The spleen lies under the ninth to eleventh ribs, under the diaphragm. It is lateral to the stomach and anterosuperior to the left kidney. The tail of the pancreas is in close anatomical proximity to the splenic hilum and amenable to injury during splenectomy or hilar clamping.

The spleen is held in place by four ligaments, which include the splenophrenic and splenorenal ligaments posterolaterally, the splenogastric ligament medially, and the splenocolic ligament inferiorly. The splenorenal ligament begins at the anterior surface of Gerota’s fascia of the left kidney and extends to the splenic hilum, as a two-layered fold that invests the tail of the pancreas and splenic vessels. The splenophrenic ligament connects the posteromedial part of the spleen to the diaphragm, and the splenocolic ligament connects the inferior pole of the spleen to the splenic flexure of the colon. The splenogastric ligament is the only vascular ligament and contains five to seven short gastric vessels that originate from the distal splenic artery and enter the greater curvature of the stomach. Excessive retraction of the splenic flexure or the gastrosplenic ligaments can easily tear the splenic capsule and cause troublesome bleeding.

Figure 28.1

(a) The spleen is held in place by four ligaments: the splenophrenic and splenorenal ligaments posterolaterally, the splenogastric medially, and the splenocolic inferiorly. Medial rotation of the spleen (inset) exposes the splenophrenic and splenorenal ligaments.

(b) Undue traction on the spleen, the stomach, or the colon may cause capsular avulsion and bleeding.

Figure 28.2 (a, b) Medial rotation of the spleen exposes the splenorenal ligament, which begins at the anterior surface of the Gerota’s fascia of the left kidney and extends to the splenic hilum.

Figure 28.3 The splenocolic ligament connects the inferior pole of the spleen to the splenic flexure of the colon, and is avascular. Excessive traction may cause capsular avulsion and bleeding.

Figure 28.4 The stomach is retracted medially and the spleen laterally revealing the gastrosplenic ligament and the short gastric vessels.

The mobility of the spleen depends on the architecture of these ligaments. In patients with short and well-developed ligaments, mobilization is more difficult and requires careful dissection in order to avoid further splenic damage.

The splenic hilum contains the splenic artery and vein and is often intimately associated with the tail of the pancreas. The extent of the space between the tail of the pancreas and the splenic hilum varies from person to person.

The splenic artery is a branch of the celiac axis that courses superior to the pancreas towards the splenic hilum where it divides into upper and lower pole arteries. There is significant variability in where this branching occurs. Most people, approximately 70%, have a distributed or medusa like branching that occurs 5–10 cm from the spleen. Simple branching occurs in approximately 30%, 1–2 cm from the spleen.

The splenic vein courses posterior and inferior to the splenic artery, receives the inferior mesenteric vein, and joins the superior mesenteric vein to form the portal vein.

The spleen is the second most commonly injured abdominal solid organ after blunt trauma and the second most commonly injured after penetrating trauma.

Nearly 80% of patients with splenic injury after blunt trauma can be managed nonoperatively, but only if they are hemodynamically stable with a stable hemoglobin and without peritonitis. Nonoperative management of splenic injuries is ill-advised in patients with a significant injury burden, coagulopathy, or severe traumatic brain injury.

Angioembolization is an adjunct to the nonoperative management of high-grade splenic injuries, especially in patients with evidence of active extravasation on contrast-enhanced CT scan.

All patients who undergo emergent splenectomy should receive vaccinations for encapsulated organisms prior to hospital discharge.