SPLEENSPLEEN

EMMANUEL G. DIAZ, MD, MHA, FPCS, FPSGSEMMANUEL G. DIAZ, MD, MHA, FPCS, FPSGS

Department of SurgeryDepartment of Surgery

De La Salle University Medical CenterDe La Salle University Medical Center

SURGICAL ANATOMYSURGICAL ANATOMY

Located at the left upper quadrantLocated at the left upper quadrant Arise from the mesodermArise from the mesoderm Evident during the 5Evident during the 5thth week of pregnancy week of pregnancy Has a notch at the anterior borderHas a notch at the anterior border

SURGICAL ANATOMYSURGICAL ANATOMY

7 – 11 cms in length7 – 11 cms in length 150 gm average weight150 gm average weight Wedge-shaped with colic, gastric, renalWedge-shaped with colic, gastric, renal

& pancreatic impressions & pancreatic impressions diaphragm separates it from left lower lung diaphragm separates it from left lower lung

& left 9& left 9thth – 11 – 11thth ribs ribs

SURGICAL ANATOMYSURGICAL ANATOMY

4 Suspensory ligaments of Spleen4 Suspensory ligaments of Spleen

1. Splenocolic1. Splenocolic

2. Gastrosplenic **2. Gastrosplenic **

3. Phrenosplenic3. Phrenosplenic

4. Splenorenal4. Splenorenal

SURGICAL ANATOMYSURGICAL ANATOMY

Vascular supplyVascular supply

Splenic arterySplenic artery

Short gastric vesselsShort gastric vessels

Splenic veinSplenic vein

HISTOLOGYHISTOLOGY

3 Elements of Splenic Parenchyma3 Elements of Splenic Parenchyma 1. Outer red pulp – cords & sinuses1. Outer red pulp – cords & sinuses

2. Middle marginal zone – plasma cell2. Middle marginal zone – plasma cell

3. Inner white pulp – lymphoid tissues3. Inner white pulp – lymphoid tissues

PHYSIOLOGYPHYSIOLOGY

Basic functions of the SpleenBasic functions of the Spleen

1. Filtration1. Filtration

2. Immunologic2. Immunologic

3. Storage3. Storage

4. Cytopoiesis4. Cytopoiesis

Diagnostic Procedures forDiagnostic Procedures forSplenic ImagingSplenic Imaging

1. Ultrasound ( US )1. Ultrasound ( US )

2. Computed Tomography ( CT )2. Computed Tomography ( CT )

3. Magnetic Resonance Imaging ( MRI )3. Magnetic Resonance Imaging ( MRI )

4. Radioscintigraphy4. Radioscintigraphy

Diagnostic tests for Splenic Diagnostic tests for Splenic DisordersDisorders

AngiographyAngiography Plain & contrast radiographyPlain & contrast radiography Diagnostic Peritoneal Lavage ( DPL )Diagnostic Peritoneal Lavage ( DPL ) Bone marrow cytologyBone marrow cytology Coomb’s testCoomb’s test LaparoscopyLaparoscopy

INDICATIONS FOR INDICATIONS FOR SPLENECTOMYSPLENECTOMY

1. Red cell disorders1. Red cell disorders

2. White cell disorders2. White cell disorders

3. Platelet disorders3. Platelet disorders

4. Bone marrow disorders4. Bone marrow disorders

5. Various diseases – 5. Various diseases – abscess, cysts, tumors, abscess, cysts, tumors,

trauma, portal hypertension, vascular trauma, portal hypertension, vascular

diseasesdiseases

SPLENIC ABSCESSSPLENIC ABSCESS

Becoming rare occurrenceBecoming rare occurrence Routes of InfectionRoutes of Infection

1. hematogenous ( 75% )1. hematogenous ( 75% )

