Download - Spleen.. Dr.banez surgery

SPLEENSPLEENJames Taclin C. Banez, MD, FPSGS, FPCSJames Taclin C. Banez, MD, FPSGS, FPCS

AnatomyAnatomy Largest reticuloendothelial Largest reticuloendothelial

organorgan Mesodermal in originMesodermal in origin Spleen size & weight Spleen size & weight

diminish in the elderlydiminish in the elderly Splenomegaly Splenomegaly – apply to – apply to

weight > 500mg and/or weight > 500mg and/or 15cm or more in length.15cm or more in length. If palpable below the left If palpable below the left

costal margin ---> double costal margin ---> double normal sizenormal size

AnatomyAnatomyBlood Supply:Blood Supply:

1.1. Splenic arterySplenic artery (pattern of terminal (pattern of terminal branches)branches)

a.a. Distributed type: (70%)Distributed type: (70%)– Short trunk w/ many long branches over ¾ of the Short trunk w/ many long branches over ¾ of the

medial surface of the spleen.medial surface of the spleen.

b.b. Magistral type: (30%)Magistral type: (30%)– Long main trunk dividing near the hilum into short Long main trunk dividing near the hilum into short

terminal branches.terminal branches.

2.2. Short gastric artery:Short gastric artery:

AnatomyAnatomySupport of the spleen:Support of the spleen:

1.1. Splenocolic lig.Splenocolic lig.

2.2. Gastrosplenic lig.Gastrosplenic lig. (short gastric (short gastric vessels)vessels)

3.3. Phrenosplenic lig.Phrenosplenic lig.

4.4. Splenorenal lig.Splenorenal lig.

AnatomyAnatomyMicrostructure of the spleen:Microstructure of the spleen:

1.1. Red pulp (75%):Red pulp (75%):– Large numbers of venous sinuses Large numbers of venous sinuses

that drains into splenic veinsthat drains into splenic veins– Sinuses is surrounded & separated Sinuses is surrounded & separated

by reticulum where the by reticulum where the macrophages lies.macrophages lies.

– Serves as a Serves as a dynamic filtrationdynamic filtration systemsystem where macrophages where macrophages remove the microorganisms, remove the microorganisms, cellular debris, Ag & Ab complexes cellular debris, Ag & Ab complexes and senescent erythrocytes.and senescent erythrocytes.

2.2. White pulp:White pulp:– Periarticular lymphatic sheathsPeriarticular lymphatic sheaths– Comprised Comprised T lymphocytesT lymphocytes and and

intermittent aggregations of intermittent aggregations of BB lymphocyteslymphocytes or lymphoid follicles. or lymphoid follicles.

FUNCTIONS FUNCTIONS

1.1. FiltrationFiltration

2.2. Host defenseHost defense

3.3. StorageStorage

4.4. CytopoiesisCytopoiesis

AnatomyAnatomy The most common anomaly of splenic The most common anomaly of splenic

embryology is the embryology is the accessory spleen.accessory spleen. 80% in the 80% in the splenic hilum and vascular splenic hilum and vascular

pediclepedicle 1.1. gastrocolic lig.gastrocolic lig.2.2. tail of pancreastail of pancreas3.3. greater omentumgreater omentum4.4. greater curve of the stomachgreater curve of the stomach5.5. splenocolic lig.splenocolic lig.6.6. small & large bowel mesenterysmall & large bowel mesentery7.7. left broad lig in womenleft broad lig in women8.8. left spermatic cord in men.left spermatic cord in men.

