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Splenectomy
Splenectomy ARKELL M. VAUGHN, M.D., F.A.C.S. * JOHN M. COLEMAN, M.D. **
THE indications for surgical intervention in conditions of the spleen have been broadened. The results of splenectomy have improved, owing in great part to improved methods of diagnosis and the combined teamwork of the hematologist and surgeon. Antibiotic agents and chemotherapeutic drugs, blood coagulants, the availability of blood for transfusion, and improvements in anesthesia have likewise enhanced the successful outcome of splenic surgery. The operative mortality in most splenectomies is low. It is our purpose to clarify the indications for splenectomy, and describe a technique of operation which has proved successful. In discussing the broad latitude for removal of the spleen, we have attempted, nevertheless, to emphasize as well the contraindications to promiscuous splenectomy. We will describe some of the potential hazards and pitfalls, in order that the inexperienced surgeon may be cognizant of technical difficulties which may make operation difficult, sometimes impossible, and cause abandonment of splenectomy. The medical aspects and problems in conditions involving the spleen, and their systemic effects are not included in this discussion. The vast subject of pathology and symptomatology of splenopathy cannot be adequately discussed in this article. INDICATIONS
There are many indications for splenectomy. We have found the following conditions more likely to require removal of the spleen. Opinions among clinicians may differ, but despite the controversy which From the Departments of Surgery and Medicine, Stritch School of Medicine, Loyola University, Mercy and Cook County Hospitals, Chicago.
* Clinical Professor of Surgery, Stritch School of Medicine, Loyola University; Profeesor of Surgery, Cook County Graduate School of Medicine; Senior Attending Surgeon, Mercy Jl.ospital and Mercy Free Dispensary; Attending Surgeon, Cook County Hospital. ** Clinical Instructor, Department of Medicine, Stritch School of Medicine, Loyola University; Junior Attending Physician, Mercy Hospital. 93
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exists concerning the indications and contraindications for splenectomy in certain pathologic conditions, the final decision is not based upon diagnosis alone, but on the clinical experience and judgment of the hematologist and surgeon. Furthermore, it should be emphasized that some of the indications listed below would not in themselves necessitate laparotomy, but would occasionally be found during a surgical operation. We are of the opinion that the following indications might at one time or other require splenectomy. I. Trauma A. Rupture 1. Spontaneous 2. Penetrating wounds of the abdomen 3. Trauma caused by physical examination of a friable spleen B. Contusions of the abdomen C. Trauma associated with surgical procedures II. Hypersplenism A. Congenital hemolytic anemia B. Acquired hemolytic anemia C. Idiopathic thrombocytopenic purpura D. Splenic neutropenia caused by destruction of the white cells by the spleen E. Hemolytic anemia, caused by increased splenic hypersequestration with blood dyscrasias or infiltrating diseases of the spleen and reticuloendothelial system, including leukemia, in selected cases F. Primary splenic panhematocytopenia G. Secondary splenic panhematocytopenia H. Felty's syndrome III. Splenomegaly Due to Various Causes A. Inflammatory lesions of the spleen, due to tuberculosis or malaria B. Congestive splenomegaly (Banti's syndrome), portal hypertension due to thrombosis of splenic vein, obstruction of splenic vein due to compression by contiguous structure, and, rarely, cirrhosis C. Gaucher's disease, Niemann-Pick disease, Hand-SchUller-Christian disease, and other infiltrations of the spleen, in selected cases IV. Vascular Lesions of the Splenic Artery A. Thrombosis B. Embolus C. Rupture V. Tumors of the Spleen of Various Types A. Benign B. Malignant VI. Cyst of the Spleen In selected cases VII. Anomalies of the Spleen A. Aneurysm of splenic artery B. Wandering spleen or displacement C. Accessory or rudimentary spleen VIII. Splenectomy as an Adjunct to Other Major Surgery Requiring A. Gastrectomy
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Splenectomy B. Pancreatectomy C. Esophageal Resections IX. Miscellaneous A. Congenital diaphragmatic hernia with splenic displacement B. Torsion of the spleen PREOPERATIVE MANAGEMENT
The preoperative preparation should be that which is practiced routinely for major abdominal operations, during which considerable blood loss is anticipated. Blood transfusions should be given before operation if anemia is marked, and blood should be available during operation and after, should the necessity arise. Some authors believe that blood transfusion, although a life-saving measure in cases of traumatic lesions, is sometimes contraindicated in cases of idiopathic thrombocytopenic purpura haemorrhagica, and in hemolytic jaundice. If blood is given in thrombocytopenic purpura haemorrhagica, it should be freshly drawn blood, in which the platelets have not degenerated. In traumatic rupture of the spleen where an emergency operation is required, much preoperative preparation will of necessity have to be dispensed with, except for the treatment of shock. In elective cases, however, the following preoperative measures are advisable: 1. 2. 3. 4. 5. 6. 7. 8. 9.
Complete blood and differential count Urinalysis Blood platelet count Sternal puncture for bone marrow studies Wassermann or Kahn test Bleeding and coagulation time determinations Blood typing and cross-matching for compatible blood Special tests where indicated, such as the Coombs test Oral hygiene
Inuuediate Preoperative Orders
1. Soapsuds enema the night before operation. 2. Nothing by mouth for six hours before operation. 3. Barbiturates, usually Seconal 0.1 gram (1;!1 grains) the night before operation, to be repeated at 7 A.M. Small doses of narcotics, such as Demerol 50 mg. or more, if pain is present. 4. Morphine sulfate 10 mg. Oi grain) and atropine sulfate 0.4 mg. 7150 grain) one hour before operation or intravenously at time of operation. 5. Insert a Levin tube into the stomach before the patient goes to the operating room. This will decompress and aspirate the stomach, and make the operative procedure easier. (We do not insert a Levin tube in cases of thrombocytopenic purpura haemorrhagica because in this condition, there is an increase in the capillary permeability ahd hemorrhage may occur by its introduction.)
