Elective Splenectomy 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Elective splenectomy, especially for very 
large spleen, is a frequent operation in resource-
limited settings. Indications fall under the following 
broad categories:  
• Hematologic: 
refractory 
immune 
thrombocytopenia with purpura or hemolytic 
anemias. Some hemolytic anemias will lead to 
pigment gallstones, so the gallbladder should be 
evaluated and history carefully taken for 
symptomatic gallbladder disease.  
• Splenic vein thrombosis after episodes of 
pancreatitis, with gastric varices and upper 
gastrointestinal bleeding.  
• Symptomatic 
enlargement 
(tropical 
splenomegaly, schistosomiasis) with or without 
anemia or thrombocytopenia caused by this 
enlargement. Symptoms can include left upper 
quadrant pain or early satiety.  
• Abscess that cannot be drained percutaneously 
(loculated, thin walled) 
• Tumor: lymphoma or lymphangiosarcoma. Often 
the diagnosis will not be known at the time of 
operation. Lymphangiosarcoma has a very poor 
prognosis.  
• Distal pancreatectomy: The spleen is removed 
most of the time as the first stage of this operation. 
It is possible to preserve the spleen’s blood 
supply while resecting some small benign 
pancreatic tumors.  
Portal hypertension caused by liver cirrhosis 
may be accompanied by massive splenomegaly. 
Avoid splenectomy, or any abdominal operation, on 
these patients. Splenectomy will not resolve 
esophageal varices in patients with cirrhosis and 
portal hypertension.  
Conversely, patients with portal hypertension 
due to schistosomiasis will have preserved liver 
function. If these patients have bleeding from 
esophageal varices, treat them with serial endoscopic 
banding until the varices are obliterated. If their 
bleeding is from gastric varices, or if their 
splenomegaly is large and bothersome to them, they 
will be well treated with splenectomy.  
In any case of splenomegaly, if the patient is 
ill enough to have ascites, be very careful about 
whether you operate on them. Your operation will 
not resolve the ascites, and their illness is likely too 
severe for them to survive the operation.  
Prepare these patients by vaccinating them at 
least 2 weeks before surgery for encapsulated 
bacteria: Streptococcus pneumoniae, Hemophilus 
influenzae, and Neisseria meningitidis. Patients 
should also be counseled to take the vaccination 
against the influenza virus yearly if possible.  
If the patient has thrombocytopenia, have 
platelets or fresh whole blood available for 
transfusion. This should be done after the splenic 
artery is ligated, as described below.  
Elective splenectomy proceeds in the 
following steps 
• Abdominal incision and exploration 
• Entry into lesser sac and ligation of splenic artery 
away from hilum of spleen.  
• Dissection and division of attachments to the 
omentum, 
transverse 
colon, 
and 
lateral 
abdominal wall 
• Serial ligation of vessels entering hilum.  
• Further dissection and division of attachments to 
lateral 
abdominal 
wall, 
diaphragm, 
and 
retroperitoneum 
• Hemostasis, inspection of tail of pancreas, and 
closure 
 
Steps: 
1. Check a complete blood count on the day of 
surgery. Often a patient who was previously 
thrombocytopenic while acutely ill will have 
platelets over 100,000 per microliter on the day 
of surgery. If the platelet count is between 50 and 
100K, proceed cautiously and have platelets or 
fresh whole blood ready. If platelet count is less 
than 50K, plan to transfuse after ligating the 
splenic artery as below. Discuss these concerns 
with anesthesia and assure adequate IV access.  
2. Subcostal incision provides the best exposure, 
especially in massive splenomegaly. If the spleen 
is small, an upper midline incision is acceptable. 
Using a midline incision forces you to pull on the 
spleen while dissecting it, which may cause it to 
tear.  
Elective Splenectomy 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
3. Explore the abdomen. Make note of dilated veins 
within the omentum indicating portosystemic 
venous anastomoses, which will make the 
operation much more difficult. Look in the 
omentum for accessory splenic tissue. This can 
be safely preserved if the operation is for 
symptomatic 
splenomegaly, 
but 
must 
be 
removed if the operation is for hemolytic anemia 
or thrombocytopenia.  
4. Lift the omentum anteriorly and find the 
avascular plane between it and the transverse 
colon, easiest entered to the left of midline.  
 
