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3. A patient is referred to you for surgical management of
medically refractory idiopathic thrombocytopenic purpura, currently being treated with daily prednisone. On
your assessment, they would benefit from a splenectomy,
but their platelet count is low enough that you are concerned for intraoperative bleeding. Which preoperative
intervention would be most beneficial?
A. Platelet transfusion
CHAPTER 34
The Spleen
B. Whole blood transfusion
C. Fresh frozen plasma
D. IV immunoglobulin
4. A patient has been referred to you on suspicion of hemolytic anemia by their primary care physician, who thinks
they may benefit from a splenectomy. Which test would
confirm a diagnosis of autoimmune hemolytic anemia?
A. Positive direct Coombs test
B. Negative indirect Coombs test
C. Increased red cell distribution width
D. Increased lactate dehydrogenase
5. Which malignancy most commonly spreads to the
spleen?
A. Lung
B. Colorectal
C. Ovarian
D. Melanoma
Answer: D
IV immunoglobulin, given at 1.0 g/kg per day for 2 to 3 days,
is indicated for internal bleeding when platelet counts remain
<5000/mm3, when extensive purpura exists, or to preoperatively boost platelets. IV immunoglobulin is thought to
impair clearance of immunoglobulin G–coated platelets by
competing for binding to tissue macrophage receptors. An
immediate response is common, but a sustained remission is
not. (See Schwartz 11th ed., p. 1526.)
Answer: A
A positive result on direct Coombs test confirms the antibody
autoimmune hemolytic anemia (AIHA) diagnosis by distinguishing autoimmune from other forms of hemolytic anemia.
(See Schwartz 11th ed., pp. 1524–1525.)
Answer: A
Lung carcinoma is the tumor that most commonly spreads
to the spleen, although colorectal, ovarian, and melanoma
may also metastasize to the spleen. (See Schwartz 11th ed.,
p. 1529.)
6. A 45-year-old woman with a diagnosis of rheumatoid
arthritis also develops splenomegaly and neutropenia.
What is the mechanism by which neutropenia develops?
A. Sequestration of leukocytes in the spleen
B. Autoimmune reaction to neutrophils
C. Marrow underproduction of the granulocyte lineage
D. Increased spleen sinusoid permeability
7. You are evaluating a 55-year-old man in clinic for an
elective operation. His surgical history is notable for a
traumatic, open splenectomy when he was 25 following
a motor vehicle collision. He says he hasn’t had any vaccines in the last 20 years, which of the following is the
most important for him to get with regard to his history
of splenectomy?
A. Influenza
B. TDap
C. Herpes Zoster
D. Measles, mumps, rubella
Answer: B
The triad of rheumatoid arthritis, splenomegaly, and neutropenia is called Felty syndrome. It exists in approximately 3%
of all patients with rheumatoid arthritis, two-thirds of whom
are women. Immune complexes coat the surface of white
blood cells, which leads to their sequestration and clearance
in the spleen with subsequent neutropenia. This neutropenia (<2000 neutrophils/mm3) increases the risk for recurrent
infections and often drives the decision for splenectomy. (See
Schwartz 11th ed., p. 1532.)
Answer: A
International guidelines recommend annual influenza vaccine for asplenic patients. The influenza vaccination provides
protection from influenza syndrome and secondary bacterial infection, and is associated with a 54% reduced risk of
death compared with unimmunized asplenic persons. (See
Schwartz 11th ed., pp. 1532–1533.)
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8. You are performing an open splenectomy for symptomatic splenomegaly. The spleen is exposed and you have
excellent visualization of the associated blood supply.
What vessel do you ligate first?
A. Splenic artery
B. Splenic vein
C. Short gastric arteries
D. Short gastric veins
9. You are counselling a patient on the risks of an elective
laparoscopic splenectomy. Which of the following cancers will the patient be at increased risk for following the
operation?