Evaluation of Size of SpleenEvaluation of Size of Spleen

Indications for imaging of the spleen:Indications for imaging of the spleen:1.1. assess size of the spleen before elective assess size of the spleen before elective

splenectomysplenectomy

2.2. investigating a left upper quadrant paininvestigating a left upper quadrant pain

3.3. delineation of tumors or cysts of the spleendelineation of tumors or cysts of the spleen

4.4. characterization of splenic abscessescharacterization of splenic abscesses

5.5. guidance for percutaneous procedures guidance for percutaneous procedures involving the spleeninvolving the spleen


1.1. Ultrasound:Ultrasound: Most cost-effectiveMost cost-effective Rapid, easy to perform, no radiationRapid, easy to perform, no radiation Sensitivity – 98%Sensitivity – 98%

2.2. CT scan:CT scan: High degree of resolutionHigh degree of resolution Identification of splenic lesionsIdentification of splenic lesions Guidance for percutaneous proceduresGuidance for percutaneous procedures Iodinated contrast materialIodinated contrast material


3.3. Plain radiographyPlain radiography4.4. MRI:MRI:

More expensiveMore expensive Offers no advantagesOffers no advantages in depicting in depicting

abnormalities of the spleenabnormalities of the spleen

5.5. Radioscintigraphy:Radioscintigraphy: Tc-sulfur colloidTc-sulfur colloid demonstrates splenic demonstrates splenic

location and sizelocation and size Very useful locating accessory spleen after Very useful locating accessory spleen after

splenectomysplenectomy


6.6. Angiography:Angiography: Little diagnostic roleLittle diagnostic role Provides an Provides an effective therapeutic modalityeffective therapeutic modality for for

embolizating bleeding splenicembolizating bleeding splenic branches in tauma branches in tauma

Splenic Index (SI):Splenic Index (SI): (by Cools) (by Cools)− expresses the size of the spleen as a volume in ml.expresses the size of the spleen as a volume in ml.− length x width x height (cm)length x width x height (cm)− NV: 120ml to 480mlNV: 120ml to 480ml

Indications for SplenectomyIndications for Splenectomy

Most common indication is Most common indication is trauma totrauma to spleenspleen, whether iatrogenic or otherwise, whether iatrogenic or otherwise

Most common Most common elective splenectomyelective splenectomy is is ITP ITP followed by followed by hereditary spherocytosishereditary spherocytosis ----> ----> autoimmune hemolytic anemiaautoimmune hemolytic anemia -----> -----> thrombotic thrombocytopenic purpurathrombotic thrombocytopenic purpura..


A.A. Red Blood Cell Disorders:Red Blood Cell Disorders:1.1. Congenital:Congenital:

a)a) Hereditary spherocytosisHereditary spherocytosis

b)b) HemoglobinopathiesHemoglobinopathiesi.i. Sickle cell diseaseSickle cell disease

ii.ii. ThalasemiaThalasemia

iii.iii. Enzyme deficienciesEnzyme deficiencies

2.2. Acquired:Acquired:a)a) Autoimmune hemolytic anemiaAutoimmune hemolytic anemia

b)b) ParasiticParasitic diseasedisease


B.B. Platelet Disorders:Platelet Disorders:1.1. Idiopathic Thrombocytopenic purpura (ITP)Idiopathic Thrombocytopenic purpura (ITP)

2.2. Thrombotic thrombocytopenic purpura (TTP)Thrombotic thrombocytopenic purpura (TTP)

C.C. White Blood Disorders:White Blood Disorders:1.1. LeukemiasLeukemias

2.2. LymphomasLymphomas

3.3. Hodgkin’s diseaseHodgkin’s disease


D.D. Bone Marrow DisordersBone Marrow Disorders::1.1. MyelofibrosisMyelofibrosis

2.2. Chronic myeloid leukemiaChronic myeloid leukemia

3.3. Acute myeloid leukemiaAcute myeloid leukemia

4.4. Chronic myelomonocytic leukemiaChronic myelomonocytic leukemia

5.5. Essential thrombocythemiaEssential thrombocythemia

6.6. Polycythemia veraPolycythemia vera


E.E. Miscellaneous disorders:Miscellaneous disorders:1.1. Infectious/abscessInfectious/abscess2.2. Storage dse/infiltrate disorderStorage dse/infiltrate disorder

a)a) Gaucher’s diseaseGaucher’s diseaseb)b) Niemann-Pick dseNiemann-Pick dsec)c) AmyloidosisAmyloidosis