2. direct contiguous2. direct contiguous

3. trauma3. trauma

4. immunosuppression4. immunosuppression

5. hemoglobinopathy5. hemoglobinopathy

SPLENIC ABSCESSSPLENIC ABSCESS

Clinical ManifestationsClinical Manifestations

- LUQ pain- LUQ pain

- fever- fever

- leukocytosis- leukocytosis

- painful splenomegaly- painful splenomegaly

SPLENIC ABSCESSSPLENIC ABSCESS

Diagnosis - US , CT ScanDiagnosis - US , CT Scan

Treatment - broad spectrum antibioticsTreatment - broad spectrum antibiotics

- percutaneous drainage- percutaneous drainage

- splenectomy- splenectomy

SPLENIC CYSTSPLENIC CYST

ClassificationClassification

1. Primary ( True )1. Primary ( True )

a. Parasitica. Parasitic

b. Non-parasiticb. Non-parasitic

2. Secondary ( False )2. Secondary ( False )

a. Traumatica. Traumatic

b. Inflammatoryb. Inflammatory

SPLENIC CYSTSPLENIC CYST

Clinical Manifestations due to :Clinical Manifestations due to :

1. mass effect1. mass effect

2. pressure & adhesion2. pressure & adhesion

3. complications3. complications

SPLENIC CYSTSPLENIC CYST

DiagnosisDiagnosis

- History & physical examination- History & physical examination

- US- US

- CT Scan- CT Scan

- MRI- MRI

Treatment - Treatment - SplenectomySplenectomy

SPLENIC TUMORSSPLENIC TUMORS

Poor medium for malignant cell growthPoor medium for malignant cell growth Metastatic lesions from lung, breastMetastatic lesions from lung, breast Non-Hodgkin’s lymphomaNon-Hodgkin’s lymphoma AngiosarcomaAngiosarcoma HemangiomasHemangiomas

SPLENIC TUMORSSPLENIC TUMORS

Clinical ManifestationsClinical Manifestations

- anorexia- anorexia

- weight loss- weight loss

- body weakness- body weakness

- splenomegaly- splenomegaly

SPLENIC TUMORSPLENIC TUMOR Diagnosis Diagnosis - US- US - CT Scan - CT Scan - Peripheral smear- Peripheral smear - Percutaneous biopsy- Percutaneous biopsy - Laparoscopy- Laparoscopy

Treatment - SplenectomyTreatment - Splenectomy

SPLENIC ARTERY SPLENIC ARTERY ANEURYSMANEURYSM

most common visceral artery aneurysmmost common visceral artery aneurysm 4x more common in elderly females4x more common in elderly females 2 cm size is indication for surgery2 cm size is indication for surgery presence of circular calcification at LUQpresence of circular calcification at LUQ

on x-ray is diagnosticon x-ray is diagnostic

Treatment - excision or ligationTreatment - excision or ligation

SPLENIC INJURYSPLENIC INJURY

increasing incidenceincreasing incidence young male > femalesyoung male > females blunt abdominal trauma ** - most commonblunt abdominal trauma ** - most common Iatrogenic injuries result from undue Iatrogenic injuries result from undue

traction during surgerytraction during surgery

SPLENIC INJURY SPLENIC INJURY

Clinical ManifestationsClinical Manifestations

- signs & symptoms of hypovolemia- signs & symptoms of hypovolemia

- Kehr’s sign , Ballance sign- Kehr’s sign , Ballance sign

- peritoneal irritation- peritoneal irritation

- left lower rib fracture- left lower rib fracture

- hematuria- hematuria

SPLENIC INJURY SPLENIC INJURY

DiagnosisDiagnosis

- History & PE- History & PE

- anemia & decreasing hematocrit - anemia & decreasing hematocrit

- leukocytosis- leukocytosis

- US , CT Scan , DPL- US , CT Scan , DPL

- laparoscopy- laparoscopy

SPLENIC INJURYSPLENIC INJURY Treatment depends on extent of injuryTreatment depends on extent of injury Splenic Injury ScaleSplenic Injury Scale ( ( AAST 1994AAST 1994 ) ) Grade I – subcapsular hematoma < 10%Grade I – subcapsular hematoma < 10%

