Surgery of the spleen · 2020-03-25 · Splenic trauma • Splenic injury ... trivial trauma •...

Surgery of the spleen

György Lázár M.D., PhD., D.Sc.

History

• The spleen had long been associated with ability to run. (Test at the Johns Hopkins Unversity)

• Spleen is not essential to life. (Vesalius)

• The first report of a splenectomy in 1826 1826 (Quittenbaum)

• The first successful splenectomy in 1867 (Pean)

György Lázár: Surgery of the Spleen

Functions of the Spleen

• Immunological (trapping of antigens, homing of lymphocytes, antibody and lymphokine production, macrophage activation)

• Filtraction

• Reservoir

• Haemopoietic (minimal)


Clinical signs

• Splenomegaly

• Abdominal pain (Kher-sign)

• Fever, jaundice, anaemia


Investigations

• Radiographic assessment

Abdominal US, CT, MR

Angiography

Spect (99mTc, 51Cr labelled red blood cells, granulocytes, thrombocytes)


Splenic cyst


Inflammatory disorders of the Spleen

• Acut inflammation – during sepsis, endocarditis

• Chronic inflammatory disorders – specific (tuberculosis), parasitic diseases (malaria, leishmania, schistosomia, echinococcus)

• Splenic abscess (traumatic, haematogenic; soliter - multiplex)


Splenic tumours

• Benign lesions:– Haemangioma, lymphangioma,

haemangioendothelioma, hamartomas, peliosis hepatis, parasitic-, non parasitic cyts)

• Malignant lesions:– Lymphploriferatív disorders

– Myeloproloferativ disorders

– Vascular tumors (Haemangio-, lymphangiosarcoma)

– Metastatic tumors

– Other lesions (fibro-, leiomyosarcoma, Kaposi’s sarcoma)


Splenic trauma

• Splenic injury can be either accidental or iatrogenic

• Most commonly associated with blunt trauma

• Often occurs in the presence of lower rib fractures

• May be common clinically apparent either early or delayed

• Delayed injury is usually due to rupture of subcapsular

haematoma

• 20% of splenic injuries occur inadvertently during other

abdominal operations

• In some patients spontaneous rupture can occur following

trivial trauma

• Spleen is invariably abnormal due to, for example, malaria

or infectious mononucleosis György Lázár: Surgery of the Spleen

Splenic trauma

• Clinical feature

• Clinical features depend on: – Degree of hypovolaemia

– Presence of associated injuries

• Clinical features range from left upperquadrant pain to shock and peritonitis

• 30 to 60% of patients have otherassocaited intraperitoneal injuries


Splenic trauma

Grading

• Grade 1 – Minor subcapsular tear or haematoma

• Grade 2 – Parenchymal injury not extending to the hilum

• Grade 3 – Major parenchymal injury involving vessels and hilum

• Grade 4 – Shattered spleen


Splenic trauma

• Management

• If cardiovascularly unstable requiresresuscitation and early surgery

• If cardiovascularly stable consider eitherultrasound or CT scan

• If isolated Grade 1 or 2 splenic injury maybe suitable for conservative management


Splenic trauma

Surgical options

• Surgical management can involve either splenectomy or splenic repair

• Main benefit of retaining the spleen is the prevention of OPSI

• If splenic conservation attempted need to preserve more than 20% of tissue


Splenic trauma

• Conservative management• Overall 20-40% of patients are suitable for conservative

management • Children can often be managed conservatively as they have

– Increased proportion of low grade injuries – Fewer multiple injuries

• Should be monitored in high dependency unit • Require cardiovascular and haematological monitoring • If successful patients should remain on:

– Bed rest for 72 hours – Limited physical activity for 6 weeks – No contact sports for 6 months

• Surgery needed if clinically hypovolaemic of they have a falling haematocrit

• Approximately 30% of patients fail conservative management • Usually occurs within the first 72 hours of injury • Failed conservative management often results in splenectomy • Overall more spleens can often be conserved by early surgery

Spleen injury/blunt abdominal trauma

Haemodinamic stability

Abdomial CT

Haemodinamic instability

SurgeryGrade III-IV injury

Grade II-III injury

Observation


Splenic trauma


Indication for splenectomy

a. lienalis aneurysm, v. lienalis thrombosis, arterio-venosus shunt

• Spleen torsion

• Primary and secondary malignant disorders, splenec cyst

• Splenic abscess

• Haematolological disorders

• Portal hypertensionGyörgy Lázár: Surgery of the Spleen

Indications for Splenectomy

• Haematological disorders:– ITP (idiopathias thrombocytopenia purpura)