A. Ovarian
B. Non-Hodgkin lymphoma
C. Sarcoma
D. Pancreatic
Answer: A
In patients with significant splenomegaly, once lesser sac
access has been achieved through either the gastrosplenic
or gastrohepatic attachments, ligating the splenic artery in
continuity along the superior border of the pancreas may
be preferable. This maneuver may serve several purposes:
allowing safer manipulation of the spleen and dissection of
the splenic hilum, facilitating some shrinkage of the spleen,
and providing an autotransfusion of erythrocytes and platelets. Further medial mobilization of the spleen is achieved by
incising its lateral peritoneal attachments, most notably the
splenophrenic ligament. Then follows individual ligation and
sequential division of the short gastric vessels, steps that if
carefully executed reduce the risk of these vessels’ retracting
and bleeding. Splenic hilar dissection then takes place. Whenever possible, care should be taken to dissect and individually
ligate the splenic artery and vein (in that order) before dividing them. (See Schwartz 11th ed., pp. 1533–1534.)
Answer: B
A Taiwanese population-based study found that individuals
who had splenectomy have higher risks of developing certain
types of cancer (adjusted hazard ratios were 2.64 and 1.29 for
nontraumatic and traumatic reasons, respectively). Splenectomy patients were found to have significantly higher risks in
esophagus, stomach, liver, other head and neck, non-Hodgkin
lymphoma, and leukemia cancers. Although the exact mechanism for the possible association between splenectomy and
cancer remains unclear, a plausible explanation is that the
spleen is thought to be involved in immunological defenses
and provides active response through humoral and cell-mediated pathways and that splenectomy may impair immune surveillance in the host. (See Schwartz 11th ed., p. 1539.)
CHAPTER 34
The Spleen
10. A 31-year-old man is admitted to the hospital 6 months
following a posttraumatic splenectomy with evidence of
sepsis. He has completed all recommended postoperative follow-ups. Which organism is the most likely cause
of the infection?
A. Staphylococcus aureus
B. Streptococcus pneumonia
C. Neisseria meningitidis
D. Escherichia coli
11. Which disorder is most likely to benefit from
splenectomy?
A. Glucose-6-phosphate dehydrogenase deficiency
B. Pyruvate kinase deficiency
C. Warm-agglutinin disease
D. Child with immune thrombocytopenic purpura
Answer: D
More recently, the bacterial patterns of post-splenectomy
sepsis have been changing. After the introduction of vaccinations and new oral antibiotics, postsplenectomy patients can
suffer from diverse strains of bacterial infection, which are
not strictly correlated with the splenic function. In a recent
cohort series, gram-negative bacteria are prevalent, representing 45% to 50% of infections in asplenic patients. In vaccinated patients, the rate of sepsis by pneumococcus is very
low. In fact, encapsulated bacteria, such as S. pneumoniae, N.
meningitidis, and H. influenzae, were rarely encountered in
those series in whom vaccination was routinely adopted. (See
Schwartz 11th ed., pp. 1538–1539.)
Answer: C
Favorable responses to splenectomy have been reported in
patients with warm-antibody autoimmune hemolytic anemia
(AIHA), with a recent series showing complete remission
of refractory AIHA following laparoscopic splenectomy at
35-month follow-up in patients over 60 years old. Transient
responses are more common, however, and many patients
eventually experience hemolysis again despite splenectomy.
The decision regarding splenectomy in the case of AIHA
should be individualized based on careful consideration of
the clinical history and frank discussion with the patient. It is
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CHAPTER 34
The Spleen
considered as a third-line therapy after failure of steroids or
anti-CD20 antibody administration. Conventional wisdom
is that splenectomy is not indicated in glucose-6-phosphate
dehydrogenase deficiency, and certainly the overwhelming
majority of patients with G6PD deficiency will neither require
nor benefit from splenectomy. However, one report described
a small case series of six symptomatic G6PD deficiency
patients who had severe hemolytic anemia and required
transfusion, all of whom were identified to share a common
mutation at exon 10. All underwent splenectomy. A complete
response occurred in four patients (transfusion requirement
eliminated), and a partial response occurred in one patient
(transfusion requirement reduced); no follow-up data were
provided for the remaining patient. This study indicates that
for a carefully select group of patients with severe hemolytic
anemia attributable to G6PD deficiency, splenectomy may be
of benefit, although more data is needed before strong recommendation can be made. The majority of pediatric immune
thrombocytopenia (ITP) patients recover spontaneously in a
few months. (See Schwartz 11th ed., pp. 1524–1527.)
