Spleen.. Dr.banez surgery

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Transcript of Spleen.. Dr.banez surgery

  • 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