3.3. Felty’s syndromeFelty’s syndrome4.4. SarcoidosisSarcoidosis5.5. Cysts & tumorsCysts & tumors6.6. Portal hypertensionPortal hypertension7.7. Splenic artery aneurysmSplenic artery aneurysm

Preoperative ConsiderationsPreoperative Considerations

1.1. Splenic artery embolizations:Splenic artery embolizations:Recommended for:Recommended for:

a)a) Massive splenomegalyMassive splenomegaly

b)b) Previous pancreatitis, gastric or pancreatic Previous pancreatitis, gastric or pancreatic surgerysurgery

c)c) Portal hypertension, varices Portal hypertension, varices

d)d) Uncorrectable thrombocytopeniaUncorrectable thrombocytopenia


1.1. Splenic artery embolizations:Splenic artery embolizations:Advantages:Advantages:

a)a) Reduced operative blood loss from Reduced operative blood loss from devascularized spleendevascularized spleen

b)b) Reduces spleen size for easier dissection and Reduces spleen size for easier dissection and removal.removal.

Disadvantages:Disadvantages:a)a) Acute left sided pain (limited duration)Acute left sided pain (limited duration)

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

b)b) pancreatitis pancreatitis

Currently no consensusCurrently no consensus


2.2. Vaccination:Vaccination: Splenectomy imparts <1 to 5% fulminant Splenectomy imparts <1 to 5% fulminant

infection (overwhelming post-splenectomy infection (overwhelming post-splenectomy infections)infections)

Vaccination against encapsulated bacteria 2 Vaccination against encapsulated bacteria 2 wks before surgery.wks before surgery.


2.2. Vaccination:Vaccination:Common bacteria:Common bacteria:

a)a) Streptococcus pneumoniaeStreptococcus pneumoniaeb)b) Hemophilus influenzae type BHemophilus influenzae type Bc)c) MeningococcusMeningococcusd)d) Grp A streptococcusGrp A streptococcuse)e) Capnocytophaga canimorsus (related to dog bites)Capnocytophaga canimorsus (related to dog bites)f)f) Grp B streptococcusGrp B streptococcusg)g) Enterococcus sp.Enterococcus sp.h)h) Bacteroides sp.Bacteroides sp.i)i) Salmonella sp.Salmonella sp.j)j) Bartonella sp.Bartonella sp.


2.2. Vaccination:Vaccination: in emergency splenectomy, trauma, give in emergency splenectomy, trauma, give

vaccine 3vaccine 3rdrd day day booster injections every booster injections every 5 – 6 yrs5 – 6 yrs regardless regardless

of the reason for splenectomy for of the reason for splenectomy for pneumococcalpneumococcal

annual influenza immunizationannual influenza immunization


3.3. Deep venous Thrombosis Prophylaxis:Deep venous Thrombosis Prophylaxis: Specially in splenectomy for Specially in splenectomy for

myeloproliferative disorders (MPD).myeloproliferative disorders (MPD). 40% risk for 40% risk for PVT (portal vein thrombosis)PVT (portal vein thrombosis)

1.1. AnorexiaAnorexia

2.2. Abdominal painAbdominal pain

3.3. Leukocytosis & thrombocytosisLeukocytosis & thrombocytosis

● Early diagnosis w/ contrast-enhanced CT scanEarly diagnosis w/ contrast-enhanced CT scan● Anticoagulation Anticoagulation ---> keys for successful tx---> keys for successful tx● Prophylaxis: --> Prophylaxis: --> subcutaneous heparinsubcutaneous heparin (5000U) (5000U)


3.3. Deep venous Thrombosis Deep venous Thrombosis Prophylaxis:Prophylaxis:

Risk factors:Risk factors:a)a) ObesityObesity

b)b) History of venous thromboembolismHistory of venous thromboembolism

c)c) Known hypercoagulable stateKnown hypercoagulable state

d)d) > 60y/o> 60y/o

SPLENECTOMYSPLENECTOMYPreparations:Preparations:

− polyvalent pneumococcal, meningococcal & polyvalent pneumococcal, meningococcal & haemophilus vaccines 1 wk. preop.haemophilus vaccines 1 wk. preop.