12. Following a splenectomy for chronic hemolytic anemia,
what hemoglobin level is indicative of success?
A. >7 g/dL
B. >8 g/dL
C. >9 g/dL
D. >10 g/dL
13. Which of the following is NOT a location where accessory spleens can be found?
A. Gastrocolic ligament
B. Gerota fascia
C. Large bowel mesentery
D. Broad ligament
14. Which of the following splenic ligaments is NOT an
avascular plane?
A. Gastrosplenic
B. Splenocolic
C. Phrenosplenic
D. Splenorenal
Answer: D
For chronic hemolytic anemias, a rise in hemoglobin levels to
>10 g/dL without the need for transfusion signifies a successful response to splenectomy. By this criterion, splenectomy has
been reported to be successful for the vast majority of patients
with chronic hemolytic anemia. For hemolytic anemia due to
spherocytosis, the success rate is usually higher, ranging from
90% to 100%. (See Schwartz 11th ed., pp. 1524–1525.)
Answer: B
The most common anomaly of splenic embryology is the
accessory spleen. Present in up to 20% of the population, one
or more accessory spleen(s) may occur in up to 30% of patients
with hematologic disease. Over 80% of accessory spleens are
found in the region of the splenic hilum and vascular pedicle.
Other locations for accessory spleens in descending order of
frequency are: the gastrocolic ligament, the tail of the pancreas, the greater omentum, the greater curve of the stomach,
the splenocolic ligament, the small and large bowel mesentery, the left broad ligament in women, and the left spermatic
cord in men. (See Schwartz 11th ed., p. 1519.)
Answer: A
Of particular clinical relevance, the spleen is suspended
in position by several ligaments and peritoneal folds to the
colon (splenocolic ligament); the stomach (gastrosplenic
ligament); the diaphragm (phrenosplenic ligament); and the
kidney, adrenal gland, and tail of the pancreas (splenorenal
ligament) (Fig. 34-1). Whereas the gastrosplenic ligament
contains the short gastric vessels, the remaining ligaments are
usually avascular, with rare exceptions, such as in a patient
with portal hypertension. The relationship of the pancreas to
the spleen also has important clinical implications. In cadaveric anatomic series, the tail of the pancreas has been demonstrated to lie within 1 cm of the splenic hilum 75% of the
time and to actually abut the spleen in 30% of patients. (See
Schwartz 11th ed., p. 1519.)
Gastrosplenic
ligament
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Phrenicocolic
ligament
FIG. 34-1. Suspensory ligaments of the spleen.
15. All of the following are functions of the spleen EXCEPT:
A. Clearance of damaged or aged red blood cells from
the blood.
B. Extramedullary site for hematopoesis and recycling
iron.
C. Initiation of adaptive immune response from filtra-
tion of lymph.
D. Clearance of encapsulated bacteria from the blood
stream.
Lesser sac
Sustentaculum
lienis
Splenocolic
ligament
Greater omentum
Answer: C
The spleen has both fast and slow circulation of blood. It is
during slow circulation that blood travels through the reticular spaces and splenic cords where it is exposed to contact
with splenic macrophages, which remove senescent blood
cells. Through this process, the spleen is also able to remove
erythrocyte inclusions such as Heinz bodies without lysing
the cells. Through the reticuloendothelial system, the spleen
clears encapsulated bacteria such as pneumococcus and
Haemophilus influenzae, which are poorly opsonized from
the hepatic reticuloendothelial system. In addition to these
functions, the spleen serves as an extramedullary site for
hematopoiesis and plays a functional role in the recycling of
iron. While the white pulp of the spleen is important in the
initiation of the adaptive immune response, material is delivered to the spleen through the blood and not the lymph. (See
Schwartz 11th ed., pp. 1520–1521.)
CHAPTER 34
The Spleen
16. Which of the following proteins is not altered in hereditary spherocytosis (HS)?
A. Pyruvate kinase
B. Spectrin
C. Ankyrin
D. Band 3 protein
Answer: A
The underlying abnormality in HS is an inherited dysfunction or deficiency in one of the erythrocyte membrane proteins (spectrin, ankyrin, band 3 protein, or protein 4.2), which
results in destabilization of the membrane lipid bilayer. This
destabilization allows a release of lipids from the membrane,
causing a reduction in membrane surface area and a lack of
deformability, leading to sequestration and destruction of the
spherocytic erythrocytes in the spleen.
