Perioperative & Surgical Care

Splenectomy: indications and post-op care

Clinical Overview and When to Suspect Need for Splenectomy

— Trauma: blunt/penetrating splenic injury with hemodynamic instability or failed non-operative management (NOM)

— Hematologic: immune thrombocytopenia (ITP) refractory to medical therapy, hereditary spherocytosis, autoimmune hemolytic anemia, thalassemia with hypersplenism, sickle cell sequestration

— Neoplastic: splenic lymphoma, large symptomatic cysts, primary splenic tumors, distal pancreatectomy bundling

— Infectious/structural: splenic abscess refractory to drainage, ruptured splenic artery aneurysm

— Iatrogenic: intraoperative injury during gastric, colonic, or pancreatic surgery

— Trauma with persistent tachycardia, hypotension, transfusion >2 units, or contrast blush on CT despite embolization

— ITP with platelets <30k after failed steroids, IVIG, and rituximab/TPO agonists

— Hereditary spherocytosis with symptomatic anemia, gallstones, or growth failure (delay until age ≥5–6 if possible)

— Massive splenomegaly causing early satiety, pain, or cytopenias from sequestration

Splenectomy = removal of the spleen, performed for trauma, hematologic disease, hypersplenism, splenic mass, or as part of staging/oncologic resection.

Core indications grouped by category:

Non-operative trends: in stable blunt trauma, NOM ± splenic artery embolization is preferred to preserve immune function, especially in children.

Approach: elective cases are typically laparoscopic (faster recovery, less morbidity); emergent trauma requires open midline laparotomy.

Suspect a patient is heading toward splenectomy when:

Step 3 management: For hemodynamically unstable blunt abdominal trauma with positive FAST → straight to OR for exploratory laparotomy; do not delay for CT. Stable patients with grade I–III injuries → admit, serial Hgb, bed rest, consider angioembolization for blush.

Board pearl: The spleen's immunologic role (opsonization of encapsulated organisms via IgM memory B cells and tuftsin) explains why post-splenectomy patients have lifelong vulnerability to OPSI—the dominant longitudinal concern on Step 3.

Presentation Patterns and Key History

— Left upper quadrant pain, left shoulder pain (Kehr sign from diaphragmatic irritation by blood)

— Mechanism: MVC with left-sided impact, handlebar injury, contact sports (especially with mononucleosis—ask about recent EBV, sore throat, fatigue)

— Pediatric: even minor trauma can rupture a spleen enlarged by EBV, malaria, or leukemia

— Mucocutaneous bleeding, petechiae, epistaxis, menorrhagia; isolated thrombocytopenia on CBC

— History of recent viral illness (children) or autoimmune disease/HIV/HCV (adults)

— Document prior treatments: corticosteroids, IVIG, anti-D, rituximab, romiplostim/eltrombopag

— Family history (autosomal dominant in 75%), neonatal jaundice, pigment gallstones, splenomegaly, aplastic crisis with parvovirus B19

— Early satiety, LUQ fullness, weight loss, B-symptoms (suggest lymphoma)

— Cytopenias from pooling/destruction

— In children, acute splenic sequestration: rapidly enlarging spleen, profound anemia, hypovolemic shock—life-threatening, may warrant splenectomy after recurrence

— Vaccination status (critical—see chunk 15)

— Prior abdominal surgeries (adhesions affect laparoscopic feasibility)

— Anticoagulant/antiplatelet use, bleeding history

— Functional status, comorbidities (cirrhosis, portal hypertension increase bleeding risk dramatically)

Trauma presentation:

ITP:

Hereditary spherocytosis:

Hypersplenism / massive splenomegaly:

Splenic abscess: fever, LUQ pain, often in IV drug users, endocarditis, immunocompromised

Sickle cell:

Pre-op history must capture:

Key distinction: Acute sequestration crisis (children with sickle cell, large tender spleen) vs autosplenectomy (older children/adults with HbSS who have already infarcted their spleen and are functionally asplenic by age 5)—the latter group needs no surgery but the same OPSI precautions.

Board pearl: A college athlete with mono and LUQ pain post-tackle = splenic rupture until proven otherwise; avoid contact sports for ≥3–4 weeks after EBV infection.

Physical Exam Findings and Hemodynamic Assessment

— Primary survey: ABCs, two large-bore IVs, type and crossmatch

— Vitals: tachycardia precedes hypotension; class III shock = HR >120, SBP falling, confusion (~30–40% volume loss)

— Abdomen: LUQ tenderness, ecchymosis, peritoneal signs if free blood

— Kehr sign: referred left shoulder pain, especially in Trendelenburg

— Balance sign: dull percussion in LUQ from clotted blood

— Seat-belt sign across abdomen → high suspicion for solid organ + hollow viscus injury

— Unstable (SBP <90 despite resuscitation): straight to laparotomy

— Transient responder: stabilizes briefly then deteriorates → likely OR vs angio

— Stable: CT with IV contrast to grade injury (AAST I–V); look for contrast extravasation (blush)

— Palpable spleen extending below costal margin (normally not palpable)

— Measure spleen tip below costal margin in cm; massive splenomegaly = crosses midline or into pelvis

— Stigmata of chronic liver disease (caput, spider angiomas) — portal HTN changes operative risk

— Jaundice, scleral icterus (hemolysis), pallor, petechiae

Trauma exam (ATLS framework):

FAST exam: free fluid in Morison pouch, splenorenal recess, pelvis; positive FAST + unstable = OR

Hemodynamic categorization for triage:

Elective/hematologic exam:

CCS pearl: In CCS unstable trauma cases, order in parallel: 2 large-bore IVs, crystalloid bolus, type and cross 4–6 units PRBC, FAST, CXR, pelvis XR, surgery consult STAT. Do not send unstable patients to CT — that is a classic exam trap (transports to "the doughnut of death").