laceration < 1 cmlaceration < 1 cm

Grade II – subcapsular hematoma 10 – 50%Grade II – subcapsular hematoma 10 – 50%

laceration 3 cmlaceration 3 cm

Grade III – subcapsular hematoma > 50%Grade III – subcapsular hematoma > 50%

laceration > 3cmlaceration > 3cm

Grade IV – deep hilar lacerationGrade IV – deep hilar laceration

Grade V – shattered spleenGrade V – shattered spleen

SPLENIC INJURYSPLENIC INJURY

Treatment Options : Treatment Options :

1. Non-operative management1. Non-operative management

2. Operative management2. Operative management

SPLENIC INJURYSPLENIC INJURY

Criteria for Non-operative managementCriteria for Non-operative management

1. Hemodynamic stability1. Hemodynamic stability

2. Negative abdominal examination2. Negative abdominal examination

3. CT Scan injury grade I, II or III3. CT Scan injury grade I, II or III

4. Younger age group4. Younger age group

5. No liver pathology5. No liver pathology

SPLENIC INJURYSPLENIC INJURY

Clinical signs of failure of non-operative Clinical signs of failure of non-operative

management :management :

1. persistent tachycardia1. persistent tachycardia

2. hypotension2. hypotension

3. worsening abdominal findings3. worsening abdominal findings

4. falling hematocrit4. falling hematocrit

5. persistent ileus5. persistent ileus

SPLENIC INJURYSPLENIC INJURY

Delayed splenic ruptureDelayed splenic rupture

- latent period of Baudet- latent period of Baudet

- occurs 2 – 7 days post trauma- occurs 2 – 7 days post trauma

- minor capsular or parenchymal - minor capsular or parenchymal

hemorrhage or lacerationhemorrhage or laceration

- diagnosis & treatment as above- diagnosis & treatment as above

SPLENIC INJURYSPLENIC INJURY

Operative managementOperative management

- salvage vs splenectomy- salvage vs splenectomy

- midline laparotomy incision- midline laparotomy incision

- packing with hemostatic pads- packing with hemostatic pads

- fibrin glue , cautery , coagulator- fibrin glue , cautery , coagulator

- Splenorrhaphy , partial splenectomy- Splenorrhaphy , partial splenectomy

- Splenectomy ( open or laparoscopic )- Splenectomy ( open or laparoscopic )

SPLENIC INJURYSPLENIC INJURY

Complications of SplenectomyComplications of Splenectomy

1. Pulmonary1. Pulmonary

2. Hemorrhagic2. Hemorrhagic

3. Infectious3. Infectious

4. Pancreatic 4. Pancreatic

5. Thromboembolic5. Thromboembolic

SPLENIC INJURYSPLENIC INJURY

Overwhelmimg Postsplenectomy SepsisOverwhelmimg Postsplenectomy Sepsis

( ( OPSSOPSS / / OPSIOPSI ) )

- highest incidence in children- highest incidence in children

- causative agents: - causative agents: S. pneumoniaS. pneumonia

H. influenzaH. influenza

E. coliE. coli

N. meningitidisN. meningitidis

OPSS / OPSIOPSS / OPSI

Clinical ManifestationsClinical Manifestations

- fever- fever

- muscle & headaches- muscle & headaches

- vomiting & diarrhea- vomiting & diarrhea

- abdominal pain- abdominal pain

- septic shock- septic shock

- DIC- DIC

OPSS / OPSIOPSS / OPSI

Uncommon but fatalUncommon but fatal No current diagnostic testNo current diagnostic test Risk remains until 2 years postoperativeRisk remains until 2 years postoperative Polyvalent vaccine Polyvalent vaccine Penicillin administrationPenicillin administration

THANK YOUTHANK YOU