From Clinic to Recovery · First Edition
Chapter 17 — Splenectomy and Living Without a Spleen
Dr. Tamer Rushdy Elalfy · 13 min read
In this chapter
The operation to remove the spleen is usually straightforward, often by keyhole surgery, and recovery is quick. The counseling is not about the operation alone. A person without a working spleen carries a lifelong risk of overwhelming infection, which is uncommon but can become fatal within hours. Most of these infections can be prevented by vaccination, antibiotics, and prompt action when fever develops. The surgeon is often the person best placed to start this lifelong protection, and the patient guide in this chapter is one that patients should keep for life. In regions where sickle cell disease and thalassemia are common, including the Eastern Province of Saudi Arabia, these conversations are frequent and often involve children and their families.
Learning objectives After reading this chapter you should be able to:
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Table 17.1. Splenectomy at a glance.
| At a glance | |
|---|---|
| Operation | Laparoscopic (keyhole) splenectomy for most planned cases; open surgery for very large spleens or emergencies |
| Hospital stay | Usually 1 to 3 days after keyhole surgery |
| Back to office work | About 2 weeks after keyhole surgery |
| Risks every patient should hear | Bleeding, injury to the pancreas, clots in the portal vein, chest infection, and lifelong risk of serious infection |
| The key counseling message | “You can live a full life without a spleen, but you must protect yourself from serious infection for life: vaccines, antibiotics, an alert card, and fast action for fever.” |
STEP 1 Explaining the reasons and the operation
17.1 Why the spleen may be removed
The reasons for splenectomy, and the alternatives, depend on the condition (Figure 17.1). In immune thrombocytopenia, newer platelet-stimulating medicines and rituximab are now alternatives to splenectomy, and guidelines suggest delaying splenectomy for at least a year after diagnosis because some patients recover [1]. In hereditary spherocytosis, thalassemia, and sickle cell disease, splenectomy may be considered for an enlarged or overactive spleen, and partial splenectomy may suit some children. After injury, most hemodynamically stable patients are managed without an operation, sometimes with embolization of the splenic artery [2].
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 17.1. Reasons for splenectomy and the alternatives.
17.2 The counseling script
Script: explaining splenectomy What the spleen does. “The spleen sits under your left ribs. It filters the blood and helps fight certain infections, especially some bacteria.” Why we remove it. “In your condition, the spleen is [destroying your platelets / destroying red cells / too large and causing problems]. Removing it is likely to help.” The operation. “We usually remove it through small keyhole cuts, with you asleep. Most people go home in one to three days.” The important part. “Without a spleen, some infections can become serious very quickly. We will protect you with vaccines before the operation, an antibiotic, and an emergency plan for fever. If you follow it, the risk is very low. This protection is for life.” |
STEP 2 Preparation, lifelong protection, and recovery
17.3 Vaccination
For planned splenectomy, vaccines should be given at least two weeks before the operation; after an emergency splenectomy, they are given about two weeks afterward, before discharge if possible [3]. Patients need vaccination against pneumococcus, Haemophilus influenzae type b, and meningococcus (groups A, C, W, Y and group B), with boosters and annual influenza vaccination, according to the national schedule [3]. Record what was given, and give the patient a written record.
Caution: do not forget vaccines after emergency splenectomy Patients who lose their spleen after trauma or emergency surgery are the most likely to leave hospital unvaccinated and uninformed. Make vaccination, antibiotics, the alert card, and the patient guide part of the discharge checklist, and inform the patient’s primary care doctor in writing. |
17.4 Lifelong infection protection
Figure 17.2 shows the five protections every patient should understand. Daily antibiotic prophylaxis is offered, at least for the first years after splenectomy and for life in patients at higher risk; all patients should also hold a supply of standby antibiotics to start immediately if fever or other signs of infection develop, and seek medical help at once [3]. Patients should carry an alert card, inform every clinician that they have no spleen, take malaria prevention seriously when traveling to endemic areas, and seek antibiotics after any animal bite [3].
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 17.2. Five lifelong protections for people without a spleen, for use with patients.