Although less common than glucose-6-phosphate dehydrogenase (G6PD) deficiency overall, pyruvate kinase deficiency is the most common red blood cell enzyme deficiency
to cause congenital chronic hemolytic anemia. (See Schwartz
11th ed., p. 1524.)
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17. The disproportionately high rate of overwhelming postsplenectomy infection in thalassemia patients is thought
to be due to an immune deficiency. Which of the following strategies has been shown to reduce mortality?
A. Partial splenectomy
B. Prophylactic antibiotic therapy
C. Delaying splenectomy until after 2 years of age
D. Transfusion to maintain a hemoglobin of >9 mg/dL
CHAPTER 34
The Spleen
18. A 30-year-old woman presents to her primary care provider with complaints of bleeding gums while brushing
her teeth as well as menorrhagia and several episodes of
epistaxis within the past month. She has been previously
healthy with no prior medical problems or surgeries.
Examination reveals petechiae and ecchymosis over the
lower extremities. Laboratory results show white blood
cell count 7000/mm3, hemoglobin 14 g/dL, hematocrit
42%, and platelet count 28,000/mm3 with numerous
megakaryocytes on peripheral smear. First-line therapy
for this condition would be:
A. Oral prednisone
B. IV immunoglobulin
C. Rituximab
D. Splenectomy
Answer: A
The increase in infectious complications associated with
splenectomy in thalassemia patients is thought to be due to a
coexisting immune deficiency that is caused by iron overload.
Iron overload is associated with both thalassemia as well as
the transfusions that accompany treatment for thalassemia.
Some investigators have tried partial splenectomy with some
success in reducing mortality associated with splenectomy in
these patients. In addition, splenectomy should be delayed
until the patient is older than 4 years of age unless absolutely
necessary. While transfusion to maintain a hemoglobin of
>9 mg/dL is part of the treatment for thalassemia it does not
reduce infectious complications associated with splenectomy
in these patients. There is little evidence supporting efficacy
of prophylactic antibiotics in asplenic patients in preventing
infectious complications associated with splenectomy. (See
Schwartz 11th ed., p. 1525.)
Answer: A
Idiopathic thrombocytopenic purpura is an autoimmune
disorder characterized by a low platelet count and mucocutaneous and petechial bleeding. The usual first line of therapy
for idiopathic thrombocytopenic purpura is oral prednisone
with most responses occurring within the first 3 weeks after
initiating therapy. IV immunoglobulin is given for internal
bleeding with platelet counts < 5000/mm3, when extensive
purpura exists, or to increase platelets preoperatively and is
thought to work by impairing clearance of immunoglobulin
G-coated platelets by competing for binding to tissue macrophage receptors. Both rituximab and thrombopoietin receptor
antagonists are second-line treatment options. Splenectomy
is an option for refractory immune thrombocytopenia (ITP)
and can provide a permanent response in about 75% to 85%
of patients. (See Schwartz 11th ed., pp. 1526–1527.)
19. The most common physical finding in a patient with
hairy cell leukemia (HCL) is:
A. Massive splenomegaly.
B. Shortness of breath.
C. Abdominal pain.
D. Joint pain.
Answer: A
HCL is an uncommon blood disorder, representing only 2%
of all adult leukemias. HCL is characterized by splenomegaly,
pancytopenia, and large numbers of abnormal lymphocytes
in the bone marrow. These lymphocytes contain irregular
hair-like cytoplasmic projections identifiable on the peripheral smear. Most patients seek medical attention because of
symptoms related to anemia, neutropenia, thrombocytopenia, or splenomegaly. The most common physical finding is
splenomegaly, which occurs in 80% of patients with HCL and
is often palpable 5 cm below the costal margin. Many patients
with HCL have few symptoms and require no specific therapy. Treatment is indicated for those with moderate to severe
symptoms related to cytopenias, such as repeated infections
or bleeding episodes, or to splenomegaly, such as pain or early
satiety. Splenectomy does not correct the underlying disorder, but does return cell counts to normal in 40% to 70% of
patients and alleviates pain and early satiety. Newer chemotherapeutic agents (the purine analogues 2ʹ-deoxycoformycin
[2ʹ-DCF] and 2-chlorodeoxyadenosine [2-CdA]) are able to
induce durable complete remission in most patients. (See
Schwartz 11th ed., p. 1527.)