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6. The abdomen is prepared with a surgical liquid soap scrub, from the nipples to midthigh, and followed by the application of aqueous Zephiran. 7. Intravenous administration of 5 per cent glucose in water should be started, preferably in the long saphenous vein at the ankle or the cubital fossa, prior to or in conjunction with the blood transfusion. A cut.down may be necessary and a cannula inserted in the vein and held by a ligature. This cut-down is of special importance if blood is to follow physiological saline or glucose solution. Anesthesia
The choice of anesthesia depends upon the condition of the patient and preference of the surgeon or medical anesthetist. In most instances, inhalation anesthesia is preferable. The anesthetic agent depends upon the skill of the anesthetist. If, however, a skilled anesthetist is not available, ether, administered by the open drop method, is the safest and best anesthetic. TECHNIQUE
Splenectomy may be simple or extremely difficult, depending upon the size and mobility of the spleen. Large adherent spleens, most commonly seen in the splenic anemias, are the most difficult to remove. Incision. A long left paramedian incision (Fig. 30, a, inset) will usually give adequate exposure. A lateral transverse extension through the rectus muscle may be necessary (Fig. 30, b, inset). The Kocher left oblique subcostal incision may be used (Fig. 30, c, inset). However, the paramedian incision is recommended for the majority of patients and is our preference. Mobilization and Removal of the Spleen. After the abdomen has been opened, and unless rupture of the spleen is evident, the abdominal cavity is carefully explored for other lesions and the size and relationships of the spleen are noted. At this stage there are two alternatives. One is to ligate and section the splenic artery, which can be reached through the gastrocolic ligament, and then mobilize the spleen (Fig. 30). Ligation and section of the splenic artery, when applicable and possible, has advantages, namely (1) autotransfusion of the patient, since it has been estimated that between 250 and 500 cc. of blood is contained in a large congested spleen at the time of removal. A full dose of epinephrine as the abdomen is opened has been employed successfully to evacuate blood from the spleen into the general circulation. Gently squeezing the spleen after ligation of the artery will likewise throw more blood into the general circulation, and reduce the size of the spleen. (2) Reduction in the size of the spleen will
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occur after ligation of the splenic artery, and facilitate mobilization and removal. This reduction in size is sometimes dramatic. The other alternative is to mobilize the spleen, then ligate the splenic pedicle through a posterior approach which provides better exposure of both the tail of the pancreas and the major splenic vessels, and puts less tension on the pedicle (Fig. 31). Patients with splenic anemia and obese patients are best treated by this method, since ligation of the
Vasa. brevia
GastroSplenic hg.
Fig. 30. Technique of splenectomy. The gastroepiploic vessels have been ligated and their division is indicated with dotted line. The vasa brevia which are shown, will be ligated and divided separately.
splenic artery and vein is tedious and there is danger of severe hemorrhage due to injury of the friable artery and vein. The right hand is inserted into the wound and the spleen dissected free by cutting the lienorenal ligament, separating adhesions to the diaphragm, usually by finger dissection. Dense adhesions should be cut and ligated to prevent bleeding. We usually doubly clamp and ligate the vessels between the spleen and stomach (vasa brevia) before complete delivery of the spleen. As soon as the spleen is delivered into the wound, moist packs are placed in the splenic bed to control oozing, and to prevent the spleen from sliding back into the abdomen.
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The splenic pedicle is identified, and the splenic artery and vein, if possible, are ligated separately if this has not been done previously. Small vessels, the vasa brevia and the gastrosplenic ligament (Fig. 30) are separately clamped and ligated. The tail of the pancreas (Fig. 31), which may be adherent to the hilus of the spleen, is separated carefully. The vessels of the splenic pedicle are isolated and doubly ligated with a chromic No. 0 ligature. Silk may be used; however, there is danger of Ad.hesions to c:liaphragm
Fig. 31. Technique of splenectomy. The tail of the pancreas has been reflected laterally from the pedicle of splenic vessels and the latter are being ligated and divided segmentally.
cutting the friable vessels by its use. Transfixation sutures are dangerous, for a suture passed through one of the thin-walled veins is likely to tear and produce excessive bleeding. We prefer to ligate each group of vessels doubly and divide between ligatures, because clamps applied to such thin-walled vessels are likely to tear through them during subsequent manipulation. Ligatures should be placed at least Yz inch apart, in order to prevent them from slipping after the vessels are divided. After the last attachment is sever~d and the spleen is removed from the field, the warm moist packs in the splenic bed are removed, and any remaining bleeding points are controlled by suture. All tension on the splenic pedicle is then released and it is inspected carefully for bleeding points.
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When all hemorrhage has been controlled, the 'pedicle is allowed to drop into its bed. We make no attempt to suture it in place, but we may cover the raw surfaces with omentum. . The abdomen is 'closed without drainage. The abdominal wall is carefully closed since wound disruption after splt3hectomy is apt to occur. The peritoneum is closed with continuous No. 0 chromic catgut, the fascia with interrupted No. 1 chromic catgutrthe subcutaneous tissue with interrupted sutures of plain catgut, and the skin is closed by interrupted silk sutures. POSTOPERATIVE MANAGEMENT
The postoperative management is like that which is practiced for major abdominal operations. Specifically, the following procedures are advised: 1. Have the patient lie on either side, never on the back, during the postanesthesia recovery period. If the patient has emesis durijig this period there is danger of aspirating the stomach contents, with aspiration pneumonia developing. 2. Record blood pressure and pulse every half hour until the blood pressure is stabilized, then every three hours for the first 24 hours. 3. Give Pantopon 20 mg. C:l-i grain), or Demerol 50 to 100 mg., if indicated, every three hours for pain for the first 24 hours, and then a~ necessary. , 4. Have patient take ten deep breaths and move legs ten times every waking hour. Patient should be encouraged to cough up anS mucus in the throat, and should be turned on the side and slapped on the back to encourage coughing and deep breathing. This may prevent atelectasis! but if the temperature and pulse rise, and if physical examination reveals findings of atelectasis, emergency chest x-ray films should be taken. If diagnosis is confirmed, a catheter may be insetted through the nose into the bronchus and the mucus aspirated. If this is not successful, immediate bronchoscopy should be performed to relieve the obstruction. 5. Intravenous fluid should be continued until patient's oral intake is adequate. Intravenous saline is not given for'the first 24 hours unless .'": some special need arises. 6. Measure the intake and output of urine Ilnd give intravenous fluid, plasma, dextran or blood, as necessary for thE;) individual requirement. 7. Antibiotic agents should be given, when;indicated. . 8. Remove Levin tube when peristaltic sou*ds are audible or patient ,,' is passing gas. 9. Patient may be ambulatory, as a rule, af~er the first 24 hours. ~ 10. Low soapsuds enema on third or fourtli postoperative day." 11. After Levin tube is removed, patient should be given liquid diet, gradually increased to soft and then general diet. 12. Blood platelet count at least every 24 hours, for the first week.
