Table Of ContentHiatt· Phillips· Morgenstern (Eds.) Surgical Diseases of the Spleen
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J. R. Hiatt E. H. Phillips 1. Morgenstern (Eds.)
Surgical Diseases
of the Spleen
Contributors
A. Allins W. Arnaout R. W. Busuttil R. A. Duensing
R. Friedman F. J. Giles J. R. Hiatt F. Hulka
M. S. Komaiko L. R. Kong J. E. Korman S. W. Lim
L. Morgenstern R. J. Mullins R. S. Neiman
E. H. Phillips S.1. Schwartz J. E. Skandalakis
R. E. Stiehm D. D. Trunkey M. Wakim W. A. Wilcox
R. A. Williams
With 113 Figures, many in Color, and 24 Tables
, Springer
JONATHAN R. HIATT, M.D.
Director, Surgical Residency Program
and Trauma Services
Cedars-Sinai Medical Center
8700 Beverly Boulevard
Los Angeles, CA 90048-1865, USA
EDWARD H. PHILLIPS, M. D.
Director, Endoscopic Surgery
Cedars-Sinai Medical Center
8700 Beverly Boulevard
Los Angeles, CA 90048-1865, USA
LEON MORGENSTERN, M. D.
Emeritus Director of Surgery
Cedars-Sinai Medical Center
444 South San Vincente Boulevard
Los Angeles, CA 90048, USA
ISBN-13: 978-3-642-64461-0 e-ISBN-13: 978-3-642-60574-1
DOl: 10.1007/ 978-3-642-60574-1
Library of Congress Cataloging-in-Publication Data
Surgical diseases of the spleen/J. R. Hiatt, E. H. Phillips, L. Morgenstern (eds.) p.cm. Includes
bibliographical references and index. 1. Splenectomy.
2. Spleen - Diseases. I. Hiatt, J.R. (Jonathan R.), 1951. II. Phillips, Edward H., 1947. III. Morgen
stern, Leon. [DNLM: 1. Splenic Diseases - surgery. 2. Splenectomy - methods. 3. Spleen - pathol
ogy. WH 600 S9613 1997] RD547.5.S87 1997 617.5'51059-dc20 DNLMIDLC for Library of
Congress
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To Jo Carol, Joseph and Jeremy
JONATHAN R. HIATT
With gratitude - To my father, the consumate physician
who taught by example
To my teachers, colleagues, and most of all, patients,
who truly educated me
To my wife and children for their loving support and daily surprises
EDWARD H. PHILLIPS
To Laurie and David
LEON MORGENSTERN
The editors express deep gratitude to Peggy Acoca
for expert clerical assistance
Preface
Among all of the organs in the surgeons workaday world, the spleen has
been something of an orphan for the better part of this century. Hidden
deep within a recess of the left upper quadrant - more rarely subject to
diseases than other solid viscera and by far the most fragile of the organs
- the spleen eluded prominence and singularly defied progress in surgical
innovation and research. Its emergence from orphanage into the realm of
modern surgical practice represents the subject and the rationale for this
book. The century closes with a vastly different view of the spleen than the
one with which it began.
What was it that brought the spleen out of its figurative hiding place
into the more prominent position it holds today? First, it was the discov
ery of the causal association of specific hematologic disorders with the
spleen, such as proposed by Micheli in 1911 for autoimmune hemolytic
anemia and Kaznelson in 1916 for idiopathic thrombocytopenic pur
pura. Splenectomy for these disorders was shown to be highly effective,
if not curative. Also, the parallel development of hematology and pathol
ogy gave rise to an ever-expanding and increasingly sophisticated list of
disorders related to splenic anomalies, dysfunction, infections, and tu
mors. "Leukocythemia:' at the turn of the century the generic neoplastic
disorder, evolved into a complex classification of lymphomas and leuke
mias. The list continues to grow and change. For all of these disorders,
as Crosby has commented, "Splenectomy goes in and out of fashion!'
The staging of Hodgkin's disease, for example, which in some centers
was a leading indication for splenectomy in the 1970s and 1980s, has fall
en out of favor; so has splenectomy as a primary approach for hairy cell
leukemia and thrombotic thrombocytopenic purpura. Splenectomy for
Gaucher's disease has yielded to treatment with enzyme replacement ther
apy, although the latter is usually unaffordable by the majority of patients
with the disease.
