.
Clinical features
- Left upper quadrant pain and tenderness; signs of haemorrhagic shock.
- Kehr sign: pain referred to the left shoulder tip from blood irritating the diaphragm (C3-5).
- Ballance sign: fixed dullness in the left flank with shifting dullness on the right.
- Delayed rupture: a subcapsular haematoma may burst days or weeks after the injury.
Investigations
- FAST ultrasound: quick bedside check for intraperitoneal blood in the unstable patient.
- Contrast-enhanced CT (stable patients only): grades the injury and shows active bleeding (contrast blush) and other injuries.
Grading (AAST, simplified)
| Grade | Injury |
|---|---|
| I | Small subcapsular haematoma (less than 10% surface) or capsular tear less than 1 cm deep |
| II | Haematoma 10-50% of surface or laceration 1-3 cm deep, not involving trabecular vessels |
| III | Haematoma over 50% or expanding, or laceration more than 3 cm deep or involving trabecular vessels |
| IV | Laceration involving segmental or hilar vessels with major devascularisation |
| V | Shattered spleen or hilar vascular injury devascularising the spleen |
Management
| Situation | Action |
|---|---|
| Haemodynamically stable, isolated injury, no peritonitis | Non-operative management (NOM): admit to HDU, bed rest, serial examination and haemoglobin, repeat imaging if needed |
| Stable with contrast blush, pseudoaneurysm or higher-grade injury | Splenic angioembolisation as part of NOM |
| Unstable (not responding to resuscitation), peritonitis, other injuries needing laparotomy, failed NOM | Laparotomy: splenectomy in the unstable or multiply injured patient; splenorrhaphy (suture, haemostatic agents, mesh wrap) or partial splenectomy if stable at operation |
- Children: NOM succeeds in most cases, because the paediatric spleen has a thicker capsule; operate only for instability.
- After NOM, advise avoiding contact sports for several weeks.
The decision between operation and observation depends on haemodynamic stability, not on the CT grade alone.
CT is for stable patients only. An unstable trauma patient with a positive FAST goes to theatre, not the scanner.
Splenectomy
Indications
| Group | Examples |
|---|---|
| Trauma (commonest) | Accidental injury, unstable patient; iatrogenic injury at other surgery |
| Haematological | ITP not responding to steroids (relapsing, persisting beyond about 6-9 months), hereditary spherocytosis, autoimmune haemolytic anaemia, thalassaemia with high transfusion needs or hypersplenism, sickle cell sequestration crises |
| Hypersplenism | Splenomegaly with cytopenias (portal hypertension, myelofibrosis, Gaucher disease, tropical splenomegaly) |
| Oncological | En bloc with radical gastrectomy or distal pancreatectomy; diagnostic or therapeutic in lymphoma and some leukaemias (hairy cell) |
| Local disease | Splenic abscess, symptomatic cysts (non-parasitic over about 5 cm, hydatid), splenic artery aneurysm, splenic vein thrombosis with gastric varices (sinistral portal hypertension), wandering spleen with torsion |
- ITP: about two-thirds of adults are cured by splenectomy. Most children recover spontaneously, so splenectomy is rarely needed.
- Hereditary spherocytosis: splenectomy cures the haemolysis but not the red cell defect; in children delay until about 6 years (OPSI risk); check for gallstones by ultrasound and remove the gallbladder at the same time if present.
Preparation for elective splenectomy
- Vaccinate at least 2 weeks before surgery: pneumococcal, Haemophilus influenzae type b, meningococcal (ACWY and B), plus yearly influenza.
- Correct anaemia; platelets available but given after the splenic artery is clamped in ITP.
- Ultrasound or CT to size the spleen and look for accessory spleens.
- DVT prophylaxis; antibiotic prophylaxis.
Technique (outline)
- Laparoscopic splenectomy is preferred for elective cases with normal or moderately enlarged spleens (patient in right lateral position).
- Open: midline or left subcostal incision; divide the short gastric vessels in the gastrosplenic ligament, divide the splenorenal ligament and rotate the spleen and pancreatic tail forward, then ligate the hilar vessels close to the spleen away from the pancreas.
- In massive splenomegaly or trauma, ligate the splenic artery early along the upper border of the pancreas.
- Search for and remove accessory spleens.
Complications of splenectomy
| Early | Late |
|---|---|
| Haemorrhage (slipped ligature, short gastric vessels) | OPSI |
| Left basal atelectasis and pleural effusion (very common) | Thromboembolism (DVT, portal or splenic vein thrombosis) |
| Pancreatic tail injury: pancreatitis, pancreatic fistula, collection | Incisional hernia |
| Gastric fundus injury (from short gastric ligation): necrosis and fistula; gastric dilatation | |
| Left subphrenic abscess | |
| Thrombocytosis (risk of thrombosis); aspirin if very high |
Blood changes after splenectomy: Howell-Jolly bodies, target cells, Heinz bodies, Pappenheimer bodies; raised platelets and white cells (can mimic sepsis).
The organ at greatest risk during splenectomy is the tail of the pancreas, which lies in the splenorenal ligament at the hilum.
Overwhelming post-splenectomy infection (OPSI)
- Rapid, fulminant sepsis (often with meningitis, DIC and adrenal haemorrhage) in an asplenic patient; high mortality even with treatment.