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13. Anticoagulant therapy in indicated dosl1ge, if platelet count approaches 1,000,000. PITFALLS
It should be emphasized that in rare cases of splenomegaly the spleen may be so firmly fastened to the diaphragm and adjacent viscera that it is impossible to mobilize the organ and ligate its abnormal vascular pedicles. Even in some conditions in which splenectomy is definitely indicated, technical difficulties may be such that operation may have to be abandoned. A careful search should be made for an accessory spleen, particularly in idiopathic thrombocytopenic purpura haemorrhagica, congenital hemolytic aneJIlias, and in some cases of splenomegaly. Accessory spleens should be excised, except where splenectomy has been performed for rupture of the spleen, as they often simulate the spleen itself in size and pathologic character. Maingot,1 in a series of 100 consecutive partial or subtotal gastrectomies for chronic peptic ulcer, found an accessory spleen in the gastrosplenic omentum and in the great omentum in 13 cases. He reports that an accessory spleen is present in 15 to 35 per cent of all necropsies, and in about 30 per cent of familial hemolytic anemias. It would follow that failure to remove these accessory spleens would give a poor clinical result in hypersplenism. Trauma to the pancreas may occur because of the close proximity of the splenic artery and vein, which run along its upper edge. This is less apt to occur with the posterior approach. A pancreatic fistula may develop if the pancreas is injured. The kidney, colon and stomach must be protected from injury. Hemorrhage may arise from the surgical bed becl1use of uncontrolled arterial bleeding, or there may be general oozing secondary to liver disease and hypoprothrombinemia. The increased bleeding tendency, because of liver damage, increases the probability of this pitfall. Indiscreet autotransfusion, when the patient's blood count is adequate, may lead to sudden polycythemia and thrombosis. While some authors do not consider it advisable to ligate the splenic artery and shrink the spleen by manual compression and epinephrine, we have in selected cases utilized this method to replace the blood ·when there is present a marked anemia. CASE REPORTS CASE I. Congenital Hemolytic Anemia. W. B., a white man aged 40, with a known family history of anemia, was admitted to Mercy Hospital on July 7, 1953 for a splenectomy. About 7 years previously he had all, increased red cell fragility test and typical spherocytes were recogni:lled on peripheral smear.
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Physical examination was negative except for an enlarged spleen palpable two fingers breadths below the left costal margin. Laboratory findings on July 7, 1953 showed red blood cells 3,810,000 and white blood cells 5500 per cu. mm.; hemoglobin 11.5 grams, and platelets 152,400. Differential count showed polymorphonuclears 63 per cent, lymphocytes 33 per cent, and monocytes 1 per cent. On July 8, the abdomen was opened through a left pararectus incision. The splenic artery was ligated as a preliminary procedure, to give autotransfusion and to reduce the size of the spleen. A 665 gram spleen was removed. On July 17, the blood count showed red cells 4,580,000 and white cells 11,200 per cu. mm.; hemoglobin 14.5 grams, and platelets 270,000. Differential count showed polymorphonuclears 74 per cent, lymphocytes 15 per cent, and monocytes 5 per cent. The postoperative course was uneventful, and the patient was dismissed on the fourteenth postoperative day. CASE II. Ruptured Spleen with "Splenic Cake." H. M., a white man aged 48, was admitted to Mercy Hospital on October 22, 1947, because of episodes of paleness and chills, followed by weakness. On October 18, he had fallen, striking his abdomen against a doorknob of his automobile. There was no discomfort noted until October 20, when he complained of mild abdominal pain. The pain, described as stabbing in character, became so severe on October 21 that he did not return to work. He stated that the pain was most severe in the left upper quadrant. On the morning of October 22, he noted increasing thirst and attacks of chills and faintness. The past history was noncontributory. On physical examination breath sounds were decreased over the left lower lobe and left lung. The heart was normal except for a rate of 108. Blood pressure was 110/78. There was some abdominal distention. Bowel sounds were absent, and percussion revealed a tympanic note. There was diffuse abdominal tenderness with rebound tenderness. Cullen's sign was positive. Tenderness was more marked on the right side. The Murphy punch was positive on the left side. Bilateral inguinal hernia was present. The laboratory findings showed red blood cells 4,050,000 and white blood cells 27,300 per cu. mm.; hemoglobin 11.5 grams. Differential count showed polymorphonuclears 88 per cent and lymphocytes 12 per cent. The urine was normal. A flat plate of the abdomen was negative. Chest x-ray revealed a rounded area of increased density in the left base. Laparotomy was carried out on October 22. The spleen, when delivered into the wound, was found to be ruptured from end to end over the posterior surface. A large clot was attached to the ruptured spleen. Splenectomy was performed. The patient was returned to his room in good condition. The platelet counts were persistently elevated and in spite of adequate anticoagulant therapy, the patient had a mild cerebral thrombosis on October 30, and some evidence of a mesenteric thrombosis On October 31. Conservative measures were utilized successfully, and the patient was dismissed on the twenty-third postoperative day in good condition. CASE III. Trauma-Gunshot Wound of the Spleen. C. B., a white man aged 39, was admitted to Mercy Hospital on April 20, 1952 because of three penetrating gunshot wounds. The patient walked to the emergency room, and other than the complaint of pain in the left shoulder, left chest and abdomen, he was not as ill as might have been expected from the nature of the injury. Other history was lacking at this time.
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On physical examination temperature was 99.2° F., pulse 80, respiration 18, and blood pressure 132/82. The lungs were clear to auscultation and percussion. The heart rate and rhythm were normal. The abdomen was scaphoid, with questionable tenderness in the upper abdomen. The points of entry of the bullets were obvious at the distal end of the left humerus near the base of the olecrannon, at the left midclavicular line in the ninth intercostal space, and at the left iliac fossa. On admission, the patient was given morphine sulfate 16 mg. (~grain) and 500 cc. of plasma. The blood was typed and cross matched. Wangensteen suction was instituted after sufficient time had been given for a methylene blue tablet to identify any upper gastrointestinal perforation. Penicillin and tetanus toxoid were given. Because of increasing upper abdominal pain and pain in the left scapula which was thought to be referred,"a diagnosis of an acute abdominal emergency was made and preparations statted for immediate operation. X-ray films revealed no free air in the abdomen or chest, nor was there any perceptible drop in blood count. A laparotomy was performed on the day of admittance, through a left upper rectus incision. On examination, the spleen had a ragged lacerated wound which did not appear to be bleeding actively. The left diaphragm was lacerated from the bullets. When the spleen was freed, much free blood was aspirated into the left· pleural cavity through the gunshot wound in the left diaphragm. The pedicle was clamped and the fJpleen removed. The opening in the diaphragm was closed with interrupted chro~ic catgut sutures, after the lungs had been expanded, and the free blood forced out of the pleural cavity into the abdominal cavity. In the absence of other abdominal injury the abdomen was closed, and the patient returned to his room. The postoperative course. was uneventful, except for a left pneumothorax noted on the first postoperative day. The patient was dismissed on the tenth postoperative day, in excellent condition. COMPLICATIONS
The complications of splenectomy are those of any major abdominal surgical procedure. However, because of the nature of the underlying causes for splenectomy, secondary hemorrhage, thrombosis and infection are more prevalent. Secondary hemorrhage, after the patient has returned to his room, is always a serious possibility. In our experience, it is usually preventable by adequate hemostasis. Thrombosis probably occurs because of the rapid rise in platelets after splenectomy. The increase in size of the megakaryocytes which become prevalent in the bone marrow after splenectomy suggests a qualitative and quantitative change in platelets. A rising platelet count-certainly one approaching one million-requires anticoagulant therapy. Infection is more prone to develop after splenectomy in children, and particularly after congestive spl~nomegaly where liver damage exists. Antibiotic agents should be employed in children. Mel1,tion should be made of other complications which occur with less frequency, such as atelectasis, subdiaphragmatic abscess, thrombophlebitis, ascites, hemolytic crisis, and idiopathic diarrhea.
