Methods of Spleen Palpation (MacLeod's approach)

Preliminary Points

• A normal spleen is not palpable - it must enlarge to nearly twice its normal size (>250 g) before it becomes detectable clinically.
• The normal spleen weighs <250 g, lies entirely within the rib cage, and has a maximum cephalocaudad diameter of ~13 cm on ultrasound.
• An enlarged spleen descends downward, forward, and medially from the left upper quadrant (LUQ).
• The characteristic notch on the anterior border is a hallmark feature of a splenic swelling.

Patient Preparation

• Patient is in the supine position with knees flexed (to relax the abdominal muscles).
• The examiner stands on the patient's right side.
• Begin palpation from the right lower quadrant (or at least from the level of the umbilicus), because a massively enlarged spleen can extend to the right iliac fossa - starting too high will cause you to miss it.

Method 1 - Standard Bimanual Palpation (Most Common)

1. Place the right hand flat on the abdomen, parallel to the left costal margin, starting at the level of the umbilicus in the right lower quadrant.
2. Fingertips point upward and inward toward the LUQ.
3. Ask the patient to breathe in and out slowly and deeply.
4. During expiration, slide the hand gradually toward the left costal margin.
5. During inspiration, keep the hand static - the splenic tip will descend and touch the lateral border of the index finger.
6. Continue moving the hand stepwise toward the costal margin with each expiration until the spleen edge is felt or the costal margin is reached.

Failure to palpate an enlarged spleen is most often due to palpating too medially - the spleen tip sits just below the tip of the 10th rib.

• S. Das Manual on Clinical Surgery, 13th Ed.

Method 2 - Bimanual Palpation with Left Hand Skin-Stretching

1. Place the left hand on the lower left ribs and slide the skin downward toward the costal margin.
2. This gives the right hand an extra bit of skin to insinuate beneath the left costal margin.
3. The right hand then palpates as in Method 1.

• S. Das Manual on Clinical Surgery, 13th Ed.

Method 3 - Left Hand Behind the Rib Cage (Pushing Forward)

1. When the right hand reaches the costal margin at the tip of the 10th rib, place the left hand around the lower left rib cage posteriorly.
2. With each inspiration, push the lower left rib cage forward with the left hand.
3. This maneuver lifts a slightly enlarged spleen anteriorly, making it palpable against the right hand.

• S. Das Manual on Clinical Surgery, 13th Ed.

Method 4 - Two-Handed Arching from Above

1. Stand at the head of the patient or to the left side.
2. Use both hands arching below the left costal margin.
3. Ask the patient to take deep slow breaths.
4. Move both hands downward and laterally with each expiration.
5. Keep fingers static during inspiration and wait for the enlarged spleen to knock against the fingertips.

• S. Das Manual on Clinical Surgery, 13th Ed.

Method 5 - Ballottement

• Harrison's Principles of Internal Medicine, 22nd Ed.

Method 6 - Palpation from Above (Middleton Maneuver)

1. The examiner stands behind or to the right of the patient.
2. Both hands are placed over the left costal area from above.
3. The patient takes a deep breath, and the descending spleen is felt against the fingertips from above.

• Harrison's Principles of Internal Medicine, 22nd Ed.

Method 7 - Right Lateral Decubitus Position

1. Turn the patient to the right lateral decubitus position (lying on the right side).
2. Gravity brings the spleen anteriorly and inferiorly, making it more accessible.
3. Repeat palpation as above.

• Bailey & Love's Short Practice of Surgery, 28th Ed.

Recording the Finding

"X cm below the left costal margin" measured from the midpoint of the umbilicus or the xiphisternal junction.

Percussion for Splenomegaly (Complementary to Palpation)

• Harrison's Principles of Internal Medicine, 22nd Ed.

Sensitivity Data

• Harrison's Principles of Internal Medicine, 22nd Ed.

Key Features That Identify a Splenic Swelling

• Characteristic notch on the anterior border
• Moves with respiration (descends on inspiration)
• Cannot be got above it (upper border not palpable)
• Dull to percussion (no resonant bowel in front)
• Extends from the LUQ toward the right iliac fossa when massive
• Not bimanually ballotable (unlike a kidney)