Board pearl: A grade IV–V splenic injury with active contrast blush on CT in a stable patient typically goes to angioembolization first; failure of embolization (ongoing transfusion requirement, hemodynamic decline) triggers splenectomy.

Diagnostic Workup — Initial Labs and Imaging

— CBC: baseline Hgb (may be normal early in acute hemorrhage—false reassurance), platelets, WBC

— Type and crossmatch for ≥2–4 units PRBC in trauma

— Coagulation panel (PT/INR, aPTT, fibrinogen); thromboelastography (TEG) in major trauma centers

— Lactate, base deficit: markers of occult shock and resuscitation adequacy

— CMP: baseline renal/hepatic function

— β-hCG in reproductive-age females before imaging

— Peripheral smear for hematologic indications: spherocytes (HS), schistocytes (TTP—do NOT splenectomize), bite cells (G6PD)

— Direct antiglobulin test (DAT/Coombs) for AIHA

— FAST: first-line in unstable trauma; sensitivity ~85% for hemoperitoneum, low for hollow viscus

— CT abdomen/pelvis with IV contrast: gold standard for stable trauma; grades injury, detects blush

— CXR: rule out concurrent thoracic injury, left hemidiaphragm elevation, lower rib fractures (9–11)

— Ultrasound abdomen: measures spleen size, identifies cysts/abscess

— MRI: rarely needed acutely; useful for indeterminate masses

— Grade I–II: subcapsular hematoma <50% surface area, lacerations <3 cm

— Grade III: hematoma >50% or expanding, lacerations >3 cm

— Grade IV: laceration involving segmental/hilar vessels with >25% devascularization

— Grade V: shattered spleen or hilar vascular injury

Labs at presentation:

Imaging:

AAST splenic injury grading (drives management):

Step 3 management: Order pre-op type and screen, CBC, CMP, coags, ECG (if age >50 or cardiac history), and CXR for any planned splenectomy; consider preoperative platelet transfusion in ITP only if platelets <20k or active bleeding—hold transfusion until splenic artery is ligated to maximize benefit.

Board pearl: A normal initial Hgb does not exclude active splenic hemorrhage; equilibration takes hours. Trend serial Hgb q4–6h in NOM.

Diagnostic Workup — Advanced and Confirmatory Studies

— ITP: diagnosis of exclusion; check HIV, HCV, H. pylori, ANA, TSH; bone marrow only if atypical features or age >60

— Hereditary spherocytosis: eosin-5-maleimide (EMA) binding test (modern standard, replaces osmotic fragility), elevated MCHC, increased reticulocytes

— AIHA: warm (IgG, DAT+) vs cold (IgM, often post-Mycoplasma/EBV); splenectomy benefits warm AIHA refractory to steroids/rituximab

— Lymphoma staging: CT chest/abdomen/pelvis, PET-CT, bone marrow biopsy; splenectomy now rarely used for staging (replaced by imaging)

— CT/MRI characterizes cysts (parasitic vs congenital), hemangiomas, lymphangiomas

— Avoid percutaneous biopsy of solid splenic lesions (bleeding risk); excisional splenectomy is often both diagnostic and therapeutic

— Blood cultures, echocardiogram (rule out endocarditis as source)

— CT-guided drainage first-line; splenectomy if multiloculated, ruptured, or drainage fails

— Doppler ultrasound of portal/splenic veins, transient elastography

— Critical because portal HTN dramatically increases intraoperative bleeding; consider TIPS or vascular embolization preoperatively

— RCRI/ACS-NSQIP risk calculator for elective cases

— Pulmonary function tests if chronic lung disease (laparoscopic CO2 insufflation tolerance)

Hematologic-indication workup:

Splenic mass evaluation:

Splenic abscess:

Portal hypertension assessment (if cirrhosis suspected):

Preoperative cardiopulmonary risk:

Key distinction: TTP presents with thrombocytopenia + MAHA + neuro/renal findings — plasma exchange, not splenectomy, is the answer. Splenectomizing a presumed-ITP patient who actually has TTP is a board trap.

Board pearl: In suspected HS, the EMA binding test has replaced osmotic fragility on modern Step 3 questions; expect "decreased EMA fluorescence on flow cytometry."

