Splenectomy, or removal of the spleen, may be indicated for a variety of disorders, with traumatic injury to this organ being the most common indication for surgery. Despite its relatively protected position behind the ribs, the spleen is still susceptible to injury from blunt and penetrating trauma. In addition, rapid deceleration, such as occurs from falls, can avulse the spleen from its attachments and cause bleeding. Since the spleen is a highly vascular organ, splenic injury can lead to life-threatening exsanguination (Fig. 10.1).

While minor injuries can be treated non-operatively, deep fractures through the parenchyma require prompt intervention. Coil embolization of the splenic artery by interventional radiology is a less invasive alternative to splenectomy in the relatively stable trauma patient. However, persistent transfusion requirements or profound hemodynamic instability are indications for immediate surgery. In the OR, simple splenectomy is the most expeditious way to control hemorrhage. However, splenic salvage can be attempted with splenorrhaphy, wherein an absorbable mesh is used to tightly wrap the spleen, allowing for tamponade and hemostasis. This approach should be particularly considered for pediatric patients, in whom splenic function is physiologically more important than adults. When an injured spleen has been managed either by splenorrhaphy or embolization, it is important to remember that delayed splenic rupture can occur up to 2 weeks after the initial insult.

Splenectomy is also often indicated for the treatment of certain hematological disorders. Historically, splenectomy was routinely performed to stage patients with Hodgkin’s lymphoma, although the development of high-resolution CT scans has made this only rarely necessary. Currently, the most common indication for elective splenectomy is for the treatment of idiopathic thrombocytopenic purpura (ITP). This disorder, which is thought to be due to the production of antiplatelet antibodies, causes increased platelet destruction along with decreased platelet production, resulting in marked thrombocytopenia. Steroid therapy is the first line of treatment, however some patients will relapse after completion of their steroid course. Splenectomy is ultimately necessary in most patients refractory to medical therapy. When performing splenectomy for ITP, a diligent search for accessory spleens must also be conducted (Figs. 10.2 and 10.3). If such accessory spleens are inadvertently left in situ, they will hypertrophy and cause recurrence of the ITP. Following splenectomy, most patients with ITP will achieve a durable, complete remission with normalization of their platelet counts.

Splenectomy may also occasionally be recommended for thrombotic thrombocytopenic purpura, myelofibrosis, hairy cell leukemia, and other hematologic disorders, although this is less common. In some hematologic disorders, the spleen can be massively enlarged, making surgical resection technically more challenging (Fig. 10.4).