Two Spleen...

If the concept of "a little bit pregnant" isn't a useful one, it turns out it IS possible for a spleen to be "a little bit ruptured." It wasn't always the case. Not much more than a couple of decades ago, the algorithm was pretty straightforward: a) see ruptured spleen; b) remove ruptured spleen. No need for a mnemonic. Very surgical. Now, God help us, we have lots of choices. a) see ruptured spleen; b) admit to ICU; c) insert thumb in ass; d) get lots of blood tests. If operating, it's repair spleen, remove part of spleen, remove all of spleen. If removing, slice up a few pieces and stick them somewhere (actually, that's a cool concept, and I liked to do it: theory being it might take hold and provide the immunity unique to the spleen). 

Some of the early work in splenic salvage for trauma was done where I trained, one of the first major designated trauma centers in the US. Here is an early article by a guy I taught a thing or two when I was chief resident and he was junior, and one of my professors. And here is an article that suggests it's all a bunch of b.s. Hard to know. Data suggest it's very much worth the effort in young kids, in whom the immune consequences of splenectomy seem to be greater than in adults. As I said in the previous posts, much of the data on OPSI (Overwhelming Post Splenectomy Infection) is muddied by not always separating those who lost their spleens for trauma from those with hematological problems. Still, I'd say there's general agreement among surgeons, this one included, that operative salvage and non-operative observation need to be in our bag of tricks. Judgment; that damnable, infuriating and aggravating judgment. Is what it takes.

Patient with multiple bad injuries -- head, liver, spleen, couple of femurs -- in shock, getting pint after pint of blood. No brainer: get that thing outta there. Middle school footballer, isolated spleen injury on CT scan, little crack in the surface, small collection of blood, stable normal vital signs. No brainer: park the kid and keep an eye on him (although, assuming he recovers without surgery, telling him how long to take it easy, and how easy, is matter of some uncertainty...) Woman in auto accident, small crack in liver, bleeding slowly from the inferior pole of her spleen, broken leg. Brainer. Toddler ran into coffee table at home, tender belly, squirming, spleen with fracture and collection of blood on CT scan, pulse a little fast. Brainer. And, I assure you, that last one in particular is not at all comfortable. 

The CT scan has both made life more complicated and easier in this regard. Complicated, in that it was the ability of the CT scan to identify injuries without the need for exploration that was part of what raised the tricky issue of non-operative management of an injury. Easier, in that time has allowed the development of CT image criteria by which it's possible to be at least somewhat predictive about what sort of injuries are likely to resolve on their own, and which will need intervention. Yin and yang. Tough stuff.

Word has it -- double sourced, as they say -- that a certain surgeon with an operation named after him often injured the spleen when he did that particular operation. As was routine for even small injuries back then, he'd take it out. AND CHARGE FOR IT! Peeling a bit of the capsule off the spleen occurs not rarely when rooting around in that part of the belly; in the past, lots of spleens were removed because of it. Now, simple application of any of several topical agents -- powders, cloths, glues -- is almost sure to stop the sort of bleeding that that creates. Repair of a bigger injury is a bigger deal: sutures don't get much purchase in that soppy substance. Likewise, deciding when it's hopeless before losing lots of blood in the effort is a skill best learned -- and applied -- early.

If you don't mind joining me for another of my trips to "back in the day," I'll mention that during training, about the worst thing anyone could do in the ER was miss the diagnosis of ruptured spleen. It happened, but not often. In those early days we didn't have CT scans or ultrasounds on which to rely, so the prime directive was always to consider the possibility. In the multiply-injured for whom a laparotomy was inevitable, it wasn't a problem. In the questionable situations, we'd very often do a "diagnostic peritoneal lavage," or DPL, or "peri-dial," in which a catheter is popped into the belly, saline infused then returned, and the fluid analyzed. High tech in the extreme, the criterion by which there was judged to be enough blood in the effluent to warrant laparotomy was inability to read newsprint through the fluid in the clear plastic drain tube (cell counts were done, too. But this was shown to be pretty reliable). Be wrong, you got some 'spleenin to do... 