Risk Stratification and First-Line Management Logic

— Unstable + positive FAST → OR for laparotomy

— Stable + low-grade injury (I–III) → NOM: ICU/step-down, bed rest, NPO initially, serial Hgb, type and screen active

— Stable + high-grade (IV–V) or contrast blush → angioembolization first; splenectomy if fails

— NOM failure rate: ~10–20%; higher with grade IV–V, age >55, large hemoperitoneum

— First-line: corticosteroids (dexamethasone pulse or prednisone) ± IVIG for urgent bleeding

— Second-line: TPO receptor agonists (eltrombopag, romiplostim), rituximab, or splenectomy

— Splenectomy now typically deferred ≥12 months after diagnosis to allow spontaneous remission and trial of newer agents

— Response rate to splenectomy: ~60–70% durable remission

— Mild: observe, folate supplementation

— Moderate–severe: splenectomy (total or partial), ideally after age 5–6 to preserve immune development

— Consider concurrent cholecystectomy if gallstones present

— Open approach often preferred over laparoscopic when spleen >20 cm or weight >1 kg

— Hand-assisted laparoscopic splenectomy is a middle ground

Trauma decision tree:

ITP management ladder (ASH 2019):

Hereditary spherocytosis severity grading:

Massive splenomegaly:

Step 3 management: For elective splenectomy, administer vaccines ≥2 weeks before surgery (preferred timing for optimal antibody response). If emergent, give vaccines ≥14 days after surgery. This timing is a frequent vignette detail.

Board pearl: Splenectomy is contraindicated or low-yield in: TTP (use PLEX), sickle cell autosplenectomized adults, cold AIHA (cold agglutinins are cleared by liver, not spleen), and myelofibrosis unless cytopenias are debilitating—high mortality.

Pharmacotherapy — Perioperative Medications

— Vaccines (see chunk 15 for full schedule): pneumococcal (PCV20 or PCV15→PPSV23), meningococcal ACWY + B, Hib, annual influenza, COVID-19—give ≥14 days pre-op

— Corticosteroid taper in ITP patients chronically on steroids; stress-dose hydrocortisone (100 mg IV) intraoperatively if on >20 mg prednisone for >3 weeks

— Platelet transfusion in ITP: only if platelets <20k or active bleeding; ideally administered after splenic artery ligation

— IVIG 1 g/kg 1–2 days pre-op can transiently raise platelets in ITP

— Single dose cefazolin within 60 min of incision (cefoxitin if bowel involvement anticipated)

— Mechanical (SCDs) intraoperatively

— Postoperative LMWH (enoxaparin 40 mg SC daily) starting 12–24 h post-op; splenectomy carries high VTE/portal vein thrombosis risk due to reactive thrombocytosis

— Continue 7–10 days minimum; longer for cancer indication

— Multimodal: scheduled acetaminophen + NSAIDs (if no bleeding concern) + opioid PRN; laparoscopic patients often discharged on oral regimen by POD 1–2

— Avoid NSAIDs if active hemolysis/AKI risk or recent significant bleeding

Preoperative:

Antibiotic prophylaxis:

VTE prophylaxis:

Postoperative pain:

Antiemetics, DVT prophylaxis, early ambulation, incentive spirometry: standard ERAS bundle

CCS pearl: On a splenectomy CCS case, key orders on POD 0–1: vitals q4h, CBC q12h initially (monitor for postoperative thrombocytosis and bleeding), SCDs, enoxaparin starting POD 1, advance diet as tolerated, ambulate, incentive spirometry, vaccines if not yet given.

Board pearl: Post-splenectomy platelet count often rises to >1,000,000/µL by POD 7–14; this is a major trigger for portal/splenic/mesenteric vein thrombosis—monitor and ensure VTE prophylaxis.

Operative Procedure and Technical Considerations

— Right lateral decubitus position

— 3–4 ports; ligate short gastric vessels along greater curve, then splenic hilum with stapler

— Spleen placed in endocatch bag and morcellated for extraction (unless oncologic—then intact specimen via mini-laparotomy or hand-assisted)

— Faster recovery, less pain, shorter LOS (1–3 days) vs open (4–7 days)

— Midline laparotomy

— Mobilize splenic flexure of colon, divide splenorenal and splenophrenic ligaments

— Control splenic artery early at superior border of pancreas (especially in ITP to maximize platelet retention)

— Ligate splenic vein at hilum, taking care to preserve pancreatic tail (pancreatic injury → fistula)

— Considered in pediatric trauma or hereditary spherocytosis to preserve immune function

— Less commonly performed but increasingly favored in children

— Present in 10–30% of patients; must be sought and removed in ITP and hematologic indications to prevent disease recurrence

— Most common locations: splenic hilum, gastrosplenic ligament, tail of pancreas, omentum

— Pancreatic tail injury → drain placement, monitor amylase/lipase in drain fluid

— Diaphragmatic injury → repair, chest tube if pneumothorax

— Gastric injury during short gastric ligation

— Angioembolization (proximal vs distal—distal preserves more parenchyma)

— Splenic artery embolization preserves immune function in ~80% of cases

Laparoscopic splenectomy (standard for elective):

Open splenectomy (trauma, massive splenomegaly, hemodynamic instability):

Partial splenectomy / splenorrhaphy:

Accessory spleens:

Intraoperative pitfalls:

Splenic preservation alternatives:

Step 3 management: When ITP recurs months to years after splenectomy with new low platelets, image for missed accessory spleen (CT or 99mTc-labeled heat-damaged RBC scan); resection of the accessory spleen restores remission.