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20. Which of the following is an indication for splenectomy
in a patient with chronic myelogenous leukemia (CML)?
A. Failure of chemotherapy to decrease splenomegaly
B. Sequestration requiring transfusion
C. Symptomatic relief of early satiety
D. Presence of bcr gene mutation
21. Which of the following is an indication for splenectomy
in polycythemia vera?
A. Failure of aspirin to prevent thrombotic complications
B. Frequent need for phlebotomy
C. Symptoms related to splenomegaly
D. Prevention of progression to myeloid metaplasia
Answer: C
CML is a disorder of the primitive pluripotent stem cell in the
bone marrow, resulting in a significant increase in erythroid,
megakaryotic, and pluripotent progenitors in the peripheral
blood smear. The genetic hallmark is a transposition between
the bcr gene on chromosome 9 and the abl gene on chromosome 22. CML accounts for 7% to 15% of all leukemias, with
an incidence of 1.5 in 100,000 in the United States. CML is
frequently asymptomatic in the chronic phase, but symptomatic patients often present with the gradual onset of fatigue,
anorexia, sweating, and left upper quadrant pain and early
satiety secondary to splenomegaly. Enlargement of the spleen
is found in roughly one half of patients with CML. Splenectomy is indicated to ease pain and early satiety. (See Schwartz
11th ed., p. 1528.)
Answer: C
Polycythemia vera (PV) is a clonal, chronic, progressive
myeloproliferative disorder characterized by an increase in
red blood cell mass, frequently accompanied by leukocytosis, thrombocytosis, and splenomegaly. Patients affected by
PV typically enjoy prolonged survival compared to others
affected by hematologic malignancies, but remain at risk for
transformation to myelofibrosis or acute myeloid leukemia
(AML). The disease is rare, with an annual incidence of 5
to 17 cases per million population. Although the diagnosis
may be discovered by routine screening laboratory tests in
asymptomatic individuals, affected patients may present with
any number of nonspecific complaints, including headache,
dizziness, weakness, pruritus, visual disturbances, excessive
sweating, joint symptoms, and weight loss. Physical findings
include ruddy cyanosis, conjunctival plethora, hepatomegaly,
splenomegaly, and hypertension. The diagnosis is established
by an elevated red blood cell mass (>25% of mean predicted
value), thrombocytosis, leukocytosis, normal arterial oxygen
saturation in the presence of increased red blood cell mass,
splenomegaly, low serum erythropoietin (EPO) stores, and
bone marrow hypercellularity. Treatment should be tailored to
the risk status of the patient and ranges from phlebotomy and
aspirin to chemotherapeutic agents. As in essential thrombocythemia (ET), splenectomy is not helpful in the early stages
of disease and is best reserved for late-stage patients in whom
myeloid metaplasia has developed and splenomegaly-related
symptoms are severe. (See Schwartz 11th ed., p. 1529.)
CHAPTER 34
The Spleen
22. Which of the following is the most common etiology of
splenic cyst worldwide?
A. Bacterial infection
B. Trauma
C. Parasitic infection
D. Congenital anomaly
Answer: C
Splenic cysts are rare lesions. The most common etiology for
splenic cysts worldwide is parasitic infestation, particularly
echinococcal. Symptomatic parasitic cysts are best treated
with splenectomy, though selected cases may be amenable to
percutaneous aspiration, instillation of protoscolicidal agent,
and reaspiration. Nonparasitic cysts most commonly result
from trauma and are called pseudocysts; however, dermoid,
epidermoid, and epithelial cysts have been reported as well.
The treatment of nonparasitic cysts depends on whether or
not they produce symptoms. Asymptomatic nonparasitic
cysts may be observed with close ultrasound follow-up to
exclude significant expansion. Patients should be advised of
the risk of cyst rupture with even minor abdominal trauma
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if they elect nonoperative management for large cysts. Small
symptomatic nonparasitic cysts may be excised with splenic
preservation, and large symptomatic nonparasitic cysts may
be unroofed. Both of these operations may be performed laparoscopically. (See Schwartz 11th ed., p. 1530.)