Our chief at the trauma center would almost never criticize us for having a look and finding nothing; to miss something serious -- that could be cause for the rapid ending of a career. It may be true (it is, I'd say) that CT scans are over-used nowadays, but missed injury in a trauma victim is pretty rare now, because of them, and because of ultrasound, now available in many ERs, used by the ER docs, not radiologists. Progress, for sure.

In doing elective open splenectomy, I liked to wear a headlight. It gets dark up there behind the ribs. Delivering the spleen into the midline, light isn't a problem. It's in the cleaning up after: that empty space where the spleen used to be is high up and back there a ways. Getting it up and out involves dividing the filmy but firm attachments between the lateral surfaces of the spleen and the peritoneal gutter in which it lies. In a dry field, it may be done sharply: long-handled scissors, or extended-length cautery with a nice bend in the tip. When the area is full of blood, you tend to do it dickless (in the sense of not dicking around. And what the heck, this is already an NC-17 blog, right?) Reach in -- in large people, it can be up to the elbow -- paddle the spleen with your fingers, like playing a sticky piano, to sense how bad it is; diggle your fingertips into the peritoneal attachments until it breaks free. Once the spleen is out, one of my favorite -- if simple -- maneuvers is the stuffing of a large sponge into the hole and then slowly rolling it back out, while looking carefully at the raw surfaces left behind as they ooze up from under the sponge, like rising dough. Spotlight, cautery, suction held by the assistant at the wound's edge to inhale the smoke: clean and dry by the time the sponge rolls to the surface.

A belly full of blood changes everything: it's about assessing and getting control as fast as possible, while not missing something important. Suctioning blood in that circumstance is too slow: you slush it out with your hands -- gelatinous black clots sliding across and out of your palms, over your fingers, like sickness itself, as you dip and dip again. And you sponge blood and clots out with pad after pad: keep 'em coming, please. I need a bunch of 'em. Force wads of dry pads into the corners while you look at the bowels, the retroperitoneum (where missed injuries are highly lethal), then come back to where the action seems to be. A broken spleen doesn't usually spurt, it oozes. Clots and liquid, in a sorry soup. Venous blood is darker than arterial; if the patient is in shock, it gets so purple it's almost black, and that's a scary sight. Rising through and around clots, it's like those satellite views of a muddy river delta: colors swirling and unmixed. It could be beautiful if it weren't so threatening. Seems like some posts on trauma might be worth considering at this point...

One Spleen...

The above is snapped off a page of the book that might have saved my life. Well, no. But it kept my mind off self-pity when I was in the waning months of my tour of duty in Vietnam. Rather than attending only to that part of the world which was within three feet of me, I could ponder the power of the human mind; could hope the stories therein weren't just chemical aberrations. (Likely, of course, they were.)

The book is "Be Here Now," by Ram Dass, formerly Richard Alpert PhD, associate of Tim Leary at Harvard; tripper on and contemplater of LSD. A friend sent it (the book, not the pharmaceutical) to me while I was serving my time. (Cool fact: all you had to do with mail to and from Vietnam soldiers was write "free" on the corner, and it got where it was aimed. I hope that's still true for the troops and their families.) The volume is divided into three parts, one of which is actually readable. In the snippet to which I refer, Ram Dass describes his first meeting, in India, with the man who would become his guru. Along with "how was the cookie?" (guess you'd have to read it), "Spleen. She died of spleen" still brings a smile when I think of it....

* * * * * *

Soon after I arrived in my current location, I was sent a patient in need of splenectomy. Neither for the first time nor the last, the operation proceeded in such a way that I plopped the organ in a pan about five or seven minutes after laying knife to skin. "Wow," said the scrub nurse. "Wow," said the anesthesiologist, turning dials and scrambling for drugs. Thanks again, Vic, I said to myself, giving homage to my most influential teacher of technique. "The spleen is a mid line organ, Dockie," he used to say, as he harassed me into quickly loosening it from its attachments to the diaphragm and pulling it toward me.

The spleen, you may properly infer, has a special place in my heart. Under it, actually. And a little to the left. Despite Vic's surgically relevant aphorism.


