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1. SPLEEN

2. INTRODUCTION
•has variously been described as the seat of laughter, the source
of black bile in the body, and the locus of conflicting
emotions.
•"spleen" in English is "ill temper.“

3. •The spleen is the organ most often damaged in cases
of abdominal trauma.
•Any injury to the spleen can cause severe internal
hemorrhage and shock.
•If surgically removed, the liver and red bone marrow
can take over the functions normally carried out by
the spleen.

4. •During periods of high infection, the spleen may
become enlarged, increasing its ability to become
injured.
•Infectious mononeucleosis is the most likely cause of
spleen enlargement.

5. ANATOMY OF THE SPLEEN
• The human spleen is a dark bean shaped organ about
the size of a person’s fist.
•weighing approximately 5-6 Ib.
•located in the upper left quadrant, just beneath the
diaphragm and posterior to the stomach.


•The shape and structure of the spleen is similar to a
lymph node, but much larger. This makes the spleen
the largest lymphatic organ in the body.

6. •The spleen is protected by the rib cage
anteriorly, laterally, and posteriorly.
•Physically the spleen is in contact with other
vital organs, specifically the left diaphragm
superiorly, the pancreatic tail medially, the
stomach anteromedially, the left kidney and
adrenal gland posteromedially, as well as the
flexure of the colon inferiorly

8. The tortuous splenic artery arises from
the coeliac axis and
runs along the upper border of the
body and tail of the pancreas,to which
it gives small branches.

9. •Blood supply:
•The splenic vein is formed from several
tributaries that drain the hilum. The vein runs
behind the pancreas, receiving several small
tributaries from the pancreas before joining
the superior mesenteric vein at the neck of
the pancreas to form the portal vein.

10. •To keep its position in the upper left quadrant, the
spleen is secured by four suspensory ligaments:
1-the gastrosplenic, which connects the stomach to the
spleen.
2-the splenorenal, which connects the spleen to the kidney.
3-the splenocolic, which connects the spleen to the colic
flexure and to the thoracic diaphragm.
4-the splenophrenic, which connects the spleen to the
diaphragm.

11. •

The spleen is surrounded by a connective tissue
capsule, called trabeculae, which extends inward to
divide the organ into lobules (compartments).
•Two types of tissue are found in the spleen which
correspond to its two most important functional roles.
This tissue is called white pulp and red pulp.

12. •The white pulp is lymphatic tissue consisting mainly
of B& T-lymphocytes around the arteries with the
purpose of immunity and phagocytic action.
•The red pulp consists of venous sinuses filled with
blood and cords of lymphatic cells, such as
lymphocytes and macrophages, which is the primary
site for mechanical filtration of the blood and the
removal of senescent red blood cells.

13. •At any given time, 1 unit or ~450mL of blood is
contained in the spleen.
•In emergencies, such as a hemorrhage, smooth
muscle in the vessel walls and in the capsule of the
spleen contracts due to sympathetic stimulation, and
squeezes ~200mL of reserved blood out of the organ
into general circulation.

14. SPLEEN FUNCTION
•The primary filtering element for the blood. Acts as a
filter against foreign organisms that infect the blood
stream.
•The site of red blood cell and platelet storage.
•Filters out old red blood cells and recycles them.

15. •Functions of the spleen
•
■
Immune
•
■
Filter function
•
■
Pitting(its ability to remove a solid [article
from cytoplasm of a red cell without destroying
the cell itself)
•
■
Reservoir
•
■
Cytopoiesis(formation of cells)
•
■
Splenectomy harms the patient
Summary box

16. •Immune function.
•Contains 66.5% and 10–15% of the body’s total T
and B lymphocyte population,
•Processes foreign antigens and is the major site
of specific immunoglobulin M (IgM) production.
•The non-specific opsonins, properdin and tuftsin,
are synthesised.
•These antibodies are of B- and T-cell origin and
bind to the specific receptors on the surface of
macrophages and leukocytes, stimulating their
phagocytic, bactericidal and tumoricidal activity

17. •Filter function.
•Macrophages –Capture cellular and non-
cellular material from the blood and plasma.
•Iron
•Bacteria
•Pneumococci.

