- Email: [email protected]
Partial splenectomy for nonparasitic splenic cysts
Partial Splenectomy for Nonparasitic Splenic Cysts
Leon Morgenstern, MD, Los Angeles, Stephen J. Shapiro, MD, Los Angeles,
California California
Splenic cysts, a rare cause of splenomegaly, are generally treated by splenectomy. Increased awareness of the late complications of splenectomy, principally sepsis, in both children and adults, has led to a recent trend toward conservatism in splenic surgery. Concomitantly, recent advances in operative techniques have made conservative surgical procedures on the spleen not only feasible but at times preferable to the standard procedure of splenectomy. We report the successful resection of intrasplenic cysts from four patients by partial splenectomy, with preservation of the normal splenic parenchyma.
g of microfibrillar collagen (AviteneQ) over the denuded medial splenic surface. Satisfactory hemostasis having been achieved, the spleen was replaced in its normal position in the left upper quadrant of the abdomen. An estimated 5 percent of the splenic parenchyma had been resected with the cyst. The region of the splenic dissection was drained for 24 hours with a 1 inch Penrose drain. No postoperative bleeding occurred. Recovery was uneventful, and the patient was discharged from the hospital on the 8th postoperative day. She has had no recurrence of the original symptoms. The pathologic diagnosis was intrasplenic cyst with mural calcification. No epithelial lining could be identified (Figure 2).
Case Reports
Case II. A 27 year old woman was admitted to the hospital with a 6 week history of epigastric pain that radiated to the left upper quadrant of the abdomen. Significant factors in the patient’s history were a vague memory of trauma to the upper left side of the abdomen at age 7 years and residence in the Basque region of Spain for 6 months at age 17 years. Abdominal examination disclosed a globular mass descending several cm below the left costal margin on deep inspiration. The mass was not tender. Significant laboratory and radiologic studies included a complement fixation test for Echinococcus, the results of which were positive; an upper gastrointestinal series that showed a large, round calcific mass in the left upper quadrant of the abdomen, interpreted as a probable calcified splenic cyst; and selective splenic arteriography which confirmed the presence of a 16 cm calcified cyst within the lower pole of the spleen (Figure 3). Abdominal exploration in January 1978 confirmed the presence of a large calcified splenic cyst occupying the lower pole of the spleen and extending beyond it (Figure 4). The operative procedure was partial splenectomy through a plane developed superior to the upper border of the cyst. Hemostasis was achieved by segmental splenic vascular ligation, hemoclips, fine vascular sutures and microfibrillar collagen (Avitene) applied topically for a small amount of residual surface oozing. The splenic remnant (an estimated 60 percent of total parenchyma) was returned to the left upper quadrant of the abdomen. The area was drained for 24 hours with a flat Jackson-Pratt suction drain,
Case I. A 48 year old woman consulted her physician for intermittent pain in the epigastrium and the left upper quadrant of the abdomen. Ten years earlier she had sustained mild abdominal trauma in a fall while skiing, but she could recall no specific symptoms immediately after that incident. The diagnosis of splenic cyst was established by splenic scan after abdominal films had shown the presence of a 10 cm rounded calcific mass in the left upper quadrant. The patient’s symptoms continued intermittently for 2 years, and then she was referred for surgical opinion regarding the advisability of splenectomy. On physical examination, the spleen was palpated 2.5 cm below the left costal margin on inspiration. Serial x-rays had shown no increase in the size of the mass. Because of continued discomfort in the left upper quadrant of the abdomen, operation was performed in July 1977. A 10 cm rounded cyst with patchy calcification of the entire wall was found occupying the hilar aspect of the spleen (Figure 1). The cyst was partially intrasplenic. Careful dissection of the cyst from the hilar vessels allowed its removal intact, with a 3 to 4 mm rim of normal splenic parenchyma overlying its most lateral portions. Hemostasis was obtained with fine hemoclips, suture of the small intrasplenic vessels with 5-O arterial silk and the use of 3.5 From the Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California. Reprint requests should be addressed to Leon Morgenstern, MD, Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, California 90048
278
The American Journal of Surgery
Partial Splenectomy
for Splenic
Cysts
Figure 7. Case I. Operative photograph of 10 cm splenic cyst in situ, arising from the hilar area.
Figure 3. Case II. Arteriogram showing the calcific rim of the cyst and displacement of the lower pole vessels of the spleen.