Splenectomy
103 DISCUSSION
Trauma is the most common indication for ~'plenectomy. Our mechanized era, with speeding automobiles, airplanes and tractors, has contributed to the increasing number of ruptured abdominal organs. The spleen is one of the most frequently involved, because of the absence of any substantial ligamentous attachments. The injured patient may present a picture of shock, or of a generally sick person slowly losing blood. The history of an injury, or of a penetrating wound with external evidence, and clinical findings to substantiate it, will often make the diagnosis of a ruptured spleen. Using the term hypersplenism in its broadest sense and not ignoring the probability of factors other than hypersequestration, hypersplenism is the next most common condition benefited by splenectomy. Congenital hemolytic anemia must be differentiated from acquired hemolytic anemia, since surgical intervention in the acquired type must be weighed much more clos~ly. The Coombs test is often the deciding factor in confirming the diagnosis of acquired hemolytic anemia. Primary and secondary thrombocytopenic purpura are differentiated frequently by a history of ingestion of an offending drug. Drugs may precipitate such a decrease in platelets. Timing for surgical intervention is a matter of clinical judgment. The patient may be aided by the use of steroids preoperatively. In certain conditions in which the relation of the spleen and bone marrow is disturbed, the granulocytes alone may be affected, leading to neutropenia. Careful study of the peripheral blood and bone marrow is indicated to rule out other causes of neutropenia, such as that produced by drugs or chemicals, aleukemie leukemia, lymphoblastoma and various infections. When hypersplenism involves all the elements of the bone marrow, there is a resulting neutropenia, anemia and thrombocytopenia, or socalled panhematocytopenia. The cause of this malady is unknown, with congenital and acquired types being described .. Bone marrow aspiration demonstrates hyperplasia of all the bone elements. Emergency splenectomy is often necessary to return the peripheral blood to normal levels. Lahey and N orcross 2 state that splenectomy is promising in panhematocytopenia. Secondary panhematocytopenia may be associated with many conditions, such as Hodgkin's disease, lymphobl~stoma, chronic malaria, rheumatoid arthritis, congestive splenomegaly, sarcoidosis, tuberculosis, Gaucher's disease, and certain drug sensitivities. In this group, selection of patients for splenectomy is a difficult problem, indeed, and depends on the underlying illness, causative factors, and/or response to medical management and clinical judgment.
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Recently, numerous articles have appeared discussing splenectomy in leukemia. Hunter and Kiernan3 reported a series of cases in which splenectomy in severe hemolytic anemia associated with leukemia promptly returned the red count to normal and produced a decrease in the leukocyte count. Selection should be determined by a falling red count. The white and platelet counts may be increased or decreased. However, the over-all benefit to the patient from splenectomy is disappointing. It has been suggested that infarction, or splenic softening, may play a role in producing hypersplenism in leukemia. Splenorenal or portacaval anastomosis, combined with splenectomy, is advisable at times in patients with portal hypertension. According to Maingot, operative mortality in portal hypertension is high, possibly because of the nature of the disease, errors in selection of patients for operation, and/or errors in technique of vascular surgery. It is our opinion, however, that in the hands of the skilled vascular surgeon with experience in portal hypertension, operative results are promising. A grossly enlarged spleen may be troublesome to the patient, and if the general status permits, removal may increase the patient's comfort. Inflammatory lesions of the spleen, such as malaria, typhoid and syphilis, may lead to eventual removal, although these are infrequent causes. Congestive splenomegaly or Banti's syndrome rarely, if ever, necessitates or permits removal of the spleen, if due to cirrhosis or schistosomiasis. The only indication for splenectomy in such a patient would be in association with a shunt procedure. However, in the presence of splenic vein obstruction whether due to thrombosis or external compression, removal may be curative. A more sudden change in arterial blood supply, whether caused by rupture, thrombosis or embolus, usually constitutes an acute abdominal emergency. Tumors of the spleen, whether primary endotheliomas, lymphangiomas or hemangiomas, are amenable to cure by surgery. Sarcomas of the spleen are often the local manifestation of a systemic disease and rarely, if ever, justify surgical removal. Lymphatic and traumatic cysts may cause enlargement sufficient to justify removal. Lymphatic cysts may rarely be part of polycystic disease. Echinococcal cyst is an occasional type of parasitic cysts of the spleen. Congenital aneurysm of the splenic artery and a misplaced or wandering spleen often become passively congested and consequently enlarged. Removal because of size is necessitated. A variety of miscellaneous conditions may be benefited by splenectomy. Torsion of the spleen requires urgent removal. Felty's syndrome, when accompanied by anemia, may be benefited by splenectomy. Ab-
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sence of a left diaphragm with displacement of the spleen may require removal when repair of the defect is carried out. Splenectomy for traumatic rupture of the spleen in the normal individual is followed usually by mild or moderate secondary anemia, which is most marked after one and one-half months. The anemia disappears usually in from three to twelve months. Polycythemia has been reported as following splenectomy but we have never observed it. The platelet count after splenectomy shows a marked increase up to 1,000,000 or more, falling to normal levels in a few days. Thrombosis of the stump of the splenic vein, with subsequent thrombosis of the portal veins, may occur. Anticoagulant drugs may be given immediately postoperatively to offset this danger. Percutaneous injection of the spleen has been done to demonstrate the contrast visualization of the portal veins, so-called splenoportophotography. It is used to determine whether portal hypertension is intrahepatic or extrahepatic, to demonstrate hepatic metastatic lesions, and to determine patency of portacaval shunts. This procedure is not, however, without danger. To our knowledge, however, no deaths have been reported. Hemorrhage may occur in the peritoneum after splenic puncture, which would necessitate immediate laparotomy and splenectomy. The merits of this procedure will have to wait further clinical evaluation. SUMMARY
Indications for splenectomy are described. The clinical considerations are discussed, and should be weighed in any diagnosis and decision relative to removal of the spleen. A technique for splenectomy, which .we have employed with satisfactory results, has been presented. Anatomical and technical difficulties and complications are explained. In the absence of a traumatic emergency, the possible benefit to the patient, in the light of the hematologic indications and contraindications, should be the deciding factor in the decision as to when splenectomy is indicated. REFERENCES 1. Maingot, R.: Splenectomy: Indications and Technique. Lancet 1 (3): 625-629 (March 29) 1952. 2. Lahey, F. and Norcross, J. W.: Splenectomy: When Is It Indicated. Ann. Surg. 128: 363-378 (Sept.) 1948. 3. Hunter, O. B. and Kiernan, P. C.: Splenectomy in Leukemia. Postgrad. Med. 8 (3): 207-213 (Sept.) 1950.