23. Which of the following is an indication for surgical treatment of a splenic aneurysm?
CHAPTER 34
A. Pregnancy
B. Size >1.5 cm
C. History of thrombocytopenia
D. History of neutropenia
The Spleen
Answer: A
Although rare, splenic artery aneurysm (SAA) is the most
common visceral artery aneurysm. Women are four times
more likely to be affected than men. The aneurysm usually
arises in the middle to distal portion of the splenic artery. The
risk of rupture is between 3% and 9%; however, once rupture
occurs, mortality is substantial (35%–50%). According to a
recent series, mortality is significantly higher in patients with
underlying portal hypertension (>50%) than in those without it (17%). SAA is particularly worrisome when discovered
during pregnancy, as rupture imparts a high risk of mortality to both mother (70%) and fetus (95%). Most patients are
asymptomatic and seek medical attention based on an incidental radiographic finding. About 20% of patients with SAA
have symptoms of left upper quadrant pain. Indications for
treatment include presence of symptoms, pregnancy, intention to become pregnant, and pseudoaneurysms associated
with inflammatory processes. For asymptomatic patients,
size > 2 cm constitutes an indication for surgery. Aneurysm
resection or ligation alone is acceptable for amenable lesions
in the mid-splenic artery, but distal lesions in close proximity to the splenic hilum should be treated with concomitant
splenectomy. An excellent prognosis follows elective treatment. Splenic artery embolization has been used to treat SAA,
but painful splenic infarction and abscess may follow. (See
Schwartz 11th ed., p. 1531.)
24. A 45-year-old man presents to the emergency department with emesis of bright red blood. Labs include HGB
10 g/dL, HCT 30%, platelets 300,000/mm3, INR 1.0, AST
30 U/L, ALT 45 U/L, and albumin 4.0 g/dL. After appropriate resuscitation, he undergoes esophagogastroduodenoscopy (EGD) which is notable for gastric varices.
What is the appropriate treatment for his condition?
A. Transjugular intrahepatic portosystemic shunt
B. Variceal band ligation
C. Splenorenal shunt
D. Splenectomy
25. Which of the following is NOT part of the triad seen with
Felty syndrome?
A. Rheumatoid arthritis (RA)
B. Splenomegaly
C. Neutropenia
D. Thrombocytopenia
Answer: D
While portal hypertension is most commonly a result of cirrhosis it can result from other causes such as splenic vein
thrombosis. Patients with splenic vein thrombosis can present with bleeding from gastric varices in the setting of normal
liver function and test results. These patients also often have a
history of pancreatic disease. Portal hypertension secondary
to splenic vein thrombosis is potentially curable with splenectomy. (See Schwartz 11th ed., p. 1531.)
Answer: D
The triad of RA, splenomegaly, and neutropenia is called
Felty syndrome. It exists in approximately 3% of all patients
with RA, two-thirds of which are women. Immune complexes
coat the surface of white blood cells, leading to their sequestration and clearance in the spleen with subsequent neutropenia. This neutropenia (<2000/mm3) increases the risk for
recurrent infections and often drives the decision for splenectomy. The size of the spleen is variable, from nonpalpable in
5% to 10% of patients, to massive enlargement in others. The
spleen in Felty syndrome is four times heavier than normal.
Corticosteroids, hematopoietic growth factors, methotrexate, and splenectomy have all been used to treat the neutropenia of Felty syndrome. Responses to splenectomy have
been excellent, with over 80% of patients showing a durable
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increase in white blood cell count. More than one-half of
patients who had infections prior to surgery did not have any
infections after splenectomy. Besides symptomatic neutropenia, other indications for splenectomy include transfusiondependent anemia and profound thrombocytopenia. (See
Schwartz 11th ed., p. 1532.)
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26. Which of the following is the most effective prevention strategy against overwhelming postsplenectomy
infection?
A. Vaccination 2 weeks after splenectomy
B. Vaccination 2 weeks before splenectomy
C. Daily antibiotic prophylaxis
D. Carrying a reserve supply of antibiotics for self-
administration
27. All of the following are TRUE regarding laparoscopic
splenectomy EXCEPT:
A. It is associated with shorter hospital stays.
B. It is associated with increased intraoperative blood
loss.