Figure 2. Case I. Typical interior of a hemisected traumatic cyst. Note the patchy hyalinized interior. The interior of the cyst in case II was practically identical.
The pathologic diagnosis was epidermoid cyst of the spleen, with intramural calcification. The postoperative coluse was uneventful, and the patient was discharged from the hospital on the 8th postoperative day. Case III. A 30 year old woman was admitted to the hospital for splenomegaly of undetermined origin. She had fallen from a bicycle 6 months hefore admission and sustained mild trauma to the left upper quadrant of the abdomen. She denied any symptoms in the left upper quadrant. Investigation during her initial hospital stay showed the splenomegaly to be secondary to the presence of’ a l-1 cm cystic mass occupying the upper pole of the spleen. The diagnosis was established both by ultrasound examination and computed tomography. No calcification wa< < .seen. On physical examination, the lower pole of the spleen wai felt 10 cm below the left costal margin and extended I o -he right of the midline. Because of the size of the cyst and its uncertain nature, elective resection of the cyst was
Vohme
139,
February
1980
Figure 4. Case II. Operative photograph of 18 cm cyst in situ, occupying the lower pole of the spleen.
decided on. In June 1978 operation was performed through a left-sided Kehr incision. Exploration revealed the presence of a tense cystic mass arising from the upper pole of the spleen, displacing the spleen and colon downward and the stomach medially. A moderate number of fine adhesions to the diaphragm and parietal peritoneum were present. The lower portion of the cyst was surrounded by a thin rim of splenic parenchyma (Figure 5). Partial splenectomy of the upper pole of the spleen including the cyst was accomplished through a plane below the inferior border of the cyst. Hemostasis was secured in the same manner noted in the previous cases. Avitene, 2.5 g, was applied to the raw area of splenic parenchyma for residual oozing. The raw area measured approximately 8
279
Partial Splenectomy
for Splenic Cysts
Figure 5. Case III. Operative photograph of 14 cm cyst in situ, arising from the upper pole of the spleen.
by 5.5 cm. Hemostasis was adequate. The left upper quadrant was drained with a Penrose drain, which was removed within 48 hours. The patient received 1 unit of autologous blood during the procedure. Her postoperative course was uneventful. She was discharged on the 7th postoperative day. The pathologic diagnosis was mesothelial cyst of the spleen. Case IV. A 25 year old woman entered the hospital with the chief complaints of left upper abdominal discomfort, cramping and postprandial diarrhea of approximately 2 months’ duration. Associated complaints were easy fatigability and an 8 pound weight loss. She denied abdominal trauma. The symptoms in the left upper abdominal quadrant had grown progressively worse. On examination the most striking finding was the presence of a mass filling the entire left upper quadrant of the abdomen. The mass descended with respiration. No bruits or friction rubs were heard over it. The platelet count was depressed to 125,000/mmz’. Computed tomography showed a large cystic mass, arising from the spleen, depressing the stomach, the colon and the left kidney. In preparation for operation, she was given an injection of antipneumococcal vaccine, and 1 unit of autologous blood was drawn for transfusion during operation if necessary.
Figure 6. Case IV. Operative photograph of 17 cm cyst in situ, arising from the upper pole of the spleen.
On August 11,19X3 the patient underwent partial splenectomy for a large splenic cyst arising from the upper pole (Figure 6). The estimated blood loss was 700 cm:‘. The superior portion of the cyst was densely adherent to the diaphragm, necessitating resection of a small portion of the diaphragm with the cyst. Approximately 70 percent of normal splenic parenchyma was conserved. The excised cyst measured 17 by 16 by 15 cm (Figure 7). A rim of normal splenic tissue surrounded a portion of it. The inner wall of the cyst was lined with white fibrous trabeculae distributed over the entire inner surface (Figure 8). The pathologic diagnosis was large cystic lymphangioma with mural fibrosis and scarifying perisplenic adhesions. The postoperative course was uneventful except for the occurrence of left pneumothorax, which was easily treated by insertion of a chest tube. She received no transfusions and was discharged on the 10th postoperative day. Comments
Cysts of the spleen have been the subject of several excellent reviews [l-4]. Some old reports describe puncture, drainage and attempted resection for the treatment of such cysts. In 1867 PCan [5] attempted resection of a large splenic cyst based on the as-
Figure 7, left. Case IV. Excised cyst with rim of spienic parenchyma. Figure 6, right. Case IV. Interior of hemisected lymphangiomatous cyst. Note the interfacing fibrous trabecutae.