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THE indications for surgical intervention in conditions of the spleen have been broadened. The results of splenectomy have improved, owing in great part to improved methods of diagnosis and the combined teamwork of the hematologist and surgeon. Antibiotic agents and chemotherapeutic drugs, blood coagulants, the availability of blood for transfusion, and improvements in anesthesia have likewise enhanced the successful outcome of splenic surgery. The operative mortality in most splenectomies is low. It is our purpose to clarify the indications for splenectomy, and describe a technique of operation which has proved successful. In discussing the broad latitude for removal of the spleen, we have attempted, nevertheless, to emphasize as well the contraindications to promiscuous splenectomy. We will describe some of the potential hazards and pitfalls, in order that the inexperienced surgeon may be cognizant of technical difficulties which may make operation difficult, sometimes impossible, and cause abandonment of splenectomy. The medical aspects and problems in conditions involving the spleen, and their systemic effects are not included in this discussion. The vast subject of pathology and symptomatology of splenopathy cannot be adequately discussed in this article. INDICATIONS
There are many indications for splenectomy. We have found the following conditions more likely to require removal of the spleen. Opinions among clinicians may differ, but despite the controversy which From the Departments of Surgery and Medicine, Stritch School of Medicine, Loyola University, Mercy and Cook County Hospitals, Chicago.
* Clinical Professor of Surgery, Stritch School of Medicine, Loyola University; Profeesor of Surgery, Cook County Graduate School of Medicine; Senior Attending Surgeon, Mercy Jl.ospital and Mercy Free Dispensary; Attending Surgeon, Cook County Hospital. ** Clinical Instructor, Department of Medicine, Stritch School of Medicine, Loyola University; Junior Attending Physician, Mercy Hospital. 93
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exists concerning the indications and contraindications for splenectomy in certain pathologic conditions, the final decision is not based upon diagnosis alone, but on the clinical experience and judgment of the hematologist and surgeon. Furthermore, it should be emphasized that some of the indications listed below would not in themselves necessitate laparotomy, but would occasionally be found during a surgical operation. We are of the opinion that the following indications might at one time or other require splenectomy. I. Trauma A. Rupture 1. Spontaneous 2. Penetrating wounds of the abdomen 3. Trauma caused by physical examination of a friable spleen B. Contusions of the abdomen C. Trauma associated with surgical procedures II. Hypersplenism A. Congenital hemolytic anemia B. Acquired hemolytic anemia C. Idiopathic thrombocytopenic purpura D. Splenic neutropenia caused by destruction of the white cells by the spleen E. Hemolytic anemia, caused by increased splenic hypersequestration with blood dyscrasias or infiltrating diseases of the spleen and reticuloendothelial system, including leukemia, in selected cases F. Primary splenic panhematocytopenia G. Secondary splenic panhematocytopenia H. Felty's syndrome III. Splenomegaly Due to Various Causes A. Inflammatory lesions of the spleen, due to tuberculosis or malaria B. Congestive splenomegaly (Banti's syndrome), portal hypertension due to thrombosis of splenic vein, obstruction of splenic vein due to compression by contiguous structure, and, rarely, cirrhosis C. Gaucher's disease, Niemann-Pick disease, Hand-SchUller-Christian disease, and other infiltrations of the spleen, in selected cases IV. Vascular Lesions of the Splenic Artery A. Thrombosis B. Embolus C. Rupture V. Tumors of the Spleen of Various Types A. Benign B. Malignant VI. Cyst of the Spleen In selected cases VII. Anomalies of the Spleen A. Aneurysm of splenic artery B. Wandering spleen or displacement C. Accessory or rudimentary spleen VIII. Splenectomy as an Adjunct to Other Major Surgery Requiring A. Gastrectomy
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Splenectomy B. Pancreatectomy C. Esophageal Resections IX. Miscellaneous A. Congenital diaphragmatic hernia with splenic displacement B. Torsion of the spleen PREOPERATIVE MANAGEMENT
The preoperative preparation should be that which is practiced routinely for major abdominal operations, during which considerable blood loss is anticipated. Blood transfusions should be given before operation if anemia is marked, and blood should be available during operation and after, should the necessity arise. Some authors believe that blood transfusion, although a life-saving measure in cases of traumatic lesions, is sometimes contraindicated in cases of idiopathic thrombocytopenic purpura haemorrhagica, and in hemolytic jaundice. If blood is given in thrombocytopenic purpura haemorrhagica, it should be freshly drawn blood, in which the platelets have not degenerated. In traumatic rupture of the spleen where an emergency operation is required, much preoperative preparation will of necessity have to be dispensed with, except for the treatment of shock. In elective cases, however, the following preoperative measures are advisable: 1. 2. 3. 4. 5. 6. 7. 8. 9.
Complete blood and differential count Urinalysis Blood platelet count Sternal puncture for bone marrow studies Wassermann or Kahn test Bleeding and coagulation time determinations Blood typing and cross-matching for compatible blood Special tests where indicated, such as the Coombs test Oral hygiene
Inuuediate Preoperative Orders
1. Soapsuds enema the night before operation. 2. Nothing by mouth for six hours before operation. 3. Barbiturates, usually Seconal 0.1 gram (1;!1 grains) the night before operation, to be repeated at 7 A.M. Small doses of narcotics, such as Demerol 50 mg. or more, if pain is present. 4. Morphine sulfate 10 mg. Oi grain) and atropine sulfate 0.4 mg. 7150 grain) one hour before operation or intravenously at time of operation. 5. Insert a Levin tube into the stomach before the patient goes to the operating room. This will decompress and aspirate the stomach, and make the operative procedure easier. (We do not insert a Levin tube in cases of thrombocytopenic purpura haemorrhagica because in this condition, there is an increase in the capillary permeability ahd hemorrhage may occur by its introduction.)