Pull the transverse colon downwards and the omentum 
upwards. An avascular plane will appear (Black arrow) more 
distinct on the left side of the transverse colon. Enter the lesser 
sac, the space between the posterior stomach and the pancreas, 
here.  
 
5. Find the splenic artery, usually running along the 
superior border of the pancreas. Confirm it is 
artery, not vein, by palpation. Encircle it 
carefully with a fine dissecting clamp and doubly 
ligate it. Do not divide it. This reduces the blood 
supply to the spleen. If you mistakenly ligate the 
splenic vein and leave the artery open at this 
point, you will have increased blood flow in the 
spleen and a more difficult operation.  
 
The splenic artery usually runs along the superior border of the 
pancreas, although it may also be found posterior to it. 
Carefully dissect it away from pancreatic tissue and ligate it. 
As with all arteries, there will be an avascular plane around the 
vessel between the media and the adventitia layers. This plane 
is easier to dissect than the plane between the adventitia and 
the pancreatic tissue.  
 
6. Dissect the omental attachments to the spleen and 
mobilize the omentum and the transverse colon 
downwards. Divide the omentum if necessary but 
take care not to divide the mesentery of the colon.  
 
The omentum and the left (“splenic”) flexure of the colon will 
be adherent to the inferior pole of the spleen. Gently dissect 
these structures off the capsule of the spleen, avoiding entering 
into the capsule. 
Elective Splenectomy 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
7. Carefully enter the plane between the spleen and 
the lateral abdominal wall. In cases of portal or 
splenic vein hypertension there will be many 
large collateral veins here. Carefully ligate and 
divide each one individually. These veins will 
continue to bleed throughout the operation if 
treated carelessly. Continue dissection as far 
back as you can safely go.  
 
With any type of longstanding splenic disease, there will be 
adhesions between the spleen and the lateral abdominal wall.  
These adhesions will contain thick, high pressure veins. Divide 
them carefully.  
 
 
As you proceed posteriorly, your operating space becomes 
tighter and vessels are more difficult to ligate. Go as far as you 
safely can: you will get another chance to ligate the deepest of 
these vessels once you have divided the vessels at the splenic 
hilum.  
 
8. Turn your attention to the medial side of the 
spleen. There will be numerous attachments here 
as you head towards the hilum. If they are 
avascular, divide them with diathermy. If they 
are vascular, ligate and divide each one 
individually. 
 
Careful dissection with a right-angle clamp while moving 
towards the hilum of the spleen allows you to see which 
adhesions can safely be divided with diathermy and which 
require ligation. As you get deeper, it is helpful to reposition 
your retractors.  
 
 
Individual vessels entering the hilum of the spleen are ligated 
and divided one at a time. You will encounter the splenic artery 
again here, distal to the point where you ligated it before. It 
must be ligated again. 
 
9. As you go between the spleen and the fundus of 
the stomach, you will encounter the short gastric 
Elective Splenectomy 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
vessels. If present, gastric varices arise from 
these 
high-pressure 
vessels. 
Ligate 
these 
individually as well.  
10. At the splenic hilum, you will encounter 
numerous vessels. It is rare to find one single 
artery and vein. Ligate and divide each one. You 
will also see the tail of the pancreas. Careful, 
bloodless dissection to this point allows you to 
see it well and dissect it away from the spleen 
parenchyma. Careless dissection leading up to 
this point makes it more difficult to see the 
pancreas in a bloody field and it may be injured, 
leading to postoperative leakage. Removing part 
of the tail of the pancreas during a splenectomy 
may rarely be necessary, but usually can be 
avoided with proper technique.  
 
Most of the hilar vessels have been divided at this point and the 
spleen becomes much more mobile.  
 
11. Continue your dissection posteriorly, dividing 
vessels 
between 
the 
spleen 
and 
the 
retroperitoneum, diaphragm, and occasionally 
the liver. As the spleen becomes more mobile, 
return to any vessels you could not reach 
previously in the posterolateral space.  
 