C. It is associated with decreased morbidity.
D. Patients are positioned in the right lateral decubitus
position or the 45o right lateral decubitus position.
Answer: B
Asplenic patients have an increased susceptibility to infection
for the remainder of their lives and although the overall lifetime risk of overwhelming postsplenectomy infection (OPSI)
is low the consequences can be devastating. Patients undergoing splenectomy for hematologic or malignant indications
have a greater risk of OPSI than patients undergoing splenectomy for trauma or iatrogenic injury and OPSI is more
common in children than adults. Providers need to have a
high index of suspicion when evaluating asplenic patients
for possible infection. Patient education and vaccinations
against encapsulated pathogens is the mainstay of preventative therapy. Patients should be vaccinated 2 weeks prior to
elective splenectomy in order to optimize antigen recognition
and processing. If splenectomy is performed emergently, vaccinations are given postoperatively with an attempt to delay
administration for 2 weeks to avoid the transient immunosuppression associated with surgery. There is little evidence
supporting efficacy of prophylactic antibiotics in asplenic
patients and vaccination remains the most effective prevention strategy. (See Schwartz 11th ed., p. 1532.)
Answer: B
Laparoscopic splenectomy has become the favored procedure
versus open splenectomy for elective splenectomy over the
past two decades and is now considered the gold standard for
elective splenectomy in patients with normal-sized spleens.
With experienced surgeons, laparoscopic splenectomy is
associated with decreased intraoperative blood loss, shorter
hospital length of stay, and lower morbidity rates as compared
to open splenectomy. Laparoscopic splenectomy is often performed with the patient in the right lateral decubitus position;
patients are sometimes placed in a 45o right lateral decubitus
position to facilitate easier access for concomitant procedures
such as laparoscopic cholecystectomy. (See Schwartz 11th ed.,
p. 1534.)
CHAPTER 34
The Spleen
28. What is the most common complication following open
splenectomy?
A. Pancreatitis
B. Left lower lobe atelectasis
C. Pleural effusion
D. Wound infection
Answer: B
Complications following splenectomy can be divided into
pulmonary, hemorrhagic, infectious, pancreatic, and thromboembolic. Pulmonary complications include left lower lobe
atelectasis, pleural effusion, and pneumonia with left lower
lobe atelectasis being the most common complication overall.
Hemorrhagic complications include intraoperative hemorrhage, postoperative hemorrhage, and subphrenic hematoma.
Infectious complications include subphrenic abscess and
wound infection. Placement of a drain in the left upper quadrant can be associated with postoperative subphrenic abscess
and is therefore not routinely recommended. Pancreatic
complications include pancreatitis, pseudocyst formation,
and pancreatic fistula and often result from intraoperative
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trauma to the pancreas during dissection of the splenic hilum.
Thromboembolic complications include deep vein thrombosis and portal vein thrombosis. (See Schwartz 11th ed.,
p. 1539.)
29. Which of the following patients is at highest risk for
overwhelming postsplenectomy infection (OPSI)?
A. A 30-year-old who underwent splenectomy for idio-
CHAPTER 34
pathic thrombocytopenic purpura
B. A 25-year-old who underwent splenectomy for iatro-
genic bleeding after a total colectomy
C. A 3-year-old who underwent splenectomy for hered-
itary spherocytosis
D. A 4-year-old who underwent splenectomy due to
bleeding after a motor vehicle crash
The Spleen
30. Which of the following asplenic patients should receive
prophylactic antibiotic therapy to protect against overwhelming postsplenectomy infection (OPSI)?
A. A 35-year-old man undergoing a tooth extraction.
B. A 4-year-old child who recently underwent
splenectomy.
C. A 15-year-old boy who underwent splenectomy at
age 13.
D. There is little evidence supporting efficacy of prophy-
lactic antibiotics.
Answer: C
While the all lifetime risk of OPSI is low (ranging from <1%
to 5%) the consequences are serious. The reason for splenectomy is the single most influential determinant of OPSI risk.