280
The American Journal of Surgery
Morgenstern
sumpt,ion that a segmental splenic blood sup& existed. an assumption since proved correct. Ran’s at:,empted resection of the cyst proved unsuccessful because of difficulties with hemostasis, and the entii+e spleen was resected. The standard modern treatment of’ splenic cysts has been splenectomy. Cysts of the spleen may be parasitic, epidermoid or (presumably) post -traumatic. More rarely. other elements may give rise to cysts that are predominantly mesothelial, lymphangiomatous or hemangiomatous. Parasitic cysts are rarely encountered in this country. Complications of splenic cysts that have been reported include rupture [6], infection [7] and even hypertension hy renal compression [S]. The heightened susceptibility to infection in splenectomized patients, children as well as adults, has heen reported with increasing frequency (9-111. Splenectomy for operative trauma [12] as well as for mrjor blunt or penetrating trauma [23,14] has been challenged in favor of saving the spleen. Recent te:hnical advances in splenic surgery permit succe+sful topical hemostasis, repair and partial excision for various causes 1IS-1 71. For the usual epidermoid and “traumatic” cysts, which frequently are surrounded by a complete calcit’ic rim, there appears t.o be little justification for sacrifice of’ the entire adjacent normal spleen. The same is true for other nonparasitic cysts, such as those in our cases III and IV. Current surgical technique allows the removal of splenic cysts to be accomplished safely with preservation of the parenchyma and the function of the spleen. The operations reported herein illustrate the feasibility of this approach. Summary
Four cases of partial splenectomy parasitic splenic cysts are described. tients it was possible to successfully
Volume
139,
February
1990
for large, nonIn all four papreserve most
of the splenic parenchyma. alization of the importance feasibility of this operative is proposed.
and Shapiro
With the increasing reof’ splenic function, the approach to splenic cysts
References 1. Davis CE, Montero JM, VanHorn CN. Large splenic cysts. Ann Surg 1971;173:686-92. 2. Ross ME, Ellwood R, Yang SS. Lucas RJ. Epidermoid splenic cysts. Arch Surg 1977;112:596-9. 3. Eisenstat TE, Morris DW, Mason GR. Cysts of the spleen: report of a case and review of the literature. Am J Surg 1977; 134:635-7. 4. Robbins FG, Yellin AE, Lingua RW. Craig JR, Turrill FL, Mikkelsen WP. Splenic epidermoid cysts. Ann Surg 1978; 187:231-5. 5. Plan J. Ovariotomie et spl¬omie, 2nd. ed. Paris, Chez Germer-BailliBre, 1869, p 129-38. 6. Lippitt WH, Akhavan T, Caplan GE. Epidermoid cyst of the spleen with rupture and inflammation. Arch Surg 1967; 95:74-8. 7. Dibble JB, Weigent CE. Epidermoid cyst of the spleen presenting as an abdominal emergency: report of a case. JAMA 1965; 194:242-4. 8. Rakowski TA, Argy WP, Pierce L, Schreiner GE. Splenic cyst causing hypertension by renal compression. JAMA 1977; 238:2528-g. 9. Singer DB. Postspienectomy sepsis. Perspect Pediatr Pathol 1973;1:285-311. 10. Balfanz JR, Nesbit ME, Jarvis C, Krivit W. Overwhelming sepsis following splenectomy for trauma. J Pediatr 1976;88:458. 11. Likhite VV. Immunological impairment and susceptibility to infection after splenectomy. JAMA 1976;236:1376-7. 12. Morgenstern L. The avoidable complications of splenectomy. Surg Gynecol Obstet 1977;145:525-8. 13. Shandling B. Splenectomy for trauma. Arch Surg 1976;lll: 1325-6. 14. Aronson DZ, Scherz AW, Einhorn AH, Becker JM, Schneider KM. Nonoperative management of splenic trauma in children: a report of six consecutive cases. Pediatrics 1977;60: 482-5. 15. Morgenstern L, Kahn FH. Weinstein IM. Subtotal splenectomy in myelofibrosis. Surgery 1966;60:336-9. 16. Burrington JD. Surgical repair of a ruptured spleen in children. Arch Surg 1977;112:417-9. 17. Ratner MH, Garrow E, Valda V, Shashikumar VL, Somers LA. Surgical repair of the injured spleen. J Pediatr Surg 1977; 12:1019-25.
