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spleen in surgery
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Spleent
Anatomy
Develops from mesenchymal
cells in the dorsal mesogastrium during the fifth
week of gestation.
Anatomy
• The most common anomaly of splenic embryology is the accessory spleen.
• 80% in the splenic hilum and vascular pedicle
The
peritoneum covering the
spleen, except in the hilum.
7cm
12 cm
3 – 4 cm
150 gr. (80 -300 gr).
Ligaments • Splenophrenic • Splenocolic
• Gastrosplenic• Splenorenal
Blood supply and venous drainage
Histology1. Red pulp (75%):
– Large numbers of venous sinuses that drains into splenic veins
– Sinuses is surrounded & separated by reticulum where the macrophages lies.
– Serves as a dynamic filtration system where macrophages remove the microorganisms, cellular debris, Ag & Ab complexes and senescent erythrocytes.
2. White pulp:– Periarticular lymphatic sheaths– Comprised T lymphocytes and
intermittent aggregations of B lymphocytes or lymphoid follicles.
FUNCTIONS
1. Filtration2. Host defense3. Storage4. Cytopoiesis
Indications for Splenectomy
• Most common indication is trauma to spleen, whether iatrogenic or otherwise
• Most common elective splenectomy is ITP followed by hereditary spherocytosis ----> autoimmune hemolytic anemia -----> thrombotic thrombocytopenic purpura.
Indications for Splenectomy
A. Red Blood Cell Disorders:1. Congenital:
a) Hereditary spherocytosisb) Hemoglobinopathies
i. Sickle cell diseaseii. Thalasemiaiii. Enzyme deficiencies
2. Acquired:a) Autoimmune hemolytic anemiab) Parasitic disease
Indications for Splenectomy
B. Platelet Disorders:1. Idiopathic Thrombocytopenic purpura (ITP)2. Thrombotic thrombocytopenic purpura (TTP)
C. White Blood Disorders:1. Leukemias2. Lymphomas3. Hodgkin’s disease
Indications for Splenectomy
D. Bone Marrow Disorders:1. Myelofibrosis2. Chronic myeloid leukemia3. Acute myeloid leukemia4. Chronic myelomonocytic leukemia5. Essential thrombocythemia6. Polycythemia vera
Indications for Splenectomy
E. Miscellaneous disorders:1. Infectious/abscess2. Storage dse/infiltrate disorder
a) Gaucher’s diseaseb) Niemann-Pick dsec) Amyloidosis
3. Felty’s syndrome4. Sarcoidosis5. Cysts & tumors6. Portal hypertension7. Splenic artery aneurysm
vaccination
• VaccinationCommon bacteria:
a) Streptococcus pneumoniaeb) Hemophilus influenzae type Bc) Meningococcus
• Vaccination against encapsulated bacteria 2 wks before surgery.
• in emergency splenectomy, trauma, give vaccine 3rd day• booster injections every 5 – 6 yrs regardless of the reason
for splenectomy for pneumococcal• annual influenza immunization
1. Splenic Trauma/Injury
The spleen is the intra-abdominal
organ most frequently
injured in blunt trauma.
Mechanism of injury
• Blunt abdominal trauma from compression or deceleration (motor vehicle accidents, falls ,direct blow
to abdomen,with haematological abnormalities)
• Penetrating trauma rare
Presentation
• Clinical symptoms vary • Pt may present with lt upper abdominal
or flank pain• Reffered pain to lt shoulder (kehr sign)• Some may be asymptomatic
Signs• Physical examination is insensitive and
non specific.• Pt may have signs of lt upper quadrant
tenderness or signs of generalized peritoneal irritation.
• May present with tachycardia ,Tachypnea, anxiety , Hypotension (shock)
The diagnosis is confirmed by
ECO - CT (hemodynamic
stability) or exploratory laparotomy
(hemodynamic instability)
Grade 1
Grade 2
Grade 3
Grade 3
Grade 4
Grade 4
Grade 5
70%Nonopertative Treatment
• Hemodynamic stability. • Normal abdominal examination.• Absence of contrast extravasation on CT. • Absence of other clear indications for exploratory
laparotomy or associated injuries requiring surgical intervention.
