Spleen.. Dr.banez surgery
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- 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