It's nice to have a spleen, but you can live without it. Put simply (and I'm a simple guy) that red-mahogany and spongy organ does two unrelated things: it acts as a giant lymph node, and it filters out aging blood cells. Absent the spleen, those functions can get carried on elsewhere, and so it is that people who lose their spleen, either from injury or because of various blood disorders, generally have no occasion to miss it. But the world is imperfect, so the previous statement is not always true.

There is, in fact, an incidence of overwhelming and highly fatal infection in a small percentage of people who have been splenectomized; the good news is that the infections tend to be by organisms for which vaccinations are available. Those vaccines ought to be given in advance of a planned splenectomy, and soon after an unplanned one. And since infectious consequences seem more frequent in children, it's recommended by some (not universally, for various reasons) that kids who lose their spleens be given daily antibiotics for prophylaxis. Who, and how long: not agreed upon.

The greatest risk is within the first two years after splenectomy. Some people give antibiotics for that interval; others till age 21; some advocate it for life. Much of the data are muddled by the fact that people lose their spleens for differing reasons: when it's removed for hematological reasons, the long-term risks are probably higher, since those people have remaining underlying pathology. Splenectomy for trauma has a higher risk of infection at the time of surgery (in part, I think, because of concomitant injuries to other organs) but lower long-term, compared to hematologic patients. Still, there's no doubt there are some risks. The only case of overwhelming post-splenectomy sepsis I ever saw was in a person who'd had it for hairy-cell leukemia. Never in a person with trauma.

The other potentially adverse consequence of splenectomy can be turned into a good thing: it's common after the operation to note a rise in platelets, those little packets of clotting paraphernalia that float in the bloodstream. Too many, and there's a risk of thrombosis (clots when you don't want them); too few, and there's risk of spontaneous or prolonged bleeding. In the condition known as ITP, for "idiopathic thrombocytopenic purpura," in which the platelet (thrombocyte) count can get dangerously low, splenectomy may be curative. That was always my favorite situation in which to see a patient needing the surgery, because, under the right circumstances, there was a pretty good chance it would work out well.

Among people with ITP who require treatment, the mainstay drug is prednisone (as you can read in the above ITP link, there are others, too). It's those people in whom it works well that I liked to see; and if that sounds like the words of a knife-happy surgeon, hear me out. Steroids like prednisone can be very effective, but, depending on dose, they can have significant side-effects. Some lucky people with ITP get their drugs, respond well, and it's over. Others, though, either require prolonged treatment with high doses, or they get a good response but recur whenever the drugs are stopped.

At some point surgery becomes a consideration; and the good news is that response to drugs is quite a good predictor of response to surgery, which is why I liked to see those people. The news isn't as good -- the outcome much less certain -- when splenectomy is pursued as a last resort after all other treatments have failed.

In many cases when the platelet count is low in ITP, bleeding during or after surgery is not a great worry: the platelets that are present are young and sexy, and clotting is less affected than in other situations with comparably low platelet counts. Surgery proceeds apace, and it's rewarding to see the counts begin to rise immediately after surgery. In those more questionable situations -- very low counts with no response to medical treatment -- surgery is carried out with more drama: platelets at the ready in the OR, the splenic artery clamped as early as possible in the proceedings, after which the platelet infusion begins (the clamping keeps the new platelets from being gobbled by the spleen.) No five-minute job; great care is taken to avoid and to control the tiniest bleeders. I should also mention that it's not rare to have "accessory" spleens, little grape-oid items tucked in various abdominal locations, failing to locate and extirpate which can lead to recurrence of the disease. Mostly, they're close to the spleen, so the search tends not to require dogs and flushers.

Residing high in the left upper abdomen, attached to the colon and the stomach as well as to the pancreas, kissing the left kidney, not far from the adrenal and stuck to the diaphragm, the spleen is anatomically more daunting on paper than in the flesh. Unless the organ is really huge, operating is usually straightforward; and yes, it's even quite amenable to the laparoscopic approach (takes a lot longer than five minutes to get it in the bucket, though). I think it has the makings of at least one more post. And we haven't yet talked much about ruptured spleens...