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6. The abdomen is prepared with a surgical liquid soap scrub, from the nipples to midthigh, and followed by the application of aqueous Zephiran. 7. Intravenous administration of 5 per cent glucose in water should be started, preferably in the long saphenous vein at the ankle or the cubital fossa, prior to or in conjunction with the blood transfusion. A cut.down may be necessary and a cannula inserted in the vein and held by a ligature. This cut-down is of special importance if blood is to follow physiological saline or glucose solution. Anesthesia
The choice of anesthesia depends upon the condition of the patient and preference of the surgeon or medical anesthetist. In most instances, inhalation anesthesia is preferable. The anesthetic agent depends upon the skill of the anesthetist. If, however, a skilled anesthetist is not available, ether, administered by the open drop method, is the safest and best anesthetic. TECHNIQUE
Splenectomy may be simple or extremely difficult, depending upon the size and mobility of the spleen. Large adherent spleens, most commonly seen in the splenic anemias, are the most difficult to remove. Incision. A long left paramedian incision (Fig. 30, a, inset) will usually give adequate exposure. A lateral transverse extension through the rectus muscle may be necessary (Fig. 30, b, inset). The Kocher left oblique subcostal incision may be used (Fig. 30, c, inset). However, the paramedian incision is recommended for the majority of patients and is our preference. Mobilization and Removal of the Spleen. After the abdomen has been opened, and unless rupture of the spleen is evident, the abdominal cavity is carefully explored for other lesions and the size and relationships of the spleen are noted. At this stage there are two alternatives. One is to ligate and section the splenic artery, which can be reached through the gastrocolic ligament, and then mobilize the spleen (Fig. 30). Ligation and section of the splenic artery, when applicable and possible, has advantages, namely (1) autotransfusion of the patient, since it has been estimated that between 250 and 500 cc. of blood is contained in a large congested spleen at the time of removal. A full dose of epinephrine as the abdomen is opened has been employed successfully to evacuate blood from the spleen into the general circulation. Gently squeezing the spleen after ligation of the artery will likewise throw more blood into the general circulation, and reduce the size of the spleen. (2) Reduction in the size of the spleen will
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occur after ligation of the splenic artery, and facilitate mobilization and removal. This reduction in size is sometimes dramatic. The other alternative is to mobilize the spleen, then ligate the splenic pedicle through a posterior approach which provides better exposure of both the tail of the pancreas and the major splenic vessels, and puts less tension on the pedicle (Fig. 31). Patients with splenic anemia and obese patients are best treated by this method, since ligation of the
Vasa. brevia
GastroSplenic hg.
Fig. 30. Technique of splenectomy. The gastroepiploic vessels have been ligated and their division is indicated with dotted line. The vasa brevia which are shown, will be ligated and divided separately.
splenic artery and vein is tedious and there is danger of severe hemorrhage due to injury of the friable artery and vein. The right hand is inserted into the wound and the spleen dissected free by cutting the lienorenal ligament, separating adhesions to the diaphragm, usually by finger dissection. Dense adhesions should be cut and ligated to prevent bleeding. We usually doubly clamp and ligate the vessels between the spleen and stomach (vasa brevia) before complete delivery of the spleen. As soon as the spleen is delivered into the wound, moist packs are placed in the splenic bed to control oozing, and to prevent the spleen from sliding back into the abdomen.
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The splenic pedicle is identified, and the splenic artery and vein, if possible, are ligated separately if this has not been done previously. Small vessels, the vasa brevia and the gastrosplenic ligament (Fig. 30) are separately clamped and ligated. The tail of the pancreas (Fig. 31), which may be adherent to the hilus of the spleen, is separated carefully. The vessels of the splenic pedicle are isolated and doubly ligated with a chromic No. 0 ligature. Silk may be used; however, there is danger of Ad.hesions to c:liaphragm
Fig. 31. Technique of splenectomy. The tail of the pancreas has been reflected laterally from the pedicle of splenic vessels and the latter are being ligated and divided segmentally.
cutting the friable vessels by its use. Transfixation sutures are dangerous, for a suture passed through one of the thin-walled veins is likely to tear and produce excessive bleeding. We prefer to ligate each group of vessels doubly and divide between ligatures, because clamps applied to such thin-walled vessels are likely to tear through them during subsequent manipulation. Ligatures should be placed at least Yz inch apart, in order to prevent them from slipping after the vessels are divided. After the last attachment is sever~d and the spleen is removed from the field, the warm moist packs in the splenic bed are removed, and any remaining bleeding points are controlled by suture. All tension on the splenic pedicle is then released and it is inspected carefully for bleeding points.
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When all hemorrhage has been controlled, the 'pedicle is allowed to drop into its bed. We make no attempt to suture it in place, but we may cover the raw surfaces with omentum. . The abdomen is 'closed without drainage. The abdominal wall is carefully closed since wound disruption after splt3hectomy is apt to occur. The peritoneum is closed with continuous No. 0 chromic catgut, the fascia with interrupted No. 1 chromic catgutrthe subcutaneous tissue with interrupted sutures of plain catgut, and the skin is closed by interrupted silk sutures. POSTOPERATIVE MANAGEMENT
The postoperative management is like that which is practiced for major abdominal operations. Specifically, the following procedures are advised: 1. Have the patient lie on either side, never on the back, during the postanesthesia recovery period. If the patient has emesis durijig this period there is danger of aspirating the stomach contents, with aspiration pneumonia developing. 2. Record blood pressure and pulse every half hour until the blood pressure is stabilized, then every three hours for the first 24 hours. 3. Give Pantopon 20 mg. C:l-i grain), or Demerol 50 to 100 mg., if indicated, every three hours for pain for the first 24 hours, and then a~ necessary. , 4. Have patient take ten deep breaths and move legs ten times every waking hour. Patient should be encouraged to cough up anS mucus in the throat, and should be turned on the side and slapped on the back to encourage coughing and deep breathing. This may prevent atelectasis! but if the temperature and pulse rise, and if physical examination reveals findings of atelectasis, emergency chest x-ray films should be taken. If diagnosis is confirmed, a catheter may be insetted through the nose into the bronchus and the mucus aspirated. If this is not successful, immediate bronchoscopy should be performed to relieve the obstruction. 5. Intravenous fluid should be continued until patient's oral intake is adequate. Intravenous saline is not given for'the first 24 hours unless .'": some special need arises. 6. Measure the intake and output of urine Ilnd give intravenous fluid, plasma, dextran or blood, as necessary for thE;) individual requirement. 7. Antibiotic agents should be given, when;indicated. . 8. Remove Levin tube when peristaltic sou*ds are audible or patient ,,' is passing gas. 9. Patient may be ambulatory, as a rule, af~er the first 24 hours. ~ 10. Low soapsuds enema on third or fourtli postoperative day." 11. After Levin tube is removed, patient should be given liquid diet, gradually increased to soft and then general diet. 12. Blood platelet count at least every 24 hours, for the first week.