Board pearl: Postoperative left lower lobe atelectasis and left pleural effusion are extremely common after splenectomy due to diaphragmatic irritation—aggressive incentive spirometry is the answer, not antibiotics, unless infection is documented.

Special Populations — Elderly and Renal/Hepatic Impairment

— Higher NOM failure rate for splenic trauma (some advocate lower threshold for operative management >55)

— Increased perioperative cardiopulmonary complications; obtain ECG, optimize comorbidities

— Cumulative immunosenescence amplifies OPSI risk—vaccination compliance is even more critical

— Lower physiologic reserve for blood loss; tighter transfusion thresholds (Hgb 8 typically)

— Polypharmacy review: hold antiplatelets/anticoagulants per timing (e.g., clopidogrel 5–7 days, apixaban 48 h preoperatively)

— Splenomegaly with hypersplenism (thrombocytopenia, leukopenia) is common in cirrhosis

— Splenectomy is usually avoided; instead consider partial splenic embolization or TIPS for portal HTN

— If splenectomy unavoidable: Child-Pugh class predicts mortality (Child C carries prohibitive risk)

— Massive intraoperative bleeding from collaterals; meticulous hemostasis

— Postoperative portal vein thrombosis risk is markedly elevated (up to 50% in cirrhotic patients)

— Adjust enoxaparin dose (CrCl <30: 30 mg SC daily) or switch to unfractionated heparin

— Avoid NSAIDs

— Contrast-induced nephropathy consideration in pre-op CT—use lowest effective contrast volume, ensure hydration

— Vaccine response may be blunted; document response titers in CKD/dialysis patients

Elderly (age >65):

Hepatic impairment / cirrhosis with portal hypertension:

Renal impairment:

Step 3 management: In a cirrhotic with severe thrombocytopenia and esophageal varices needing intervention, TIPS or partial splenic embolization outperforms splenectomy. New oral TPO agonists (avatrombopag, lusutrombopag) can raise platelets pre-procedurally without surgery.

Board pearl: Post-splenectomy portal vein thrombosis classically presents POD 5–14 with abdominal pain, fever, leukocytosis, transaminitis; diagnose with Doppler ultrasound or CT venography, treat with anticoagulation for 3–6 months.

Special Populations — Pregnancy and Pediatrics

— Spleen has critical immune function in young children—delay elective splenectomy until age ≥5–6 when possible (especially HS)

— Non-operative management is preferred for >95% of pediatric blunt splenic trauma; pediatric spleens heal remarkably well

— Pediatric trauma protocols favor angioembolization only if NOM fails

— Partial splenectomy preserves immune function in HS and is increasingly used

— Vaccinations: ensure full primary series of PCV13/15/20, Hib, MenACWY, MenB completed

— Post-splenectomy daily penicillin prophylaxis (penicillin V 125 mg BID <5 yo; 250 mg BID ≥5 yo) until at least age 5 and minimum 1 year post-op; many recommend lifelong in high-risk children

— Elective splenectomy should be deferred until postpartum when feasible

— If essential (refractory ITP with severe bleeding, splenic rupture): second trimester is safest window

— ITP in pregnancy: first-line treatment is corticosteroids or IVIG; splenectomy reserved for refractory disease with platelets <20k or bleeding

— Maternal IgG anti-platelet antibodies cross placenta—monitor neonate for thrombocytopenia

— Mode of delivery determined by maternal platelet count and obstetric factors, not fetal platelet count

Pediatric considerations:

Pregnancy:

Splenic rupture in pregnancy: rare but life-threatening; consider in late-pregnancy hypotension with hemoperitoneum; emergent laparotomy regardless of trimester to save mother

Key distinction: Gestational thrombocytopenia (mild, late pregnancy, platelets usually >70k, no treatment) vs ITP in pregnancy (more severe, earlier onset, may require treatment, neonatal implications). Don't operate on gestational thrombocytopenia.

Board pearl: Acute splenic sequestration crisis in a sickle cell toddler (rapidly enlarging spleen + Hgb drop + shock) is treated emergently with transfusion; recurrent episodes are an indication for splenectomy after age 2.