Once the vessels of the hilum have been divided completely, the 
spleen can be mobilized medially or laterally, allowing you to 
reposition it and approach vessels that may have been 
impossible to ligate earlier.  
 
Another view of the way the spleen can be repositioned after all 
the hilar vessels have been divided.  
 
12. Remove the spleen. If there is profuse bleeding 
from the splenic recess, pack with gauze sponges, 
hold pressure, and then remove each sponge 
individually while ligating any bleeding vessels 
you see.  
Elective Splenectomy 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The enlarged spleen, after removal, shows all the places where 
blood vessels enter it, not only at the hilum but throughout the 
organ.  
 
After gauze sponges are packed into the splenic bed, they are 
individually removed and each bleeding point is  clamped and 
ligated.  
 
13. Inspect the tail of the pancreas. If you suspect 
injury to the tail, carefully suture the lacerated 
tissue with a 4-0 non-absorbable suture and leave 
a drain in the splenic bed.  
 
The splenic bed after the spleen has been removed and 
hemostasis achieved. There are several ties on vessels adjacent 
to pancreatic tissue, but no sign of injury to the pancreas itself.  
 
14. If the spleen is large, consider leaving a drain to 
avoid accumulation of fluid in the “dead space.”  
15. Assure hemostasis one last time and then close 
the abdominal wall.  
 
Pitfalls 
• Bleeding can be quite serious, especially in 
patients with portal hypertension or splenic vein 
thrombosis. These surgeries must be done slowly 
and meticulously. Ties on veins under pressure 
can slip off, so examine your surgical field very 
carefully after the spleen is removed; take your 
time and make sure hemostasis has been 
achieved. This is not an operation that favors the 
“get it out, then control the bleeding” approach! 
• Pancreatic injury is an avoidable complication: 
again, do not allow uncontrolled bleeding to 
occur, especially during dissection of the hilum 
of the spleen. Pancreatic fistula is very difficult 
to manage in a resource-limited setting, so it is 
best avoided altogether.  
• Patients 
who 
are 
coagulopathic 
due 
to 
thrombocytopenia can bleed more than normal 
during this operation. If you feel that bleeding is 
excessive 
despite 
your 
excellent 
surgical 
technique, transfuse platelets or fresh whole 
blood. The approach to the splenic artery is a 
relatively bloodless technique. If the patient has 
thrombocytopenia due to platelet consumption, 
Elective Splenectomy 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
ligate the splenic artery before giving platelets or 
fresh whole blood.  
• Post-splenectomy infections can include life 
threatening infections with the encapsulated 
bacteria listed above, malaria, or other parasites 
such as babesiosis. In addition to vaccines pre-
splenectomy, patients should get the influenza 
vaccine yearly if possible. Patients should advise 
their physician of their splenectomy status, 
especially if being treated for infectious 
symptoms. Many guidelines advocate for 
prophylactic oral penicillin for all children <5 
years, and for all adults for 2 years after 
splenectomy. 
This 
advice 
is 
especially 
appropriate for anyone who does not have ready 
access to medical care.  
• Post-splenectomy sepsis is sudden, severe septic 
shock with coagulopathy and often adrenal 
insufficiency. Treatment is supportive with 
standard critical care, antibiotics and stress-dose 
steroids if needed. Risk is highest in the first 1-4 
years after splenectomy or in children <2 years of 
age. Mortality is 50%. Patients should be 
counseled about this possibility on several 
occasions, both before and after surgery. They 
should be advised to seek medical attention if 
they have sudden onset of fever, chills, nausea 
and headache. 
• Another post-splenectomy infection of concern is 
malaria: patients should take measures to avoid 
exposure, use prophylaxis, and treat malaria 
when symptoms are present. Episodes of malaria 
are more severe in patients who have had their 
spleen removed, and may be more likely fatal.  
 
Richard Davis MD, FACS, FCS(ECSA)  
AIC Kijabe Hospital  
Kenya 
 
February 2023 