281
Leon Morgenstern, MD, Los Angeles, Stephen J. Shapiro, MD, Los Angeles,
California California
Splenic cysts, a rare cause of splenomegaly, are generally treated by splenectomy. Increased awareness of the late complications of splenectomy, principally sepsis, in both children and adults, has led to a recent trend toward conservatism in splenic surgery. Concomitantly, recent advances in operative techniques have made conservative surgical procedures on the spleen not only feasible but at times preferable to the standard procedure of splenectomy. We report the successful resection of intrasplenic cysts from four patients by partial splenectomy, with preservation of the normal splenic parenchyma.
g of microfibrillar collagen (AviteneQ) over the denuded medial splenic surface. Satisfactory hemostasis having been achieved, the spleen was replaced in its normal position in the left upper quadrant of the abdomen. An estimated 5 percent of the splenic parenchyma had been resected with the cyst. The region of the splenic dissection was drained for 24 hours with a 1 inch Penrose drain. No postoperative bleeding occurred. Recovery was uneventful, and the patient was discharged from the hospital on the 8th postoperative day. She has had no recurrence of the original symptoms. The pathologic diagnosis was intrasplenic cyst with mural calcification. No epithelial lining could be identified (Figure 2).
Case Reports
Case II. A 27 year old woman was admitted to the hospital with a 6 week history of epigastric pain that radiated to the left upper quadrant of the abdomen. Significant factors in the patient’s history were a vague memory of trauma to the upper left side of the abdomen at age 7 years and residence in the Basque region of Spain for 6 months at age 17 years. Abdominal examination disclosed a globular mass descending several cm below the left costal margin on deep inspiration. The mass was not tender. Significant laboratory and radiologic studies included a complement fixation test for Echinococcus, the results of which were positive; an upper gastrointestinal series that showed a large, round calcific mass in the left upper quadrant of the abdomen, interpreted as a probable calcified splenic cyst; and selective splenic arteriography which confirmed the presence of a 16 cm calcified cyst within the lower pole of the spleen (Figure 3). Abdominal exploration in January 1978 confirmed the presence of a large calcified splenic cyst occupying the lower pole of the spleen and extending beyond it (Figure 4). The operative procedure was partial splenectomy through a plane developed superior to the upper border of the cyst. Hemostasis was achieved by segmental splenic vascular ligation, hemoclips, fine vascular sutures and microfibrillar collagen (Avitene) applied topically for a small amount of residual surface oozing. The splenic remnant (an estimated 60 percent of total parenchyma) was returned to the left upper quadrant of the abdomen. The area was drained for 24 hours with a flat Jackson-Pratt suction drain,
Case I. A 48 year old woman consulted her physician for intermittent pain in the epigastrium and the left upper quadrant of the abdomen. Ten years earlier she had sustained mild abdominal trauma in a fall while skiing, but she could recall no specific symptoms immediately after that incident. The diagnosis of splenic cyst was established by splenic scan after abdominal films had shown the presence of a 10 cm rounded calcific mass in the left upper quadrant. The patient’s symptoms continued intermittently for 2 years, and then she was referred for surgical opinion regarding the advisability of splenectomy. On physical examination, the spleen was palpated 2.5 cm below the left costal margin on inspiration. Serial x-rays had shown no increase in the size of the mass. Because of continued discomfort in the left upper quadrant of the abdomen, operation was performed in July 1977. A 10 cm rounded cyst with patchy calcification of the entire wall was found occupying the hilar aspect of the spleen (Figure 1). The cyst was partially intrasplenic. Careful dissection of the cyst from the hilar vessels allowed its removal intact, with a 3 to 4 mm rim of normal splenic parenchyma overlying its most lateral portions. Hemostasis was obtained with fine hemoclips, suture of the small intrasplenic vessels with 5-O arterial silk and the use of 3.5 From the Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California. Reprint requests should be addressed to Leon Morgenstern, MD, Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, California 90048
278
The American Journal of Surgery
Partial Splenectomy
for Splenic
Cysts
Figure 7. Case I. Operative photograph of 10 cm splenic cyst in situ, arising from the hilar area.
Figure 3. Case II. Arteriogram showing the calcific rim of the cyst and displacement of the lower pole vessels of the spleen.
Figure 2. Case I. Typical interior of a hemisected traumatic cyst. Note the patchy hyalinized interior. The interior of the cyst in case II was practically identical.