Complications and Adverse Outcomes

— Bleeding: from short gastrics, splenic hilum, or diaphragm—watch drain output, hematocrit drop, tachycardia

— Subphrenic abscess: fever POD 5–10, left shoulder pain, persistent leukocytosis → CT abdomen, drainage + antibiotics

— Pancreatic injury/fistula: elevated drain amylase, persistent leukocytosis; manage with drain, octreotide, NPO/TPN

— Atelectasis, left pleural effusion: very common, treat with incentive spirometry, ambulation

— Gastric injury from short gastric ligation or thermal spread → leak presents POD 3–7

— Wound infection, ileus: standard postoperative issues

— Overwhelming Post-Splenectomy Infection (OPSI): lifetime risk ~5%, mortality 50–70%

– Pathogens: S. pneumoniae (>50%), H. influenzae type b, N. meningitidis, also Capnocytophaga (dog bite), Babesia, malaria

– Presents as fulminant sepsis from minor febrile illness; can progress to death within hours

— Thromboembolic disease:

– Postoperative thrombocytosis (peaks POD 7–14, platelets often >1M)

– Portal vein thrombosis (PVT): 5–10% overall, up to 50% with splenomegaly/cirrhosis

– DVT/PE, mesenteric vein thrombosis

— Pulmonary hypertension: reported with long-term post-splenectomy state in hematologic disease

— Increased atherosclerotic risk: emerging data

— ITP recurrence (~30%): consider missed accessory spleen

— HS recurrence: rare, usually due to splenosis from incomplete removal

Early postoperative complications:

Late complications:

Disease-specific failure:

CCS pearl: Post-splenectomy patient POD 7 with fever, abdominal pain, transaminitis, and platelet count of 950k → order Doppler ultrasound of portal vein (or CT venography); start therapeutic anticoagulation if PVT confirmed.

Board pearl: Howell-Jolly bodies on smear confirm functional asplenia; their presence in a non-splenectomized patient suggests autosplenectomy (sickle cell) or splenic infiltration.

When to Escalate — ICU, Consult, and Inpatient Triage

— Hemodynamic instability or massive transfusion requirement

— Trauma cases with multi-organ injury

— Massive splenomegaly resection with significant blood loss

— Cirrhotic patients (high decompensation risk)

— Significant cardiopulmonary comorbidity

— Hemodynamic instability with falling Hgb despite transfusion

— Drain output >300 mL/h of blood

— Acute abdomen with peritonitis suggestive of leak or missed injury

— Hematology: refractory ITP, AIHA, lymphoma; co-management of platelet/coag issues

— Infectious disease: post-splenectomy febrile patient with possible OPSI; severe drug-resistant pneumococcal infection

— Interventional radiology: angioembolization candidates, drainage of postoperative collections

— Pulmonology: persistent pleural effusion requiring thoracentesis

— Critical care/MICU: septic shock from OPSI

— ANY fever in an asplenic patient = emergency until proven otherwise

— Blood cultures × 2, CBC, CMP, lactate, urinalysis, CXR

— Empiric broad-spectrum antibiotics within 1 hour: ceftriaxone 2 g IV ± vancomycin if MRSA/PCN-resistant pneumococcus risk

— Admit for observation even if appears well—decompensation can be rapid

— Outpatient management acceptable only after careful risk stratification with reliable follow-up

Indications for ICU admission post-splenectomy:

Surgical re-exploration triggers:

Consults:

Triage of post-splenectomy patient presenting to ED with fever:

Step 3 management: Outpatient asplenic patient calls with fever and is hours from healthcare access—instruct them to take their stand-by "pill-in-pocket" antibiotic (amoxicillin-clavulanate 875/125 or levofloxacin) immediately and proceed to nearest ED. Every asplenic patient should be prescribed and counseled on this.

Board pearl: Asplenic patient + dog/cat bite + fulminant sepsis = Capnocytophaga canimorsus; cover with amoxicillin-clavulanate or piperacillin-tazobactam.

Key Differentials — Same-Category (Surgical Abdomen)

— Liver laceration: most common solid organ injury overall; RUQ tenderness; AAST grading; >80% managed non-operatively

— Renal injury: hematuria, flank pain; CT with delayed phase

— Pancreatic injury: epigastric pain, elevated amylase/lipase; ductal injury requires repair/distal pancreatectomy

— Ruptured AAA: older patient, hypotension, pulsatile abdominal mass, back pain

— Ruptured ectopic pregnancy: reproductive-age female, β-hCG positive, hemodynamic instability

— Hemorrhagic ovarian cyst: usually self-limiting, supportive care

— Splenic artery aneurysm rupture: mortality 20%, more common in pregnant or cirrhotic patients

— Atrial fibrillation, endocarditis, sickle cell, hypercoagulable states

— LUQ pain, fever, leukocytosis—usually managed medically, splenectomy if abscess develops

— Abscess: febrile, leukocytosis, fluid collection with rim enhancement; drainage first-line

— Cyst: incidental finding; observe if asymptomatic and <5 cm; splenectomy if symptomatic, large, or suspicious

Splenectomy decisions overlap with other causes of LUQ pain, hemoperitoneum, and cytopenias. Key surgical differentials:

Other solid organ injuries in trauma:

Hemoperitoneum from non-traumatic causes:

Splenic infarction:

Splenic abscess vs splenic cyst:

Gastric ulcer/perforation: epigastric/LUQ pain, free air on imaging—different surgical approach

Key distinction: Splenic abscess typically responds to percutaneous drainage + IV antibiotics; splenectomy is reserved for multiloculated, gas-forming, or treatment-failure cases. Don't jump straight to splenectomy in a stable patient with abscess.

Board pearl: Splenic artery aneurysm is most common visceral artery aneurysm; rupture risk increases in pregnancy and portal hypertension; elective repair indicated if >2 cm, symptomatic, in women of childbearing age, or in liver transplant candidates.