There is evidence that those who undergo splenectomy for
hematologic disease are far more susceptible to OPSI than
patients who undergo splenectomy for trauma or iatrogenic
reasons. When taking age into consideration, children who
are 5 years of age or younger and adults who are 50 years of
age or older seem to be at an elevated risk. The interval since
splenectomy also seems to be a factor with the greatest risk
occurring in the first 2 years after splenectomy; however,
it is important to remember that cases of OPSI can occur
decades later and asplenic patients remain at lifelong risk.
(See Schwartz 11th ed., pp. 1538–1539.)
Answer: D
Antibiotic therapy in asplenic patients falls into three categories: deliberate therapy for established or presumed infections, prophylaxis in anticipation of invasive procedures,
and general prophylaxis. There is little evidence supporting
efficacy of prophylactic antibiotics in anticipation of invasive
procedures or efficacy of general prophylaxis and guidelines
are not uniform. Common recommendations include daily
antibiotics until 5 years of age or at least 5 years after splenectomy with some advocating continuing antibiotics until
young adulthood; however, there is little evidence supporting efficacy. It is unlikely that randomized controlled trials on
this issue will be performed due to the low incidence of OPSI
as well as its serious consequences. (See Schwartz 11th ed.,
p. 1542.)
CHAPTER 35
https://t.me/medicina_free
Abdominal Wall, Omentum, Mesentery,
and Retroperitoneum
1. A cutaneous malignancy of the anterior abdominal wall
2 inches above the umbilicus will drain to which of the
following lymphatic basins?
A. Umbilical
B. Axillary
C. Retroperitoneal
D. Inguinal
2. Materials used for mesh repair of an abdominal wall
hernia include synthetic meshes and biologic meshes.
Which of the following statements is TRUE regarding
biologic mesh materials?
A. Biologic mesh is designed to be absorbed over time.
B. Biologic mesh is manufactured from commercially
prepared algae.
C. Biologic mesh is similar in cost to synthetic mesh
materials.
D. Biologic mesh is superior to synthetic mesh in pre-
venting hernia recurrence.
3. The appropriate treatment of rectus abdominis diastasis
is:
A. Observation.
B. Resection and primary repair.
C. Mesh overlay.
D. Lateral component separation.
Answer: B
The lymphatic drainage of the anterior abdominal wall is
principally to the axillary nodal basin and the inguinal nodal
basin. The area of demarcation is roughly the arcuate line
(semilunar line of Douglas) at the level of the anterior iliac
spine. Malignancies above the arcuate line drain superiorly and
those below the line drain inferiorly. (See Schwartz 11th ed.,
p. 1550.)
Answer: A
Biologic mesh is derived from decellularized, collagenrich porcine, bovine, or human tissue. The biologic mesh is
designed to be absorbed over time after allowing for ingrowth
of host tissues. They are more expensive than synthetic
mesh but may be advantageous in the setting of an infected
wound. Their benefit in preventing hernia recurrence is as yet
unproven. (See Schwartz 11th ed., p. 1555.)
Answer: A
Rectus abdominis diastasis (or diastasis recti) is a separation
of the two rectus abdominis muscular pillars. This results in
a bulge of the abdominal wall that is sometimes mistaken for
a ventral hernia despite the fact that the midline aponeurosis
is intact and no hernia defect is present. Computed tomography (CT) scanning can provide an accurate measure of the
distance between the rectus pillars and will differentiate rectus diastasis from a true ventral hernia. Surgical correction
has been described for cosmetic reasons but is unnecessary
and risks the formation of a true postoperative hernia. (See
Schwartz 11th ed., p. 1556.)
4. Postoperative incisional hernia of a midline incision is
best prevented by which of the following suture techniques for closure of an abdominal incision?
A. Widely spaced 1.5 to 2.0 cm interrupted mattress
sutures
B. Narrowly spaced 5 to 8 mm interrupted sutures
C. A running suture of absorbable suture material
D. A running suture of polypropylene suture material
Answer: B
Classically, the midline fascia is closed with interrupted
1 cm synthetic sutures placed 1 cm apart. Recent studies indicate a reduced risk of incisional hernia with narrowly spaced
sutures of 5 to 8 mm in length placed 5 mm apart. The value
of mesh reinforcement of midline closure is still under evaluation. (See Schwartz 11th ed., pp. 1550–1551.)
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