17.5 Before and after the operation
- Before. Vaccines given at least two weeks earlier; blood count and blood products planned according to the condition; for immune thrombocytopenia, platelet support or medicines as advised by the hematologist.
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Clot prevention. Clots in the portal or splenic vein can occur after splenectomy, especially with a large spleen or certain blood disorders. Follow the unit’s thromboprophylaxis plan.
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After. Walk early, use breathing exercises, and report left shoulder or upper abdominal pain, fever, or vomiting.
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Platelet count. The platelet count often rises after splenectomy; the team will check it and advise on any treatment.
Table 17.2. Typical recovery after splenectomy.
| Activity | After keyhole surgery | After open surgery |
|---|---|---|
| Walking | The same or next day | The next day |
| Driving | About 1 to 2 weeks | About 3 to 4 weeks |
| Office work | About 2 weeks | About 4 to 6 weeks |
| Lifting and sport | About 4 weeks | About 6 to 8 weeks |
| Prayer | From the first day | From the first day; pray seated at first if needed |
| Ramadan fasting | When eating normally and recovered | When recovered |
| Travel abroad | When recovered; check vaccines, malaria advice, and carry antibiotics | As for keyhole surgery |
STEP 3 Questions patients ask
“Can I live without my spleen?”
Yes. Other organs take over most of its work. The main change is a higher risk of certain serious infections, which you can greatly reduce with vaccines, antibiotics, and quick action for fever.
“Will I always be getting infections?”
No. Most people do not get more everyday infections. The concern is a rare but serious infection that can develop quickly, which is why we ask you to act fast if you have a fever.
“Do I need antibiotics forever?”
We usually advise a daily antibiotic for at least the first years, and for life in some people. Everyone should keep a standby course at home [3].
“What should I do if I get a fever?”
Take your standby antibiotic at once, and see a doctor the same day. Tell them you have no spleen and show your card.
“Can I go for Umrah or Hajj?”
Yes. Make sure your vaccines are up to date, including meningococcal vaccine, take your antibiotics with you, and seek help early if you feel unwell.
“Can I travel to countries with malaria?”
Malaria is more dangerous without a spleen. If possible, avoid these areas; if you must go, get specialist travel advice, take preventive tablets, and use mosquito protection.
“Can I keep pets?”
Yes, but any bite or scratch from an animal needs antibiotics. See a doctor the same day.
“Will my platelets stay normal after surgery?”
For many people with immune thrombocytopenia, splenectomy brings lasting improvement, but not for everyone. Your hematologist will follow your counts [1].
“My child needs the operation. Is it different for children?”
Children have a higher risk of infection without a spleen, so vaccines and antibiotics are especially important. For some conditions, removing only part of the spleen is possible. We will plan with the pediatric team (Chapter 25).
STEP 4 Risks, warning signs, and consent
17.6 Material risks
Table 17.3. Material risks of splenectomy. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Common | Pain in the left upper abdomen and shoulder | Many patients, for a few days | “Shoulder-tip pain is common and settles.” |
| Less common | Bleeding needing transfusion or return to the operating room | [unit data] | “Rarely, bleeding needs another operation.” |
| Less common | Collection of fluid or infection under the diaphragm; chest infection | [unit data] | “A collection may need a drain.” |
| Less common | Leak from the tail of the pancreas | [unit data] | “The pancreas lies close by; a small leak usually settles with a drain.” |
| Less common | Clot in the portal or splenic vein | [unit data]; higher with a large spleen and some blood disorders | “A clot can form in the vein of the liver; we use blood thinners to prevent and treat it.” |
| Less common | Conversion to open surgery | [unit data] | “A few operations need a larger cut.” |
| Rare but serious | Overwhelming infection, lifelong | Uncommon but can be fatal; reduced by vaccines, antibiotics, and fast treatment [3] | “A serious infection is rare, but can be fast. That is why you must act on fever.” |
17.7 Consent checklist
Before the patient signs ☐ Reason for splenectomy explained, with alternatives for the condition. ☐ Vaccines given at least two weeks before planned surgery, or planned after emergency surgery; record given. ☐ Antibiotic prophylaxis, standby antibiotics, and the fever plan explained and understood (teach-back). ☐ Alert card, travel advice, and animal bites explained. ☐ Operative risks from Table 17.3 explained, including clots and pancreatic leak. ☐ Who will perform the operation, including trainee involvement under supervision. ☐ Primary care doctor to be informed in writing; patient guide given. |
17.8 Warning signs
Table 17.4. Green, amber, and red warning signs after splenectomy.