− check hgb and coagulation status of pt. (at check hgb and coagulation status of pt. (at least 10g/dl)least 10g/dl)

− 2 to 4 units of cross-matched bld. available at time 2 to 4 units of cross-matched bld. available at time of surgery.of surgery.

− platelet transfusion (thrombocytopenia) started platelet transfusion (thrombocytopenia) started right after ligation of splenic artery.right after ligation of splenic artery.

SPLENECTOMYSPLENECTOMY

Preparations:Preparations:− pt. on corticosteroid therapy shd. receive it pt. on corticosteroid therapy shd. receive it

parenteralyparenteraly− deep vein thrombosis prophylaxisdeep vein thrombosis prophylaxis− 11stst generation cephalosporin IV as brought to generation cephalosporin IV as brought to

the OR.the OR.− NGT to decompress the stomach after placing NGT to decompress the stomach after placing

the endotracheal tube.the endotracheal tube.

SPLENECTOMYSPLENECTOMY1.1. Open Splenectomy:Open Splenectomy:

Indication:Indication:1.1. traumatic rupture of the spleen (most traumatic rupture of the spleen (most

common)common)2.2. massive splenomegalymassive splenomegaly3.3. ascitesascites4.4. portal hypertensionportal hypertension5.5. multiple prior operationsmultiple prior operations6.6. extensive splenic radiationsextensive splenic radiations7.7. possible splenic abscesspossible splenic abscess

SPLENECTOMYSPLENECTOMY

1.1. Open Splenectomy:Open Splenectomy:Position:Position:

a)a) Supine:Supine:a)a) midline incision for rupture or massive midline incision for rupture or massive

splenomegaly or for staging Hodgkin’s splenomegaly or for staging Hodgkin’s dse.dse.

b)b) Left subcostal incision – for elective Left subcostal incision – for elective splenectomiessplenectomies

SPLENECTOMYSPLENECTOMY2.2. Laparoscopic Splenectomy:Laparoscopic Splenectomy:

− for normal size spleensfor normal size spleens− Position: Position:

− supine or low lithotomy position (needs 5-6 supine or low lithotomy position (needs 5-6 trocars)trocars)

− Right lateral decubitus (needs 3-4 trocars)Right lateral decubitus (needs 3-4 trocars)

− Excised spleen placed in a durable nylon Excised spleen placed in a durable nylon sac and is morcellated and extracted sac and is morcellated and extracted piecemeal using a blunt instrument avoiding piecemeal using a blunt instrument avoiding splillage ----> splenosis.splillage ----> splenosis.

Partial SplenectomyPartial Splenectomy

Indicated:Indicated:1.1. children (risk of splenectomy sepsis)children (risk of splenectomy sepsis)2.2. Lipid storage disorders (Gaucher’s dse)Lipid storage disorders (Gaucher’s dse)3.3. Some blunt & penetrating splenic injuriesSome blunt & penetrating splenic injuries

open or laparoscopicallyopen or laparoscopically Bleeding from cut surface of the spleen Bleeding from cut surface of the spleen

is controlled by:is controlled by:1.1. cauterizationcauterization2.2. argon coagulationargon coagulation3.3. application of hemostatic agents (cellulose application of hemostatic agents (cellulose

gauze / fibrin glue)gauze / fibrin glue)

Changes in blood after Changes in blood after splenectomiessplenectomies

1.1. Appearance of Howell-Jolly bodies & Appearance of Howell-Jolly bodies & siderocytessiderocytes

2.2. LeukocytosisLeukocytosis

3.3. Increased platelet countsIncreased platelet counts

Complications of Complications of SplenectomiesSplenectomies

1.1. Pulmonary complications:Pulmonary complications:a)a) Left lower lobe atelectasis (most common) Left lower lobe atelectasis (most common)

b)b) Pleural effusionPleural effusion

c)c) PneumoniaPneumonia

2.2. Hemorrhage Hemorrhage ----->subphrenic hematoma----->subphrenic hematoma

3.3. Infectious complication:Infectious complication:a)a) Subphrenic abscessSubphrenic abscess (due to placement of (due to placement of

drains, hence not routinely recommended)drains, hence not routinely recommended)