– Herediter spherocytosis

– Thalassemia

– Autoimmune hemolitic anaemia

– Thrombocytopenic thrombotic purpura

– Lymphoma, Leukemia

– Myelofibrosis

– Splenic infarctGyörgy Lázár: Surgery of the Spleen

Complications of Splenectomy

• Bleeding

• Pancreatic injuries

• Overwhelming Post Splenectomy Infection (OPSI)

50% strep. Pneumoniae

other microorganisms: – Haemophilus influenzae

– Neisseria meningitidis

4% occurs without prophylaxis

Mortality: 50%

Risk of infections within 2 yearsGyörgy Lázár: Surgery of the Spleen

• Overwhelming Post SplenectomyInfection (OPSI)

Prophylaxis

Antibiotic prophylaxis

– Penicillin/ amoxycillin

– Immunisation

Pneumococcus/ Haemophilus

2 weeks before surgery


Preoperative assessment

• Haematological / gastroenterological check-up

• Abdominal US/CT

• Polyvalent pneumococcal vaccination

• Antibiotic prophylaxis


Surgical technique

• Supine position

• General anaesthesia

• 3 or 4 operating ports

• Ultrasonic dissection

• Linear cutting stapler


Laparoscopic splenectomy


Laparoscopic splenectomy -results

• Surgical time

• Est. blood loss

• Spleen weight

• Conversions

• Complications

• Lenght of hospital stay

– 130 (90-180) min.

– 150 (50-250) ml

– 310 g (200-2100)

– N: 2 (10 %)

– none

– 5 (4-7) daysGyörgy Lázár: Surgery of the Spleen

Laparoscopic unroofings -results

• Surgical time

• Est. blood loss

• Conversions

• Complications

• Lenght of hospital stay

– 50 (40-90) min.

– 100 (50-200) ml

– None

– None

– 4 (3-6) days


Preoperative clinical parametersOpen vs. laparoscopic splenectomy

Open N:10

Laparoscopic N:15

Indication for surgery

ITP ITP

Mean age/range(years)

45 (30-67) 49 (28-72)

Body weight ( kg) 63 (50-110) 60 (48-105)

ASA score 1.9 (1-3) 1.8 (1-3)

PrePLT (T/L) 41 (20-100) 39 (10-90)

Preop. htkr (L/L) 38 (25-40) 35 (20-38)

Open/ laparoscopic splenetomiesOutcomes

OpenN:10

Laparoscopic N:15

Operating time (min)

80 (50-120) 90 (60-180)

Est. blood loss (ml) 150 (50-300) 150 (50-250)

Weight of the spleen (g)

190 180

Liquid diet (days) 3 (2-4) 2 (1-3)

Post.op. bowel paralysis (days)

3,5 (3-4) 2 (1-3)

Hospital stay (days) 7 (6-12) 5 (4-7)

Gr. I.< 350 g(n=42)

Gr. II.350-1000 g

(n=19)

Gr. III. 1000 g <

(n=9)

P1

valueP2

value

Op.time (min) 117 (50-220) 128 (85-210) 134 (80-190)0,258 0,37

4

Conversion 3 (7,1%) 1(5,3%) 1 (11,1%)0,479 0,25

8

Reoperation 1 (2,4%) 1 (5,3%) 00,145 0,48

9

Hospital stay (day) 5 (3-11) 5,2 (3-9) 5,4 (4-9)0,846 0,66

1

Post.op. Bowel paralysis (day)

2,5 (0-6) 2,9 (1-6) 3,3 (1-5)0,452 0,20

7

Pfannenstiel incision

2 (4,7%) 4 (21%) 5 (55,6%)0,845 0,27

4

Specimen weight (g) 160(67-325) 578 (403-873)1494 (1000-

2067)- -


Conclusions

• Laparoscopic splenectomy or unroofing is feasible and safe,

• resulting brief hospitalization, minimal recovery time.

• LS can be safely performed even for enlarged spleens.


Surgery of the spleen · 2020-03-25 · Splenic trauma • Splenic injury ... trivial trauma •...

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