| Level | Signs after splenectomy, and for life | What to do |
|---|---|---|
| Green | Mild wound and shoulder pain improving each day Tiredness for a few weeks | Expected. Follow the guide. |
| Amber | Redness or discharge from a wound A cough with phlegm Any animal bite or scratch | Call the clinic or your doctor the same day; start standby antibiotics for a bite if advised. |
| Red | Fever of 38 °C or more, shivering, or feeling suddenly very unwell, at any time in life Severe abdominal pain, vomiting, or swelling of the abdomen after surgery Breathlessness or chest pain | Take your standby antibiotic and go to the emergency department now. Say that you have no spleen. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Complete the vaccine and antibiotic record, and add your unit’s name, phone numbers, and review date before use.
PATIENT GUIDE Living Without a Spleen Keep this guide for life. Show it to every doctor you see. |
Why this matters
Your spleen helped fight some infections. Without it, these infections can become serious very fast. You can protect yourself with five simple steps, for the rest of your life.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
1. My vaccines
| Vaccine | Date given | Next dose due |
|---|---|---|
| Pneumococcal | ||
| Meningococcal ACWY | ||
| Meningococcal B | ||
| Haemophilus influenzae type b (Hib) | ||
| Influenza (every year) |
2. My antibiotics
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Daily antibiotic: ______________________ until: ______________________
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Standby antibiotic at home: ______________________
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Check the expiry date and replace it when needed.
3. If I get a fever
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Fever of 38 °C or more, shivering, or feeling suddenly very unwell is an emergency.
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Take your standby antibiotic at once.
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Go to a doctor or emergency department the same day. Say: “I have no spleen.”
4. My alert card
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Carry your alert card in your wallet or phone case at all times.
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Tell every doctor, dentist, and pharmacist that you have no spleen.
5. Travel and animals
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Before travel, check your vaccines and take your antibiotics with you.
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Malaria is more dangerous without a spleen. Get specialist advice before visiting malaria areas.
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For Umrah or Hajj, make sure your meningococcal vaccine is up to date.
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Any animal bite or scratch: see a doctor the same day for antibiotics.
6. After the operation
| Activity | Usually from |
|---|---|
| Walking | The first day |
| Driving | About 1 to 2 weeks after keyhole surgery |
| Office work | About 2 weeks after keyhole surgery |
| Lifting and sport | About 4 weeks after keyhole surgery |
| Prayer | From the first day |
7. Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Mild wound or shoulder pain that improves; tiredness | This is normal. Keep following this guide. |
| AMBER | Redness or discharge from a wound; a cough with phlegm; an animal bite or scratch | Call your doctor today. |
| RED | Fever, shivering, or feeling suddenly very unwell, at any time in life; severe tummy pain or vomiting after surgery; breathlessness | Take your standby antibiotic and go to the emergency department now. Say you have no spleen. |
My contacts Surgical team: ______________________ Hematologist: ______________________ Primary care doctor: ______________________ [Unit name] [Guide version and review date] |
References
1. Neunert C, Terrell DR, Arnold DM, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv. 2019;3(23):3829-3866.
2. Coccolini F, Montori G, Catena F, et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg. 2017;12:40.
3. Davies JM, Lewis MPN, Wimperis J, et al. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standards in Haematology. Br J Haematol. 2011;155(3):308-317.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.
PART III
Special Patient Populations, Chronic Conditions, and High-Risk Medicines
Chapters 18 to 27
The procedure chapters assume a healthy adult. Many patients are not. Part III explains how counseling, preparation, and recovery change for people with diabetes, heart and lung disease, and other long-term conditions, for those taking medicines that affect surgery, and for older adults and children. These chapters are written to be used alongside the procedure chapters.