Iatrogenic Splenectomy

Iatrogenic SplenectomyProcedures in which mobilization of the left upper quadrant is done (such as reflection of the spleen and pancreas medially to expose retroperitoneal tissue, left adrenalectomy, and left nephrectomy) put the spleen at risk for injury during the dissection.

Simple mobilization of the splenic flexure can lead to bleeding from the inferior pole of the spleen that may be difficult to control. The ligaments that go directly from the omentum to the capsule of the spleen may be the cause of iatrogenic splenic trauma, as it is a common practice to aggressively retract the omentum as needed for exposure. If there are direct branches that sometimes may be sizable from the omentum to the splenic capsule, this could lead to capsular disruption and troublesome bleeding. A national database on antireflux procedures of 86,411 patients reported an incidence of iatrogenic splenectomy of 2.3%, which translates into 1987 iatrogenic splenectomies for that indication alone over a 6-year period.

Probably the best data for the incidence of iatrogenic splenectomy come from the recently reported series that listed 73 iatrogenic splenectomies over a 10-year period, or an average of 7 per year. This comprised 8.1% of all splenectomies performed during that time interval. There are probably several times that number of minor or moderate injuries to the spleen during unrelated operations in which the spleen was not removed but was repaired or salvaged. Just as in trauma to the spleen, the techniques of splenorrhaphy can be employed to preserve the spleen. A recent report indicates that use of a mesh wrap splenorrhaphy even in the setting of bowel surgery does not lead to an increased incidence of infection. For minor capsular disruption, the use of the argon coagulator for surface cautery is a helpful technique.

The primary teaching point regarding iatrogenic injuries is that the best way to preserve the spleen is to not damage it in the first place. This requires caution in mobilizing tissue in and around the spleen as well as visual inspection of the attachments of the spleen prior to blunt mobilization. Whenever possible, the spleen should be attempted to be preserved to decrease the risk of post-splenectomy sepsis.

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