Complications of SplenectomiesComplications of Splenectomies

4.4. Pancreatic complicationsPancreatic complications: due to intra-op : due to intra-op trauma to tail of pancreastrauma to tail of pancreas

a)a) PancreatitisPancreatitis

b)b) PseudocytsPseudocyts

c)c) Pancreatic fistulaPancreatic fistula

5.5. Thromboembolic phenomenaThromboembolic phenomena (5-10%) (5-10%) For pt. w/ hemolytic anemia / myeloproliferative For pt. w/ hemolytic anemia / myeloproliferative

disorders and splenomegalydisorders and splenomegaly Subcutaneous heparin & low-dose Subcutaneous heparin & low-dose

anticoagulantion therapy postopanticoagulantion therapy postop

Complications of SplenectomiesComplications of Splenectomies

Overwhelming Postsplenectomy Overwhelming Postsplenectomy Infection (OPS):Infection (OPS):

− lifetime risk of severe infection (1-5%)lifetime risk of severe infection (1-5%)− incidence similar among children & adult but incidence similar among children & adult but

mortality is higher in children.mortality is higher in children.− mortality is highest in hematologic mortality is highest in hematologic

conditions:conditions:1.1. Thalaseemia majorThalaseemia major

2.2. Sickle cell dseSickle cell dse

− lowered due to pneumococcal vaccinelowered due to pneumococcal vaccine

Complications of SplenectomiesComplications of SplenectomiesOverwhelming Postsplenectomy Overwhelming Postsplenectomy

Infection (OPS):Infection (OPS):− Loss the ability to filter and phagocytose Loss the ability to filter and phagocytose

bacteria and parasitized bld cells ----> bacteria and parasitized bld cells ----> infection to encapsulated bacteria or infection to encapsulated bacteria or parasitesparasites

− Loss a significant source of antibody Loss a significant source of antibody production:production:

1.1. Streptococcus pneumoniae (most common Streptococcus pneumoniae (most common infection 50-90%)infection 50-90%)

2.2. Haemophilus influenzae type BHaemophilus influenzae type B3.3. MeningococcusMeningococcus4.4. Grp A streptococcusGrp A streptococcus

Complications of SplenectomiesComplications of SplenectomiesOverwhelming Postsplenectomy Overwhelming Postsplenectomy

Infection (OPS):Infection (OPS):Risk Factors:Risk Factors:

1.1. Splenectomies for hematologic indicationsSplenectomies for hematologic indications

2.2. Compromised immune system:Compromised immune system:− Hodgkin’s dse.Hodgkin’s dse.− taking chemotherapy / radiation therapytaking chemotherapy / radiation therapy

3.3. Children usually develops w/in 2 yrs Children usually develops w/in 2 yrs postsplenectomypostsplenectomy

− Shd. always have a 5 day supply of stand-by Shd. always have a 5 day supply of stand-by antibiotics antibiotics

Complications of Complications of SplenectomiesSplenectomies

Overwhelming Postsplenectomy Overwhelming Postsplenectomy Infection (OPS):Infection (OPS):

− Immunoprophylaxis:Immunoprophylaxis:1.1. 7 – 14 days before splenectomies or as soon as 7 – 14 days before splenectomies or as soon as

possible after surgerypossible after surgery

2.2. Pneumococcal vaccine – booster injection every Pneumococcal vaccine – booster injection every 5-6yrs5-6yrs

3.3. Annual influenza immunizationAnnual influenza immunization

− Antibiotic prophylaxis usually single daily Antibiotic prophylaxis usually single daily dose of penicillin or amoxillin for children for dose of penicillin or amoxillin for children for 11stst 2 yrs after splenectomies 2 yrs after splenectomies

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