Key Differentials — Other-Category (Medical and Hematologic)

— TTP: MAHA, neuro changes, AKI, fever; ADAMTS13 <10%; plasma exchange, NOT splenectomy

— HIT: heparin exposure, drop in platelets >50%, thrombosis; stop heparin, start argatroban/bivalirudin

— DIC: low fibrinogen, elevated D-dimer, prolonged PT/aPTT; treat underlying cause

— Drug-induced thrombocytopenia: quinine, vancomycin, linezolid; withdraw agent

— Hypersplenism from cirrhosis: pancytopenia + splenomegaly + liver disease findings

— Infectious: EBV, CMV, malaria, leishmaniasis, TB, endocarditis, HIV

— Hematologic malignancy: CLL, CML, lymphoma, hairy cell leukemia, myelofibrosis

— Storage diseases: Gaucher disease (most common indication for splenectomy among storage disorders before enzyme replacement)

— Portal hypertension: cirrhosis, portal/splenic vein thrombosis

— Autoimmune: Felty syndrome (RA + neutropenia + splenomegaly), SLE

— HS: yes, splenectomy curative (clinically)

— G6PD deficiency: NO, splenectomy not indicated (hemolysis is intravascular, triggered)

— Sickle cell: only for recurrent sequestration or hypersplenism in pediatric patients

— PNH: NO, splenectomy not standard (use eculizumab)

— Warm AIHA refractory to steroids/rituximab: yes, splenectomy is second/third-line

Causes of thrombocytopenia mimicking ITP (don't splenectomize wrong diagnosis):

Causes of splenomegaly:

Hemolytic anemias—splenectomy role varies:

Key distinction: Felty syndrome (triad of RA, neutropenia, splenomegaly) may respond to splenectomy if recurrent infections—but DMARDs (methotrexate) are first-line; splenectomy reserved for severe cases.

Board pearl: Splenectomy in myelofibrosis is high-risk (high mortality, accelerates hepatomegaly and thrombocytosis) and reserved for symptomatic massive splenomegaly, transfusion-dependent anemia, or portal hypertension—now often replaced by ruxolitinib.

Secondary Prevention — Vaccines, Antibiotics, Discharge Plan

— Preferred: single dose PCV20 alone, OR

— Alternative: PCV15 followed by PPSV23 ≥8 weeks later; second PPSV23 dose 5 years later

— MenACWY (Menactra/Menveo): 2 doses 8 weeks apart, then booster every 5 years

— MenB (Bexsero or Trumenba): 2- or 3-dose series, then booster every 2–3 years

— Elective splenectomy: vaccinate ≥14 days before surgery

— Emergent splenectomy: vaccinate ≥14 days after surgery

— If patient on immunosuppression (rituximab), antibody response is blunted—coordinate with hematology

— Daily penicillin V (or amoxicillin) in all children <5 yo for ≥1 year post-splenectomy

— Continue until age 5 minimum; many recommend through age 18 or lifelong in high-risk

— Adults: not routinely prescribed daily; provide "on-hand" emergency antibiotics (amoxicillin-clavulanate or levofloxacin) for febrile illness when ED is >1 h away

— Penicillin allergy: erythromycin or clarithromycin

— Wear medical alert bracelet identifying asplenia

— Travel: pre-travel consultation for malaria prophylaxis (asplenic patients more vulnerable)

— Avoid contact with sick individuals when feasible; meticulous oral hygiene; dental prophylaxis per individual risk

Vaccinations (CDC/ACIP for asplenia)—the highest-yield Step 3 topic in this entire module:

Pneumococcal:

Haemophilus influenzae type b (Hib): single dose if not previously vaccinated

Meningococcal:

Influenza: annual inactivated vaccine

COVID-19: per current guidelines

Timing:

Antibiotic prophylaxis:

Patient education / Medical alert:

Step 3 management: Document and verify on every post-splenectomy clinic visit: vaccine status, booster dates, possession of standby antibiotic, medical alert ID, fever action plan. This bundle is a CCS-style "discharge prevention" win.

Board pearl: Lifelong OPSI risk persists; vaccines reduce but do not eliminate risk—patient counseling about fever urgency is just as important as the vaccines themselves.

Follow-Up, Monitoring, and Rehabilitation

— Wound check: POD 7–14

— 4–6 weeks: assess recovery, review pathology if indication was oncologic/hematologic

— 3 months: confirm vaccine completion, repeat CBC, assess for disease response (ITP, HS)

— Annual: review vaccine boosters, infection history, address ongoing health maintenance

— CBC:

– POD 1–7: monitor for bleeding, watch rising platelets

– Platelets >1M: ensure VTE prophylaxis adequate; consider aspirin 81 mg if >1.5M and persistent

– Watch for Howell-Jolly bodies, Heinz bodies, target cells—confirm functional asplenia

— Disease-specific:

– ITP: platelet count weekly initially, then monthly; relapse may prompt search for accessory spleen

