Spleen: surgical diseases and injuries. Blood disorders and diseases of surgical importance
ANATOMY AND FUNCTIONS
The spleen lies in the left upper quadrant beneath ribs 9–11, with the long axis parallel to the tenth rib. It is intraperitoneal except at the hilum and is related to the stomach, left kidney, colon and diaphragm. The splenic artery arises from the coeliac trunk; venous drainage joins the portal system. Functions include filtration of abnormal erythrocytes, immune response to encapsulated bacteria, platelet and blood-cell sequestration, and removal of opsonised organisms.
SURGICAL DISEASES
Splenomegaly occurs in portal hypertension, haematological malignancy, haemolytic disease, infection and infiltrative disorders. Hypersplenism produces cytopenias due to pooling/destruction of blood cells. Splenic cysts may be congenital, post-traumatic or parasitic (hydatid). Splenic abscess is uncommon and associated with bacteraemia, endocarditis or immunosuppression; fever and left-upper-quadrant pain prompt imaging and antibiotics with drainage or splenectomy in selected cases. Primary splenic tumours are rare; lymphoma and metastases are more common than primary solid malignancy.
SPLENIC INJURY
Blunt abdominal trauma is the commonest cause, often from road traffic collisions, falls or sports. Injury ranges from subcapsular haematoma to laceration, hilar disruption and active haemorrhage. Patients may have left upper-quadrant pain, referred left shoulder pain (Kehr sign), abdominal tenderness, tachycardia or shock. A normal early haemoglobin does not exclude major bleeding. Evaluate with ATLS primary survey, eFAST and contrast CT in haemodynamically stable patients. CT grades injury and identifies contrast blush, pseudoaneurysm and associated injuries.
MANAGEMENT OF TRAUMA
Unstable patients with suspected intra-abdominal haemorrhage require immediate resuscitation and operative control; do not delay for CT. Stable patients are often managed non-operatively with monitoring, serial examination and haemoglobin, with angiographic embolisation for selected vascular injuries or higher-grade injuries. Splenectomy is required for persistent instability, uncontrolled bleeding, hilar disruption or failed non-operative management. Splenic salvage is preferred where safe, particularly in children. After splenectomy, vaccinate against pneumococcus, meningococcus and Haemophilus influenzae type b according to national schedule, educate about urgent assessment for fever, and use antibiotic prophylaxis in selected patients.
HAEMATOLOGICAL CONDITIONS AND SURGICAL RELEVANCE
Splenectomy may be considered in selected immune thrombocytopenia refractory to medical therapy, hereditary spherocytosis, some haemolytic anaemias and staging/diagnostic situations in haematological disease; indications are now more selective because of infection and thrombosis risk. Preoperative assessment includes blood film, haemolysis tests, coagulation and haematology input. Avoid splenectomy for unexplained splenomegaly without diagnosis. Complications include haemorrhage, pancreatic tail injury, subphrenic abscess, portal/splenic vein thrombosis and overwhelming post-splenectomy infection (OPSI).