Splenectomy
What the Examiner Expects
Surgical removal of the spleen, performed either emergently for traumatic splenic injury with hemodynamic instability or electively for hematologic conditions. The examiner expects you to know the AAST grading system for splenic injury (I–V), that nonoperative management is the standard of care for hemodynamically stable patients with blunt splenic injuries of any grade, and that angioembolization is used for active contrast extravasation or pseudoaneurysm in stable patients. Splenectomy is required for unstable patients failing resuscitation, hilar vascular injuries, and grade V injuries with shattered spleen.
Key Examiner Focus Points
- Most common indication in trauma: high-grade splenic injury with hemodynamic instability
- Elective indications: ITP refractory to medical therapy, hereditary spherocytosis, splenic abscess
- Vaccinate against encapsulated organisms: pneumococcus, meningococcus, H. influenzae (ideally 2 weeks pre-op or within 2 weeks post-op)
- Overwhelming post-splenectomy infection (OPSI) is rare but often fatal
- Nonoperative management with observation + angioembolization is standard for stable splenic injuries
Common Curveballs
Patient has a grade III splenic injury, is hemodynamically stable, but develops a pseudoaneurysm on follow-up CT
Splenic artery angioembolization. This can be proximal (main splenic artery) or distal (selective), preserving some splenic function. Follow with serial imaging. If embolization fails and the patient becomes unstable, splenectomy is required.
Patient undergoes emergent splenectomy and you notice an accessory spleen in the splenic hilum
In trauma, leave it — it's not relevant. For ITP splenectomy, ALL accessory spleens (present in 10–30% of patients) must be identified and removed, or the ITP may recur. Check the splenic hilum, gastrosplenic ligament, greater omentum, and left ovary/spermatic cord.
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