• Absence of associated health conditions that carry an increased risk for bleeding (coagulopathy, hepatic failure, use of anticoagulants, specific coagulation factor deficiency)
• Injury grade I to III.
Surgical treatment of a
splenic injury depends on its
severit the presence of shock, and
associated injuries.
Organ Injury Scaling-American Association of the Surgery of Trauma (OIS-AAST)
From
Moo
re E
E, C
ogbi
ll TH
, Jur
kovi
ch G
J, et
al:
Org
an in
jury
sca
ling:
Spl
een
and
liver
(1
994
revi
sion
). J T
raum
a 38
:323
-324
, 199
5, w
ith p
erm
issi
on.
Grade Injury Description
I Haematoma: Subcapsular, <10% surface areaLaceration: Capsular tear, <1cm parenchymal depth
II Haematoma: Subcapsular, 10-50% surface area Intraparenchymal, <5cm diameterLaceration: 1-3cm parenchymal depth not involving a parenchymal vessel.
III Haematoma: Subcapsular, >50% surface area or expanding. Ruptured subcapsular or parenchymal haematoma. Intraparencymal haematoma >5cmLaceration: >3cm parenchymal depth or involving trabecular vessels
IV Laceration: Laceration of segmental or hilar vessels producing major devascularization (>25% of spleen)
V Laceration: Completely shattered spleenVascular: Hilar vascular injury which devascularized spleen
Grade V
Grade IV
Capsular tears of the spleen can be controlled
by compression only or by
using topical hemostatic agents.
Deeper lacerations can be controlled with horizontal absorbable
mattress sutures.
Major lacerations involving less than 50% of the splenic parenchyma and not extending into the
hilum can be treated by segmental or partial splenic resection.
Resection is indicated only if the patient is stable and no other major injuries are present.
More extensive injuries involving the hilum or the central portion of the
spleen…
• Splenectomy.
2. Splenich abscess
Spleen Abcess
• Epid : rare 0.05-0.7% , high mortality• Etiology :
- Hematogenic Spread >>- Infected Trauma- Infected spleenic infarction- Alcoholism,DM,Immunosupressan, drug abuser >>
• Pathophysiology- Hematogenous embolization- Spread from altered splenic architecture- Contiguous spread
Clinical Presentations
• Fever• Abdominal Pain (punctum maximum in the
left hypochondrium )• Shoulder pain (Involvement of the
diaphragmatic pleura )• Pleuritic chest pain • General malaise• Dyspeptic symtoms
Imaging
• Plain photo• US• CT• MRI
Computed Tomography
• NECT :- Low attenuation, ill-defined lesion within splenic
parenchyma- May rarely contain gas bubbles or air-fluid levels
• CECT: - Low attenuation, nonenhancing complex fluid
collection- May extend to subcapsular location
Diagnostic Imaging : Abdomen
Pyogenic splenic abscess on CECT. Note low attenuation abscess bulging splenic parenchyma (arrow).
Pyogenic splenic abscess on axial CECT.Note thin septations within abscess (arrows)
CECT
Diagnostic Imaging : Abdomen
NECT
Nonenhanced CT scan shows a 6-cm hypoattenuating mass within the spleen (large arrow), with inflammatory soft tissue stranding in the adjacent extraperitoneal fat (small arrow)
RadioGraphics 1994; 14:307-332
Microabcess of Spleen
Axial CECT of fungal microabscesses. Note : numerous hypodense lesions.
Axial CECT demonstrates splenic microabscesses. Note small < 1 cm lesions diffusely throughout the spleen.
Treatment and complication
• Splenectomy for most cases• Percutaneous drainage
• Complications – Spontaneous rupture– Peritonitis– sepsis
3. Tumors
Types
• Benign – Hemangiomas – Lymphangioma– Hamartoma – Primary cyst \ echinoccocus cyst
types
• Malignant – Lymphomas or myeloprolifrative diseases– Rare site for solid tumors but more common in
lung and breast tumors
Thank you