A dramatic change in surgical attitudes toward splenectomy for trauma
and some benign splenic disorders began in the early 1960s: with partial
splenectomies performed by Campos Christo for trauma and Morgenstern
for a hematologic disorder, the myth of the "surgical inviolability" of the
spleen was successfully challenged and discredited. It was not, however,
until the 1980s that the conservative approach to splenic injuries (with
VIII Preface
conservation of functioning splenic tissue as a primary goal) achieved
prominence in trauma centers worldwide. Validating the shift toward
splenic salvage for trauma, rather than wholesale extirpation of the or
gan, was a growing body of evidence that the spleen had important im
munologic functions. Peculiarly, this validation was recognized widely
only after the techniques of splenic conservation were perfected. Evi
dence continues to accumulate that the spleen has hitherto undiscov
ered immunologic functions, and new techniques of splenic conserva
tion continue to evolve, including the use of absorbable mesh, more ef
fective methods of hemostasis, and nonoperative management, which is
the ultimate technique for conservation.
As the century draws to a close, the most dramatic development in
splenic surgery is the successful application of laparoscopic techniques
to splenectomy, both total and partial. Laparoscopic splenectomy is ra
pidly becoming the procedure of choice for idiopathic thrombocytopenic
purpura in adults and older children. The laparoscopic approach is less
well suited to the splenomegaly of neoplastic or hematologic diseases,
but the barriers there are also falling quickly, as techniques, instrumenta
tion, and surgical skills continue to improve.
It would be a blatant omission to neglect the important role that var
ious imaging modalities have assumed in the diagnosis and, occasion
ally, the treatment of splenic diseases. The supersedance of the physical
examination by imaging studies is often alluded to jokingly, but the truth
is that the spleen is very photogenic. Radionuclide studies, ultrasonogra
phy, computed tomography, and magnetic resonance imaging have all
made diagnosis more precise, treatment more timely, and followup more
meaningful. The new and constantly improving imaging techniques have
been a great boon to splenic surgery.
There is little doubt that some diseases for which splenectomy is cur
rently indicated will be treated by alternative methods, as has happened
with hairy cell leukemia and Gaucher's disease. The converse phenom
enon - new diseases which create new indications for splenectomy - is
also real: Witness the broad new spectrum of splenic disorders, inflam
matory and neoplastic, secondary to the human immunodeficiency
virus. Also, the spleen may serve as a home for genetically altered hepa
tocytes or other cell lines, and the ultimate role for the organ in trans
plant surgery has yet to be explored.
This volume undertakes to present what we believe is the latest and
best information on the surgery of the spleen. In medical history, the
spleen is a treasure trove of fact, fable, and fantasy. It took its early
place in medicine as the source of black bile, one of the four cardinal
humors. The relation of black bile to the emotion of melancholy even
found its way into the literature of the nineteenth century in the works
of the poets Baudelaire and Verlaine. To the spleen were also assigned
the sometimes contradictory attributes of anger, laughter, scorn, and, in
Elizabethan times, even a reproductive function. At present, the major
Preface IX
functions of this mysterious organ are hematologic and immunologic.
What the future holds in store for the spleen in terms of functions as
yet undiscovered and techniques as yet untried can only be imagined
and reserved for future editions of the present volume.
LEON MORGENSTERN
JONATHAN R. HIATT
EDWARD H. PHILLIPS Los Angeles, California, 1996
Contents
Section I: Basic Concepts
A History of Splenectomy 3
1. MORGENSTERN
Anatomy and Embryology of the Spleen ................... 15
1. MORGENSTERN and J. E. SKANDALAKIS
Pathology of the Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 25
R.S. NEIMAN
The Spleen in Infection and Immunity 53
R. E. STIEHM and MARY WAKIM
Spleen Imaging ...................................... 61
M. S. KOMAIKO
Section II: Splenic Diseases
Benign Neoplasms of the Spleen 91
1. MORGENSTERN
Malignant Splenic Lesions .............................. 105
F. J. GILES and S. W. LIM
Splenectomy for Hematologic Disorders ................... 131
S. I. SCHWARTZ
Infections of the Spleen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 143
R. A. WILLIAMS and R. A. DUENSING
Metabolic Disorders and the Spleen. . . . . . . . . . . . . . . . . . . . . .. 161
W.A. WILCOX
Portal Hypertension and Disorders of the Splenic Circulation 175
R. W. BUSUTTIL and W. ARNAOUT
XII Contents
Section III: Splenic Surgery
Open Splenectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 197
J. R. HIATT, A. ALLINS, and 1. R. KONG
Laparoscopic Splenectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 211
E. H. PHILLIPS, J. E. KORMAN, and R. FRIEDMAN
Splenic Trauma ...................................... 233
D. D. TRUNKEY, FRIEDA HULKA, and R. J. MULLINS
Partial Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 263
1. MORGENSTERN
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 281