18. EVALUATION OF SIZE AND FUNCTION
•Ultrasound (US) is the most cost-effective mode of
splenic imaging for routine elective splenectomy. The
sensitivity of US for detecting textural lesions of the
spleen is as high as 98% in experienced hands.
•(CT) scanning affords a high degree of resolution and
detail of the spleen as well.

19. SPLENECTOMY
INDICATIONS
1-Red cell disorders:
A. Congenital
i.Hereditary spherocytosis
ii.Hemoglobinopathies (SCD,Thalassemia,Enzyme deficiencies)
B. Acquired
i.Autoimmune hemolytic anemia
ii.Parasitic diseases

20.  2.
   Platelet disorders
a.
   Idiopathic thrombocytopenic purpura (ITP)
b.
   Thrombotic thrombocytopenic purpura (TTP)
 3.
   White cell disorders
a.
   Leukemias
b.
   Lymphomas
c.
   Hodgkin's disease

21.  
 
4.
   Bone marrow disorders (myeloproliferative disorders)
a.Myelofibrosis (myeloid metaplasia)
b.Chronic myeloid leukemia (CML)
c.Acute myeloid leukemia (AML)
d.Chronic myelomonocytic leukemia (CMML)
e.Essential thrombocythemia
f.Polycythemia vera

22. 5.
 Miscellaneous disorders and lesions
a.
  Infections/abscess
b.
   Storage diseases/infiltrative disorders
i.
 Gaucher's disease
ii.
 Nieman-pick disease
iii.
 Amyloidosis
c.
   Felty syndrome's
d.
  Sarcoidosis
e.
  Cysts and tumors
f.
   Portal Hypertension
g.
  Splenic artery aneurysm

23. Hereditary Spherocytosis (HS)Hereditary Spherocytosis (HS)
•Most common type of hemolytic anemia
•Autosomal dominant
•Spectrin deficiency (RBC membrane) → Loss of osmotic stability
•Osmotic fragility testing
•Splenomegaly & Gall stones
•Dx by (+) spherocytes in the blood
•TOC(trasition of care)s Splenectomy in the 4
th
year of life
•+/- cholecystectomy if (+) cholelithiasis

24. Sickle Cell Disease (SCD)Sickle Cell Disease (SCD)
•B-globin gene A→T substitution (Hb S/SS)
•autosomal dominant
•Sickling of RBCs in tissues with low O
2
tension
•Red & White pulps
•Splenic microinfarcts
–Painful
–Abscess
–Infections
–Anemia
•Splenectomy (palliative)Splenectomy (palliative)
–Acute sequestration crises (recurrence = 40%-50% with 20% Mortality rate)
–Rapid hypersplenism
–Abscess formation

25. ThalassemiaThalassemia
•Thalassemia major (homozygous B)
•autosomal-dominant disease
•Decreased expression of beta-chains
•Pallor, Growth retardation, head enlargement
•Splenectomy indicated if:
–Symptomatic splenomegaly
–Anemia
–Pain due to infarctions
–increased PRBC’s requirements (>200 ml/kg/year)
•↑ rate of infections after splenectomy
•Risk vs. Benefit

26. •Myelofibrosis & Myeloproliferative disorders
–Splenectomy for symptoms due to enlarged spleen

27. •Splenomegaly is a common feature of many disease
processes many
•conditions affecting the spleen, such as idiopathic
thrombocytopenic purpura, may be associated with
enlargement, but the gland is seldom palpable. Few of the
conditions causing
•splenomegaly will require splenectomy as part of their
treatment.
•Hypersplenism is an indefinite clinical syndrome that is
characterised by splenic enlargement, any combination of
anaemia, leucopenia or thrombocytopenia, compensatory
bone marrow hyperplasia and improvement after
splenectomy.
SPLENOMEGALY AND
HYPERSPLENISM

28. Splenectomy
Indications
•Trauma resulting from an accident or during a surgical
procedure,
•Removal en bloc with the stomach as part of a radical
gastrectomy,
or with the pancreas as part of a distal or total
pancreatectomy;
•To reduce anaemia or thrombocytopenia in spherocytosis,
•Idiopathic thrombocytopenic purpura or hypersplenism;
•In association with shunt or variceal surgery for portal
hypertension.