– HS: hemoglobin normalization, reticulocyte count drop, bilirubin normalization

– AIHA: DAT, haptoglobin, LDH trending

— Laparoscopic: light activity 1–2 weeks, return to most activities by 4 weeks

— Open: lifting restriction <10 lb for 6 weeks

— Resume contact sports gradually; in pediatric HS, gradual return

— Fever ≥101°F (38.3°C) → take standby antibiotic and seek ED immediately

— Abdominal pain + fever weeks post-op → rule out PVT, subphrenic abscess

— New respiratory symptoms, leg swelling → rule out VTE

— Smoking cessation (postoperative pulmonary risk and lifelong infection risk)

— Avoid tick-exposure activities without protection (babesiosis, ehrlichiosis higher risk)

— Dental hygiene, prompt treatment of skin infections

Post-operative follow-up cadence:

Lab monitoring:

Activity restrictions:

Counseling on warning signs:

Behavioral and lifestyle:

Step 3 management: A patient previously splenectomized for ITP who returns 2 years later with low platelets—recheck peripheral smear (Howell-Jolly bodies? if absent, suggests accessory spleen still functioning) and order CT or scintigraphy to localize accessory splenic tissue.

Board pearl: Hyposplenism markers on smear (Howell-Jolly bodies, target cells, acanthocytes, Pappenheimer bodies) appear within days post-splenectomy and persist indefinitely; their absence in a splenectomized patient suggests retained splenic tissue.

Ethical, Legal, and Patient Safety Considerations

— Must include lifetime OPSI risk, vaccination requirements, thromboembolic risks, surgical complications, and alternative therapies (medical management, embolization, partial splenectomy)

— In ITP, document that newer agents (TPO-RAs, rituximab) have shifted splenectomy later in the treatment algorithm—patient should understand this trajectory

— Pediatric assent with parental consent; involve child in age-appropriate discussion of lifelong implications

— Pre-op optimization: erythropoietin, IV iron, tranexamic acid, cell salvage (cell salvage may be acceptable)

— Document specific products accepted/refused in writing

— Consider preoperative embolization to reduce blood loss

— Discuss transfusion threshold and ethics committee if minor involved

— Trauma cases involving suspected interpersonal violence, child abuse (splenic injury without adequate mechanism in young child), elder abuse

— Penetrating injuries from gunshot/stab wounds reported to law enforcement per state law

— Discharge packet must include: vaccine record, standby antibiotic prescription, medical alert ID information, fever action plan, follow-up appointments, signs of PVT/VTE

— Communication to PCP: explicit handoff identifying vaccine schedule responsibilities and infection precautions—this is the single most common Step 3 safety gap

— Health literacy assessment; teach-back method for fever protocol

— Wrong-site surgery prevention (universal protocol time-out)

— Retained surgical items (count) in trauma laparotomy

— VTE risk assessment and prophylaxis (Caprini score) on every patient

— Surgical site infection bundle compliance

Informed consent:

Religious/personal refusal of blood products (Jehovah's Witness):

Mandatory reporting:

Transition-of-care safety bundles:

Patient safety / quality:

Step 3 management: A previously splenectomized patient transferring care—reconcile vaccine record, ensure PCP knows of asplenia status, prescribe and confirm possession of emergency antibiotics, and provide written fever/illness instructions. Failure to do this is a documented sentinel event pattern.

Board pearl: A vignette where an asplenic patient dies of pneumococcal sepsis after a missed vaccine booster is a malpractice/safety scenario—the answer is systems-level immunization tracking and patient education, not individual blame.

High-Yield Associations and Rapid-Fire Facts

— Unstable + positive FAST → OR

— Stable + blush → angioembolization

— Stable, low grade → NOM with serial Hgb

Howell-Jolly bodies, Heinz bodies, target cells, Pappenheimer bodies, acanthocytes = peripheral smear findings of asplenia/hyposplenism

Kehr sign = left shoulder pain from splenic rupture/diaphragmatic irritation

OPSI organisms: Streptococcus pneumoniae (>50%), Haemophilus influenzae type b, Neisseria meningitidis, Capnocytophaga canimorsus (dog bite), Babesia, Plasmodium

Mononucleosis + splenic rupture: avoid contact sports ≥3–4 weeks

Vaccines required: pneumococcal, Hib, meningococcal ACWY + B, influenza annually, COVID

Vaccine timing: ≥14 days before elective splenectomy or after emergent

Daily penicillin prophylaxis: children <5 yo, minimum 1 year post-op

Post-splenectomy thrombocytosis peaks POD 7–14; portal vein thrombosis is the dreaded complication

Accessory spleens in 10–30% of patients; must be sought in hematologic indications

ITP splenectomy response rate: ~60–70% durable remission

Hereditary spherocytosis: EMA binding test is modern diagnostic; splenectomy curative; delay to age ≥5

Don't splenectomize: TTP (PLEX), G6PD, PNH (eculizumab), cold AIHA, sickle cell adults (already autosplenectomized), most myelofibrosis

Splenic artery aneurysm: most common visceral artery aneurysm; ruptures in pregnancy; repair if >2 cm

Trauma triage:

Felty syndrome: RA + neutropenia + splenomegaly

Splenosis: residual splenic tissue from trauma or incomplete surgery—may give functional immunity

Capnocytophaga canimorsus: dog/cat bite + asplenia + fulminant sepsis

AAST splenic injury grade IV–V: high failure rate of NOM, especially in older patients

Stress-dose steroids intraoperatively if chronic steroid user (ITP)

CCS pearl: On a CCS case, the highest-impact orders in the longitudinal follow-up of a splenectomy patient are: vaccines, standby antibiotics, medical alert ID, fever education, VTE prophylaxis, and platelet monitoring.