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13. Anticoagulant therapy in indicated dosl1ge, if platelet count approaches 1,000,000. PITFALLS
It should be emphasized that in rare cases of splenomegaly the spleen may be so firmly fastened to the diaphragm and adjacent viscera that it is impossible to mobilize the organ and ligate its abnormal vascular pedicles. Even in some conditions in which splenectomy is definitely indicated, technical difficulties may be such that operation may have to be abandoned. A careful search should be made for an accessory spleen, particularly in idiopathic thrombocytopenic purpura haemorrhagica, congenital hemolytic aneJIlias, and in some cases of splenomegaly. Accessory spleens should be excised, except where splenectomy has been performed for rupture of the spleen, as they often simulate the spleen itself in size and pathologic character. Maingot,1 in a series of 100 consecutive partial or subtotal gastrectomies for chronic peptic ulcer, found an accessory spleen in the gastrosplenic omentum and in the great omentum in 13 cases. He reports that an accessory spleen is present in 15 to 35 per cent of all necropsies, and in about 30 per cent of familial hemolytic anemias. It would follow that failure to remove these accessory spleens would give a poor clinical result in hypersplenism. Trauma to the pancreas may occur because of the close proximity of the splenic artery and vein, which run along its upper edge. This is less apt to occur with the posterior approach. A pancreatic fistula may develop if the pancreas is injured. The kidney, colon and stomach must be protected from injury. Hemorrhage may arise from the surgical bed becl1use of uncontrolled arterial bleeding, or there may be general oozing secondary to liver disease and hypoprothrombinemia. The increased bleeding tendency, because of liver damage, increases the probability of this pitfall. Indiscreet autotransfusion, when the patient's blood count is adequate, may lead to sudden polycythemia and thrombosis. While some authors do not consider it advisable to ligate the splenic artery and shrink the spleen by manual compression and epinephrine, we have in selected cases utilized this method to replace the blood ·when there is present a marked anemia. CASE REPORTS CASE I. Congenital Hemolytic Anemia. W. B., a white man aged 40, with a known family history of anemia, was admitted to Mercy Hospital on July 7, 1953 for a splenectomy. About 7 years previously he had all, increased red cell fragility test and typical spherocytes were recogni:lled on peripheral smear.
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Physical examination was negative except for an enlarged spleen palpable two fingers breadths below the left costal margin. Laboratory findings on July 7, 1953 showed red blood cells 3,810,000 and white blood cells 5500 per cu. mm.; hemoglobin 11.5 grams, and platelets 152,400. Differential count showed polymorphonuclears 63 per cent, lymphocytes 33 per cent, and monocytes 1 per cent. On July 8, the abdomen was opened through a left pararectus incision. The splenic artery was ligated as a preliminary procedure, to give autotransfusion and to reduce the size of the spleen. A 665 gram spleen was removed. On July 17, the blood count showed red cells 4,580,000 and white cells 11,200 per cu. mm.; hemoglobin 14.5 grams, and platelets 270,000. Differential count showed polymorphonuclears 74 per cent, lymphocytes 15 per cent, and monocytes 5 per cent. The postoperative course was uneventful, and the patient was dismissed on the fourteenth postoperative day. CASE II. Ruptured Spleen with "Splenic Cake." H. M., a white man aged 48, was admitted to Mercy Hospital on October 22, 1947, because of episodes of paleness and chills, followed by weakness. On October 18, he had fallen, striking his abdomen against a doorknob of his automobile. There was no discomfort noted until October 20, when he complained of mild abdominal pain. The pain, described as stabbing in character, became so severe on October 21 that he did not return to work. He stated that the pain was most severe in the left upper quadrant. On the morning of October 22, he noted increasing thirst and attacks of chills and faintness. The past history was noncontributory. On physical examination breath sounds were decreased over the left lower lobe and left lung. The heart was normal except for a rate of 108. Blood pressure was 110/78. There was some abdominal distention. Bowel sounds were absent, and percussion revealed a tympanic note. There was diffuse abdominal tenderness with rebound tenderness. Cullen's sign was positive. Tenderness was more marked on the right side. The Murphy punch was positive on the left side. Bilateral inguinal hernia was present. The laboratory findings showed red blood cells 4,050,000 and white blood cells 27,300 per cu. mm.; hemoglobin 11.5 grams. Differential count showed polymorphonuclears 88 per cent and lymphocytes 12 per cent. The urine was normal. A flat plate of the abdomen was negative. Chest x-ray revealed a rounded area of increased density in the left base. Laparotomy was carried out on October 22. The spleen, when delivered into the wound, was found to be ruptured from end to end over the posterior surface. A large clot was attached to the ruptured spleen. Splenectomy was performed. The patient was returned to his room in good condition. The platelet counts were persistently elevated and in spite of adequate anticoagulant therapy, the patient had a mild cerebral thrombosis on October 30, and some evidence of a mesenteric thrombosis On October 31. Conservative measures were utilized successfully, and the patient was dismissed on the twenty-third postoperative day in good condition. CASE III. Trauma-Gunshot Wound of the Spleen. C. B., a white man aged 39, was admitted to Mercy Hospital on April 20, 1952 because of three penetrating gunshot wounds. The patient walked to the emergency room, and other than the complaint of pain in the left shoulder, left chest and abdomen, he was not as ill as might have been expected from the nature of the injury. Other history was lacking at this time.
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On physical examination temperature was 99.2° F., pulse 80, respiration 18, and blood pressure 132/82. The lungs were clear to auscultation and percussion. The heart rate and rhythm were normal. The abdomen was scaphoid, with questionable tenderness in the upper abdomen. The points of entry of the bullets were obvious at the distal end of the left humerus near the base of the olecrannon, at the left midclavicular line in the ninth intercostal space, and at the left iliac fossa. On admission, the patient was given morphine sulfate 16 mg. (~grain) and 500 cc. of plasma. The blood was typed and cross matched. Wangensteen suction was instituted after sufficient time had been given for a methylene blue tablet to identify any upper gastrointestinal perforation. Penicillin and tetanus toxoid were given. Because of increasing upper abdominal pain and pain in the left scapula which was thought to be referred,"a diagnosis of an acute abdominal emergency was made and preparations statted for immediate operation. X-ray films revealed no free air in the abdomen or chest, nor was there any perceptible drop in blood count. A laparotomy was performed on the day of admittance, through a left upper rectus incision. On examination, the spleen had a ragged lacerated wound which did not appear to be bleeding actively. The left diaphragm was lacerated from the bullets. When the spleen was freed, much free blood was aspirated into the left· pleural cavity through the gunshot wound in the left diaphragm. The pedicle was clamped and the fJpleen removed. The opening in the diaphragm was closed with interrupted chro~ic catgut sutures, after the lungs had been expanded, and the free blood forced out of the pleural cavity into the abdominal cavity. In the absence of other abdominal injury the abdomen was closed, and the patient returned to his room. The postoperative course. was uneventful, except for a left pneumothorax noted on the first postoperative day. The patient was dismissed on the tenth postoperative day, in excellent condition. COMPLICATIONS
The complications of splenectomy are those of any major abdominal surgical procedure. However, because of the nature of the underlying causes for splenectomy, secondary hemorrhage, thrombosis and infection are more prevalent. Secondary hemorrhage, after the patient has returned to his room, is always a serious possibility. In our experience, it is usually preventable by adequate hemostasis. Thrombosis probably occurs because of the rapid rise in platelets after splenectomy. The increase in size of the megakaryocytes which become prevalent in the bone marrow after splenectomy suggests a qualitative and quantitative change in platelets. A rising platelet count-certainly one approaching one million-requires anticoagulant therapy. Infection is more prone to develop after splenectomy in children, and particularly after congestive spl~nomegaly where liver damage exists. Antibiotic agents should be employed in children. Mel1,tion should be made of other complications which occur with less frequency, such as atelectasis, subdiaphragmatic abscess, thrombophlebitis, ascites, hemolytic crisis, and idiopathic diarrhea.
