1.SPLEEN James Taclin C. Banez, MD, FPSGS, FPCS

2. Anatomy

Largest reticuloendothelial organ

Mesodermal in origin

Spleen size & weight diminish in the elderly

Splenomegaly apply to weight > 500mg and/or 15cm or more in length.

• If palpable below the left costal margin ---> double normal size

3. Anatomy

Blood Supply:

Splenic artery(pattern of terminal branches)

• Distributed type: (70%)

• • Short trunk w/ many long branches over of the medial surface of the spleen.

• Magistral type: (30%)

• • Long main trunk dividing near the hilum into short terminal branches.

Short gastric artery:

4. Anatomy

Support of the spleen:

• Splenocolic lig.

• Gastrosplenic lig.(short gastric vessels)

• Phrenosplenic lig.

• Splenorenal lig.

5. Anatomy

Microstructure of the spleen:

• Red pulp (75%):

• • Large numbers of venous sinuses that drains into splenic veins

• • Sinuses is surrounded & separated by reticulumwhere the macrophages lies.

• • Serves as adynamic filtration systemwhere macrophages remove the microorganisms, cellular debris, Ag & Ab complexes and senescent erythrocytes.

• White pulp:

• • Periarticular lymphatic sheaths

• • ComprisedT lymphocytesand intermittent aggregations ofB lymphocytesor lymphoid follicles.

6. FUNCTIONS

Filtration

Host defense

Storage

Cytopoiesis

7. Anatomy

The most common anomaly of splenic embryology is theaccessory spleen.

80% in thesplenic hilum and vascular pedicle

• • gastrocolic lig.

• • tail of pancreas

• • greater omentum

• • greater curve of the stomach

• • splenocolic lig.

• • small & large bowel mesentery

• • left broad lig in women

• • left spermatic cord in men.

8. Evaluation of Size of Spleen

Indications for imaging of the spleen:

• assess size of the spleen before elective splenectomy

• investigating a left upper quadrant pain

• delineation of tumors or cysts of the spleen

• characterization of splenic abscesses

• guidance for percutaneous procedures involving the spleen

9. Evaluation of Size of Spleen

Ultrasound:

• Most cost-effective

• Rapid, easy to perform, no radiation

• Sensitivity 98%

CT scan:

• High degree of resolution

• Identification of splenic lesions

• Guidance for percutaneous procedures

• Iodinated contrast material

10. Evaluation of Size of Spleen

Plain radiography

MRI:

• More expensive

• Offers no advantagesin depicting abnormalities of the spleen

Radioscintigraphy:

• Tc-sulfur colloiddemonstrates splenic location and size

• Very useful locating accessory spleen after splenectomy

11. Evaluation of Size of Spleen

Angiography:

• Little diagnostic role

• Provides aneffective therapeutic modalityforembolizating bleeding splenicbranches in tauma

Splenic Index (SI):(by Cools)

• expresses the size of the spleen as a volume in ml.

• lengthxwidthxheight (cm)

• NV: 120ml to 480ml

12. Indications for Splenectomy

Most common indication istrauma to spleen , whether iatrogenic or otherwise

Most commonelective splenectomyisITPfollowed byhereditary spherocytosis---->autoimmune hemolytic anemia----->thrombotic thrombocytopenic purpura .

13. Indications for Splenectomy

Red Blood Cell Disorders:

• Congenital:

• • Hereditary spherocytosis

• • Hemoglobinopathies

• • • Sickle cell disease

• • • Thalasemia

• • • Enzyme deficiencies

• Acquired:

• • Autoimmune hemolytic anemia

• • Parasitic disease

14. Indications for Splenectomy

Platelet Disorders:

• Idiopathic Thrombocytopenic purpura (ITP)

• Thrombotic thrombocytopenic purpura (TTP)

White Blood Disorders:

• Leukemias

• Lymphomas

• Hodgkins disease

15. Indications for Splenectomy

Bone Marrow Disorders :

• Myelofibrosis

• Chronic myeloid leukemia

• Acute myeloid leukemia

• Chronic myelomonocytic leukemia

• Essential thrombocythemia

• Polycythemia vera

16. Indications for Splenectomy

Miscellaneous disorders:

• Infectious/abscess

• Storage dse/infiltrate disorder

• • Gauchers disease

• • Niemann-Pick dse

• • Amyloidosis

• Feltys syndrome

• Sarcoidosis

• Cysts & tumors

• Portal hypertension

• Splenic artery aneurysm

17. Preoperative Considerations

Splenic artery embolizations:

• Recommended for:

• • Massive splenomegaly

• • Previous pancreatitis, gastric or pancreatic surgery

• • Portal hypertension, varices

• • Uncorrectable thrombocytopenia

18. Preoperative Considerations

Splenic artery embolizations:

• Advantages:

• • Reduced operative blood loss from devascularized spleen

• • Reduces spleen size for easier dissection and removal.

• Disadvantages:

• • Acute left sided pain (limited duration)

• • • This is mitigated by general anesthesia ---> OR

• • pancreatitis

• Currently no consensus

19. Preoperative Considerations

Vaccination:

• Splenectomy imparts keys for successful tx

• Prophylaxis: -->subcutaneous heparin(5000U)

23. Preoperative Considerations

Deep venous Thrombosis Prophylaxis:

• Risk factors:

• • Obesity

• • History of venous thromboembolism

• • Known hypercoagulable state

• • > 60y/o

24. SPLENECTOMY

Preparations:

• polyvalent pneumococcal, meningococcal & haemophilus vaccines 1