The pathologic diagnosis was epidermoid cyst of the spleen, with intramural calcification. The postoperative coluse was uneventful, and the patient was discharged from the hospital on the 8th postoperative day. Case III. A 30 year old woman was admitted to the hospital for splenomegaly of undetermined origin. She had fallen from a bicycle 6 months hefore admission and sustained mild trauma to the left upper quadrant of the abdomen. She denied any symptoms in the left upper quadrant. Investigation during her initial hospital stay showed the splenomegaly to be secondary to the presence of’ a l-1 cm cystic mass occupying the upper pole of the spleen. The diagnosis was established both by ultrasound examination and computed tomography. No calcification wa< < .seen. On physical examination, the lower pole of the spleen wai felt 10 cm below the left costal margin and extended I o -he right of the midline. Because of the size of the cyst and its uncertain nature, elective resection of the cyst was
Vohme
139,
February
1980
Figure 4. Case II. Operative photograph of 18 cm cyst in situ, occupying the lower pole of the spleen.
decided on. In June 1978 operation was performed through a left-sided Kehr incision. Exploration revealed the presence of a tense cystic mass arising from the upper pole of the spleen, displacing the spleen and colon downward and the stomach medially. A moderate number of fine adhesions to the diaphragm and parietal peritoneum were present. The lower portion of the cyst was surrounded by a thin rim of splenic parenchyma (Figure 5). Partial splenectomy of the upper pole of the spleen including the cyst was accomplished through a plane below the inferior border of the cyst. Hemostasis was secured in the same manner noted in the previous cases. Avitene, 2.5 g, was applied to the raw area of splenic parenchyma for residual oozing. The raw area measured approximately 8
279
Partial Splenectomy
for Splenic Cysts
Figure 5. Case III. Operative photograph of 14 cm cyst in situ, arising from the upper pole of the spleen.
by 5.5 cm. Hemostasis was adequate. The left upper quadrant was drained with a Penrose drain, which was removed within 48 hours. The patient received 1 unit of autologous blood during the procedure. Her postoperative course was uneventful. She was discharged on the 7th postoperative day. The pathologic diagnosis was mesothelial cyst of the spleen. Case IV. A 25 year old woman entered the hospital with the chief complaints of left upper abdominal discomfort, cramping and postprandial diarrhea of approximately 2 months’ duration. Associated complaints were easy fatigability and an 8 pound weight loss. She denied abdominal trauma. The symptoms in the left upper abdominal quadrant had grown progressively worse. On examination the most striking finding was the presence of a mass filling the entire left upper quadrant of the abdomen. The mass descended with respiration. No bruits or friction rubs were heard over it. The platelet count was depressed to 125,000/mmz’. Computed tomography showed a large cystic mass, arising from the spleen, depressing the stomach, the colon and the left kidney. In preparation for operation, she was given an injection of antipneumococcal vaccine, and 1 unit of autologous blood was drawn for transfusion during operation if necessary.
Figure 6. Case IV. Operative photograph of 17 cm cyst in situ, arising from the upper pole of the spleen.
On August 11,19X3 the patient underwent partial splenectomy for a large splenic cyst arising from the upper pole (Figure 6). The estimated blood loss was 700 cm:‘. The superior portion of the cyst was densely adherent to the diaphragm, necessitating resection of a small portion of the diaphragm with the cyst. Approximately 70 percent of normal splenic parenchyma was conserved. The excised cyst measured 17 by 16 by 15 cm (Figure 7). A rim of normal splenic tissue surrounded a portion of it. The inner wall of the cyst was lined with white fibrous trabeculae distributed over the entire inner surface (Figure 8). The pathologic diagnosis was large cystic lymphangioma with mural fibrosis and scarifying perisplenic adhesions. The postoperative course was uneventful except for the occurrence of left pneumothorax, which was easily treated by insertion of a chest tube. She received no transfusions and was discharged on the 10th postoperative day. Comments
Cysts of the spleen have been the subject of several excellent reviews [l-4]. Some old reports describe puncture, drainage and attempted resection for the treatment of such cysts. In 1867 PCan [5] attempted resection of a large splenic cyst based on the as-
Figure 7, left. Case IV. Excised cyst with rim of spienic parenchyma. Figure 6, right. Case IV. Interior of hemisected lymphangiomatous cyst. Note the interfacing fibrous trabecutae.