Board pearl: A college student with mononucleosis returning to football too early ruptures spleen → presents with Kehr sign + hypotension → emergent splenectomy → lifelong vaccination protocol—classic combined Step 2/Step 3 vignette.

Board Question Stem Patterns

Stem 1 — Trauma triage: 22-year-old MVC, LUQ pain, HR 130, SBP 80, FAST positive. Next step? → Exploratory laparotomy (NOT CT). Trap: ordering CT in unstable patient.

Stem 2 — NOM: Stable patient with grade III splenic laceration, Hgb stable, no blush. Management? → Admit, bed rest, serial Hgb, type and screen, monitor. Trap: rushing to surgery.

Stem 3 — ITP refractory: Adult with platelets 8k after steroids and IVIG, no response to rituximab. Next? → Splenectomy (or TPO-RA per current ladder). Trap: missing accessory spleen workup later.

Stem 4 — Vaccine timing: Patient scheduled for elective splenectomy in 1 week. When to vaccinate? → Today or ASAP, ≥14 days pre-op. Trap: "after surgery."

Stem 5 — OPSI: Asplenic patient with fever 102°F, mild URI symptoms, well-appearing. Action? → Empiric IV ceftriaxone, blood cultures, admit for observation. Trap: outpatient management based on well appearance.

Stem 6 — Post-op POD 8: Splenectomy patient with platelets 1.1M, abdominal pain, fever, elevated LFTs. Diagnosis? → Portal vein thrombosis; order Doppler US, anticoagulate.

Stem 7 — Recurrent ITP: Post-splenectomy patient with falling platelets and absent Howell-Jolly bodies. Next step? → CT or scintigraphy for accessory spleen; resection if found.

Stem 8 — Mono and sports: College athlete with EBV, returns to football week 2, sudden LUQ pain, hypotension. Most likely? → Splenic rupture.

Stem 9 — Hereditary spherocytosis: Child age 8 with chronic hemolytic anemia, gallstones, splenomegaly. Management? → Splenectomy + cholecystectomy (and ensure vaccines + PCN prophylaxis).

Stem 10 — Don't splenectomize: Patient with MAHA, thrombocytopenia, fever, AKI, neuro changes. Treatment? → Plasma exchange for TTP. Trap: assuming ITP.

Stem 11 — Capnocytophaga: Asplenic patient with recent dog bite, fulminant sepsis. Pathogen? → C. canimorsus; treat with amox-clav or piperacillin-tazobactam.

Stem 12 — Cirrhotic with splenomegaly: Patient with portal HTN and severe thrombocytopenia. Best option? → Partial splenic embolization or TIPS, not splenectomy.

Step 3 management: Recognize that Step 3 stems frequently test longitudinal management decisions (vaccine timing, antibiotic prophylaxis, follow-up labs, transition-of-care) rather than the operative decision itself.

One-Line Recap

Splenectomy is a high-impact operation whose indications span trauma, refractory hematologic disease, and selected splenic pathology—but its consequences (lifelong OPSI risk, post-operative thrombocytosis and portal vein thrombosis) make pre-operative vaccination, standby antibiotics, VTE prophylaxis, and disciplined longitudinal follow-up the true determinants of patient outcome.

Indications: hemodynamically unstable splenic trauma (or failed NOM/embolization), refractory ITP, hereditary spherocytosis, warm AIHA, hypersplenism, splenic abscess/mass/aneurysm—not TTP, G6PD, PNH, or cold AIHA

Perioperative bundle: vaccinate ≥14 days pre-op (PCV20 or PCV15→PPSV23, Hib, MenACWY + MenB, influenza, COVID); search for and remove accessory spleens in hematologic cases; VTE prophylaxis with LMWH starting POD 1

Post-operative vigilance: platelets peak POD 7–14 (watch for portal vein thrombosis with abdominal pain, fever, transaminitis); aggressive incentive spirometry for atelectasis; recognize subphrenic abscess and pancreatic fistula early

Lifelong prevention: daily penicillin in children <5 yo for ≥1 year, on-hand emergency antibiotics for adults, medical alert ID, fever action plan ("any fever = emergency antibiotic + ED within 1 hour"), booster vaccines per schedule, PCP handoff with explicit asplenia documentation

Board pearl: The single most-tested Step 3 splenectomy concept is OPSI prevention through the vaccine-antibiotic-education triad; the single most-tested complication is portal vein thrombosis from post-splenectomy thrombocytosis.

CCS pearl: When in doubt on a CCS splenectomy case, your "always order" set is: CBC trend, VTE prophylaxis, incentive spirometry, vaccines if not yet given, PCP follow-up, standby amox-clav prescription, fever counseling.