Splenectomy
103 DISCUSSION
Trauma is the most common indication for ~'plenectomy. Our mechanized era, with speeding automobiles, airplanes and tractors, has contributed to the increasing number of ruptured abdominal organs. The spleen is one of the most frequently involved, because of the absence of any substantial ligamentous attachments. The injured patient may present a picture of shock, or of a generally sick person slowly losing blood. The history of an injury, or of a penetrating wound with external evidence, and clinical findings to substantiate it, will often make the diagnosis of a ruptured spleen. Using the term hypersplenism in its broadest sense and not ignoring the probability of factors other than hypersequestration, hypersplenism is the next most common condition benefited by splenectomy. Congenital hemolytic anemia must be differentiated from acquired hemolytic anemia, since surgical intervention in the acquired type must be weighed much more clos~ly. The Coombs test is often the deciding factor in confirming the diagnosis of acquired hemolytic anemia. Primary and secondary thrombocytopenic purpura are differentiated frequently by a history of ingestion of an offending drug. Drugs may precipitate such a decrease in platelets. Timing for surgical intervention is a matter of clinical judgment. The patient may be aided by the use of steroids preoperatively. In certain conditions in which the relation of the spleen and bone marrow is disturbed, the granulocytes alone may be affected, leading to neutropenia. Careful study of the peripheral blood and bone marrow is indicated to rule out other causes of neutropenia, such as that produced by drugs or chemicals, aleukemie leukemia, lymphoblastoma and various infections. When hypersplenism involves all the elements of the bone marrow, there is a resulting neutropenia, anemia and thrombocytopenia, or socalled panhematocytopenia. The cause of this malady is unknown, with congenital and acquired types being described .. Bone marrow aspiration demonstrates hyperplasia of all the bone elements. Emergency splenectomy is often necessary to return the peripheral blood to normal levels. Lahey and N orcross 2 state that splenectomy is promising in panhematocytopenia. Secondary panhematocytopenia may be associated with many conditions, such as Hodgkin's disease, lymphobl~stoma, chronic malaria, rheumatoid arthritis, congestive splenomegaly, sarcoidosis, tuberculosis, Gaucher's disease, and certain drug sensitivities. In this group, selection of patients for splenectomy is a difficult problem, indeed, and depends on the underlying illness, causative factors, and/or response to medical management and clinical judgment.
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Arkell M. Vaughn; John M. Coleman
Recently, numerous articles have appeared discussing splenectomy in leukemia. Hunter and Kiernan3 reported a series of cases in which splenectomy in severe hemolytic anemia associated with leukemia promptly returned the red count to normal and produced a decrease in the leukocyte count. Selection should be determined by a falling red count. The white and platelet counts may be increased or decreased. However, the over-all benefit to the patient from splenectomy is disappointing. It has been suggested that infarction, or splenic softening, may play a role in producing hypersplenism in leukemia. Splenorenal or portacaval anastomosis, combined with splenectomy, is advisable at times in patients with portal hypertension. According to Maingot, operative mortality in portal hypertension is high, possibly because of the nature of the disease, errors in selection of patients for operation, and/or errors in technique of vascular surgery. It is our opinion, however, that in the hands of the skilled vascular surgeon with experience in portal hypertension, operative results are promising. A grossly enlarged spleen may be troublesome to the patient, and if the general status permits, removal may increase the patient's comfort. Inflammatory lesions of the spleen, such as malaria, typhoid and syphilis, may lead to eventual removal, although these are infrequent causes. Congestive splenomegaly or Banti's syndrome rarely, if ever, necessitates or permits removal of the spleen, if due to cirrhosis or schistosomiasis. The only indication for splenectomy in such a patient would be in association with a shunt procedure. However, in the presence of splenic vein obstruction whether due to thrombosis or external compression, removal may be curative. A more sudden change in arterial blood supply, whether caused by rupture, thrombosis or embolus, usually constitutes an acute abdominal emergency. Tumors of the spleen, whether primary endotheliomas, lymphangiomas or hemangiomas, are amenable to cure by surgery. Sarcomas of the spleen are often the local manifestation of a systemic disease and rarely, if ever, justify surgical removal. Lymphatic and traumatic cysts may cause enlargement sufficient to justify removal. Lymphatic cysts may rarely be part of polycystic disease. Echinococcal cyst is an occasional type of parasitic cysts of the spleen. Congenital aneurysm of the splenic artery and a misplaced or wandering spleen often become passively congested and consequently enlarged. Removal because of size is necessitated. A variety of miscellaneous conditions may be benefited by splenectomy. Torsion of the spleen requires urgent removal. Felty's syndrome, when accompanied by anemia, may be benefited by splenectomy. Ab-
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sence of a left diaphragm with displacement of the spleen may require removal when repair of the defect is carried out. Splenectomy for traumatic rupture of the spleen in the normal individual is followed usually by mild or moderate secondary anemia, which is most marked after one and one-half months. The anemia disappears usually in from three to twelve months. Polycythemia has been reported as following splenectomy but we have never observed it. The platelet count after splenectomy shows a marked increase up to 1,000,000 or more, falling to normal levels in a few days. Thrombosis of the stump of the splenic vein, with subsequent thrombosis of the portal veins, may occur. Anticoagulant drugs may be given immediately postoperatively to offset this danger. Percutaneous injection of the spleen has been done to demonstrate the contrast visualization of the portal veins, so-called splenoportophotography. It is used to determine whether portal hypertension is intrahepatic or extrahepatic, to demonstrate hepatic metastatic lesions, and to determine patency of portacaval shunts. This procedure is not, however, without danger. To our knowledge, however, no deaths have been reported. Hemorrhage may occur in the peritoneum after splenic puncture, which would necessitate immediate laparotomy and splenectomy. The merits of this procedure will have to wait further clinical evaluation. SUMMARY
Indications for splenectomy are described. The clinical considerations are discussed, and should be weighed in any diagnosis and decision relative to removal of the spleen. A technique for splenectomy, which .we have employed with satisfactory results, has been presented. Anatomical and technical difficulties and complications are explained. In the absence of a traumatic emergency, the possible benefit to the patient, in the light of the hematologic indications and contraindications, should be the deciding factor in the decision as to when splenectomy is indicated. REFERENCES 1. Maingot, R.: Splenectomy: Indications and Technique. Lancet 1 (3): 625-629 (March 29) 1952. 2. Lahey, F. and Norcross, J. W.: Splenectomy: When Is It Indicated. Ann. Surg. 128: 363-378 (Sept.) 1948. 3. Hunter, O. B. and Kiernan, P. C.: Splenectomy in Leukemia. Postgrad. Med. 8 (3): 207-213 (Sept.) 1950.
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