29. •Indications for splenectomy
•Trauma
•
■
Accidental
•
■
Operative
•Oncological
•
■
Part of en bloc resection
•
■
Diagnostic
•
■
Therapeutic
•Haematological
•
■
Spherocytosis
•
■
Purpura (ITP)
•
■
Hypersplenism
•Portal hypertension
•
■
Variceal surgery

30. Pre operative Preparation
Bleeding tendency
•Blood,
•Fresh-frozen plasma
•Cryoprecipitate
•Platelets.
Coagulation profiles should be as near normal as
possible at operation,
Antibiotic prophylaxis
The risk of postsplenectomy sepsis

31. Vaccination in Elective Slenectomy
•Vaccination against pneumococcus, meningococcus C
(both repeated every 5 years) and H. influenzae type B
(Hib) (repeated every 10 years).
•Yearly influenza vaccination has been recommended
•Vaccinations should be administered at least 2 weeks
before elective surgery or as soon as possible after
recovery from surgery but before discharge from
hospital.
•Pneumococcal vaccination is recommended in those
patients aged over 2 years.
•Haemophilus influenzae type b vaccination is
recommended irrespective of age.

32. Splenectomy in trauma
•Vaccination can be given in the postoperative
period,
•Resulting antibody levels will be protective
•Antibody levels are, however, less than 50% of
those achieved if vaccination is given in the
presence of an intact spleen.

33. •All patients with compromised immune
function should receive prophylaxis.
•Satisfactory oral prophylaxis
•Penicillin, Erythromycin, Amoxicillin or co-
amoxiclav.
•Suspected infection-intravenously with these
same antibiotics and cefotaxime or
ceftriaxone, or chloramphenicol in patients
allergic to penicillin and cephalosporins.

34. •Splenectomy
•
■
Remember preoperative immunisation
•
■
Prophylactic antibiotics in the long term
•
■
OPSI is a real clinical danger

35. Medical Alert
•Asplenic patients-
•Medical alert
•Up-to-date vaccination card.
•Travel advice
•Travel to malaria endemic country
•Use all physical antimosquito barriers
•Antimalarial therapy.

36. Specific advice regarding animal handling.
•Overwhelming postsplectomy sepsis due to
Capnocytophaga
•canimorsus may result from dog, cat or other
animal bites.

37. •Postoperative thrombocytosis –
•Platelet count exceeds 1 × 106/mL,
prophylactic aspirin is recommended.
•Thromboprophylaxis
•Postsplenectomy septicaemia
•Streptococcus pneumoniae, Neisseria
meningitides, Haemophilus influenzae and
Escherichia coli.

38. Risk of
•Pneumonia
•Meningitis
•Major sepsis-three-fold
At risk population
•Young patient
•Splenectomised patients treated with
chemoradiotherapy
•Splenectomy for thalassaemia, sickle cell disease
and autoimmune anaemia or thrombocytopenia.

39. Risk of
•Pneumonia
•Meningitis
•Major sepsis-three-fold
At risk population
•Young patient
•Splenectomised patients treated with
chemoradiotherapy
•Splenectomy for thalassaemia, sickle cell disease
and autoimmune anaemia or thrombocytopenia.

40. Opportunist postsplenectomy
infection (OPSI)
•Appropriate and timely immunisation,
•Antibiotic prophylaxis
•Education and prompt treatment of infection.
•Splenectomy before the age of 5 years
•Daily dose of penicillin until the age of 10 years.
•Prophylaxis in older children should be continued
at
•least until the age of 16 years
•Less well defined in adults

41. Post operative Complications
Haemorrhage
•Slipped ligature.
•Haematemesis from gastric mucosal damage and gastric dilatation is
uncommon.
Respiratory Complications
•Left basal atelectasis
•Pleural effusion
Adjacent structures at risk
Gastric Fistula- damage to the greater curvature of the stomach during
•ligation of the short gastric vessels.
Pancreatic Fistula
•Damage to the tail of the pancreas may result in pancreatitis, a localised
abscess or a
•pancreatic fistula.