- Organisms: encapsulated bacteria: Streptococcus pneumoniae (commonest), Haemophilus influenzae type b, Neisseria meningitidis; also E. coli, Capnocytophaga canimorsus (dog bites) and severe malaria.
- Highest risk: young children (especially under 5), the first 2-3 years after splenectomy, splenectomy for haematological disease (thalassaemia, sickle cell) rather than trauma, and immunosuppressed patients. The risk lasts for life.
Prevention
- Vaccination: pneumococcal, Hib and meningococcal; at least 2 weeks before elective splenectomy, or after an emergency splenectomy when the patient has recovered (around 2 weeks after surgery, or before discharge if follow-up is uncertain). Boost pneumococcal vaccine about every 5 years; yearly influenza vaccine.
- Antibiotic prophylaxis: daily oral penicillin V (or amoxicillin; erythromycin if allergic), at least for the first 2-3 years and lifelong in high-risk patients; children usually until at least 16.
- Standby antibiotics at home to start at the first sign of fever, then seek urgent care.
- Education: medical alert card or bracelet; caution with animal bites and travel to malarial areas (strict mosquito protection and prophylaxis).
OPSI bugs are the "capsule club": Pneumococcus, Haemophilus, Meningococcus ("SHiN": Strep, Haemophilus, Neisseria).
Vaccination after an emergency splenectomy should be given once the patient has recovered (about 2 weeks), not left to the GP months later; antibody responses without a spleen are weaker, so prophylaxis is still needed.
Other splenic conditions
| Condition | Key points |
|---|---|
| Splenic artery aneurysm | Commonest visceral artery aneurysm; more in women; rupture risk is high in pregnancy (third trimester) with high maternal and fetal mortality; treat if symptomatic, enlarging or large, or in women of child-bearing age; embolisation or stenting, or surgery |
| Splenic infarction | Emboli (AF, endocarditis), sickle cell disease, myeloproliferative disorders, massive splenomegaly; left upper quadrant pain and friction rub; usually conservative |
| Splenic abscess | Endocarditis, IV drug use, immunosuppression; CT; percutaneous drainage and antibiotics, or splenectomy |
| Splenic cysts | Hydatid (Echinococcus), true (epidermoid) cysts, pseudocysts after trauma or pancreatitis; treat large or symptomatic cysts by partial splenectomy or deroofing |
| Hypersplenism | Splenomegaly with any combination of anaemia, leucopenia and thrombocytopenia, marrow hyperplasia and improvement after splenectomy |
| Wandering spleen | Lax ligaments; mobile mass; may twist and infarct; splenopexy or splenectomy |
Causes of massive splenomegaly (worth knowing)
Chronic myeloid leukaemia, myelofibrosis, chronic malaria (hyperreactive malarial splenomegaly), visceral leishmaniasis (kala-azar), Gaucher disease, thalassaemia major, schistosomiasis with portal hypertension.
Expect: the spleen as the commonest organ injured in blunt trauma; Kehr sign; non-operative management for stable patients and splenectomy for unstable ones; angioembolisation; splenectomy indications (trauma commonest, ITP, spherocytosis); structures at risk (tail of pancreas, stomach) and early complications (left basal atelectasis, bleeding, pancreatic fistula, subphrenic abscess, thrombocytosis); post-splenectomy blood film (Howell-Jolly bodies); OPSI organisms, timing of vaccines and penicillin prophylaxis; accessory spleens in ITP; spherocytosis surgery timing; splenic artery aneurysm in pregnancy.
Quick revision
- Spleen = commonest organ hurt in blunt trauma; Kehr sign = left shoulder tip pain.
- Stable: CT, non-operative management, embolise a blush. Unstable: laparotomy, splenectomy.
- Splenectomy indications: trauma (commonest), ITP, spherocytosis, hypersplenism, en bloc cancer surgery.
- At risk: tail of pancreas (fistula), stomach (short gastrics). Very common early complication: left basal atelectasis.
- After splenectomy: Howell-Jolly bodies, thrombocytosis.
- OPSI: pneumococcus, Hib, meningococcus; vaccinate 2 weeks before elective surgery or about 2 weeks after emergency surgery; penicillin V; alert card.
- Find accessory spleens in ITP. Delay spherocytosis splenectomy until about 6 years.
- Splenic artery aneurysm: commonest visceral aneurysm; ruptures in pregnancy.
Written by The House Job from standard references (Bailey & Love).
FAQ
Can a ruptured spleen be treated without surgery?
Yes. A haemodynamically stable patient, especially a child, with an isolated splenic injury on CT is usually observed closely, with angioembolisation if there is active bleeding; instability means theatre.
Which organism most often causes OPSI?
Streptococcus pneumoniae, followed by Haemophilus influenzae type b and Neisseria meningitidis.
When should vaccines be given for splenectomy?
At least 2 weeks before an elective operation, or about 2 weeks after an emergency splenectomy once the patient has recovered, and before discharge if follow-up is uncertain.
Why must accessory spleens be removed in ITP?
Remaining splenic tissue keeps destroying antibody-coated platelets, so the disease relapses if a splenunculus is left behind.
What are the common early complications after splenectomy?
Left lower lobe atelectasis with or without a pleural effusion is very common; bleeding, pancreatic fistula and subphrenic abscess are the important specific ones.