280
The American Journal of Surgery
Morgenstern
sumpt,ion that a segmental splenic blood sup& existed. an assumption since proved correct. Ran’s at:,empted resection of the cyst proved unsuccessful because of difficulties with hemostasis, and the entii+e spleen was resected. The standard modern treatment of’ splenic cysts has been splenectomy. Cysts of the spleen may be parasitic, epidermoid or (presumably) post -traumatic. More rarely. other elements may give rise to cysts that are predominantly mesothelial, lymphangiomatous or hemangiomatous. Parasitic cysts are rarely encountered in this country. Complications of splenic cysts that have been reported include rupture [6], infection [7] and even hypertension hy renal compression [S]. The heightened susceptibility to infection in splenectomized patients, children as well as adults, has heen reported with increasing frequency (9-111. Splenectomy for operative trauma [12] as well as for mrjor blunt or penetrating trauma [23,14] has been challenged in favor of saving the spleen. Recent te:hnical advances in splenic surgery permit succe+sful topical hemostasis, repair and partial excision for various causes 1IS-1 71. For the usual epidermoid and “traumatic” cysts, which frequently are surrounded by a complete calcit’ic rim, there appears t.o be little justification for sacrifice of’ the entire adjacent normal spleen. The same is true for other nonparasitic cysts, such as those in our cases III and IV. Current surgical technique allows the removal of splenic cysts to be accomplished safely with preservation of the parenchyma and the function of the spleen. The operations reported herein illustrate the feasibility of this approach. Summary
Four cases of partial splenectomy parasitic splenic cysts are described. tients it was possible to successfully
Volume
139,
February
1990
for large, nonIn all four papreserve most
of the splenic parenchyma. alization of the importance feasibility of this operative is proposed.
and Shapiro
With the increasing reof’ splenic function, the approach to splenic cysts
References 1. Davis CE, Montero JM, VanHorn CN. Large splenic cysts. Ann Surg 1971;173:686-92. 2. Ross ME, Ellwood R, Yang SS. Lucas RJ. Epidermoid splenic cysts. Arch Surg 1977;112:596-9. 3. Eisenstat TE, Morris DW, Mason GR. Cysts of the spleen: report of a case and review of the literature. Am J Surg 1977; 134:635-7. 4. Robbins FG, Yellin AE, Lingua RW. Craig JR, Turrill FL, Mikkelsen WP. Splenic epidermoid cysts. Ann Surg 1978; 187:231-5. 5. Plan J. Ovariotomie et spl¬omie, 2nd. ed. Paris, Chez Germer-BailliBre, 1869, p 129-38. 6. Lippitt WH, Akhavan T, Caplan GE. Epidermoid cyst of the spleen with rupture and inflammation. Arch Surg 1967; 95:74-8. 7. Dibble JB, Weigent CE. Epidermoid cyst of the spleen presenting as an abdominal emergency: report of a case. JAMA 1965; 194:242-4. 8. Rakowski TA, Argy WP, Pierce L, Schreiner GE. Splenic cyst causing hypertension by renal compression. JAMA 1977; 238:2528-g. 9. Singer DB. Postspienectomy sepsis. Perspect Pediatr Pathol 1973;1:285-311. 10. Balfanz JR, Nesbit ME, Jarvis C, Krivit W. Overwhelming sepsis following splenectomy for trauma. J Pediatr 1976;88:458. 11. Likhite VV. Immunological impairment and susceptibility to infection after splenectomy. JAMA 1976;236:1376-7. 12. Morgenstern L. The avoidable complications of splenectomy. Surg Gynecol Obstet 1977;145:525-8. 13. Shandling B. Splenectomy for trauma. Arch Surg 1976;lll: 1325-6. 14. Aronson DZ, Scherz AW, Einhorn AH, Becker JM, Schneider KM. Nonoperative management of splenic trauma in children: a report of six consecutive cases. Pediatrics 1977;60: 482-5. 15. Morgenstern L, Kahn FH. Weinstein IM. Subtotal splenectomy in myelofibrosis. Surgery 1966;60:336-9. 16. Burrington JD. Surgical repair of a ruptured spleen in children. Arch Surg 1977;112:417-9. 17. Ratner MH, Garrow E, Valda V, Shashikumar VL, Somers LA. Surgical repair of the injured spleen. J Pediatr Surg 1977; 12:1019-25.
281