Spleen in surgery

A short tutorial about spleen for surgical students

1. SPLEEN

2. ANATOMY
Develops from
mesenchymal cells
in the dorsal
mesogastrium
during the
5th week of
gestation.

3. Anatomy
•The most
common anomaly
of splenic
embryology is the
accessory spleen.
•80% in the splenic
hilum and
vascular pedicle

4. •It lies in the left hypochondrium
between the gastric fundus and the
left hemidiaphragm, with its long
axis lying along the tenth rib.
•The hilum sits in the angle
between the stomach and the
kidney and is in contact with the
tail of the pancreas.

5. The
peritoneum
covering the
spleen, except in
the hilum.

6. 7cm
12 cm
3 – 4 cm
150gm.
(75 -300
gm)
•There is a notch on the
inferolateral border,
•and this may be palpated when
the spleen is enlarged.

7. Ligaments
•Splenophrenic
•Splenocolic
•Gastrosplenic
•Splenorenal

9. BLOOD SUPPLY AND
VENOUS DRAINAGE

10. LYMPHATIC DRAINAGE
•The lymphatic drainage comprises efferent
vessels in the white pulp that run with the
arterioles and emerge from nodes at the
hilum.
•These nodes and lymphatics drain via
retropancreatic nodes to the coeliac nodes.

11. Histology
Red pulp (75%):
Large numbers of venous sinuses
that drains into splenic veins
Sinuses is surrounded & separated by
reticulum where the macrophages
lies
Serves as a dynamic filtration system
where macrophages remove
the microorganisms, cellular debris,
Ag & Ab complexes and senescent
erythrocytes.
White pulp:
–Periarticular lymphatic sheaths
–Comprised T lymphocytes and
intermittent aggregations of
B lymphocytes or lymphoid
follicles.

13. FUNCTIONS
1.Filtration- Macrophages in the reticulum capture cellular and non-
cellular material from the blood and plasma.
(removal of effete platelets & RBC, Iron is removed from the
degraded hemoglobin, pneumococci)
1.Host defense- The spleen processes foreign antigens and is the
major site of specific immunoglobulin M (IgM) production.
The non-specific opsonins, properdin and tuftsin, are synthesized.
1.Storage
2.Cytopoiesis

14. •Pitting:
•Particulate inclusions from red cells are removed, and
the repaired red cells are returned to the circulation.
•These include Howell–Jolly and Heinz bodies, which
represent nuclear remnants and precipitated
hemoglobin or globin subunits, respectively.

15. •Most common indication is trauma to
spleen, whether iatrogenic or otherwise
•Most common elective splenectomy is ITP
•followed by hereditary spherocytosis ---->
autoimmune hemolytic anemia ----->
thrombotic thrombocytopenic purpura.
INDICATIONS FOR SPLENECTOMY

16. INDICATIONS FOR SPLENECTOMY

17. B.Platelet Disorders:
1.Idiopathic Thrombocytopenic purpura (ITP)
2.Thrombotic thrombocytopenic purpura (TTP)
1.White Blood Disorders:
1.Leukemias
2.Lymphomas
INDICATIONS FOR SPLENECTOMY

18. D.Bone Marrow Disorders:
1.Myelofibrosis
2.Chronic myeloid leukemia
3.Acute myeloid leukemia
4.Chronic myelomonocytic
leukemia
5.Essential thrombocythemia
6.Polycythemia vera
INDICATIONS FOR SPLENECTOMY

19. E.Miscellaneous disorders:
Infections/abscess
Storage disease/infiltrate disorder
a)Gaucher’s disease
b)Niemann-Pick disease
c)Amyloidosis
a)Felty’s syndrome-rheumatoid arthritis, splenomegaly, and
abnormally low WBC count.
b)Sarcoidosis
c)Cysts & tumors
d)Portal hypertension
e)Splenic artery aneurysm
INDICATIONS FOR SPLENECTOMY

20. PRE-OPERATIVE
CONSIDERATIONS

21. SPLENIC ARTERY EMBOLIZATION
•Advantages:
▫ a) Reduced operative blood loss from
devascularized spleen
▫b) Reduces spleen size for easier dissection and
removal.
•Disadvantages:
Acute left sided pain
•Currently no consensus

22. VACCINATION
Common bacteria:
a)Streptococcus pneumoniae
b)Hemophilus influenzae type B
c)Meningococcus
a)Vaccination against encapsulated bacteria 2 wks before
surgery.
b)In emergency splenectomy, trauma, give vaccine as
soon as possible.
c)Booster injections every 5 – 6 yrs regardless of the
reason for splenectomy for pneumococcal
d)Annual influenza immunization

23. DEEP VENOUS THROMBOSIS
PROPHYLAXIS
•Specially in splenectomy for myeloproliferative
disorders (MPD).
• 40% risk for PVT (portal vein thrombosis)
•Anticoagulation ---> keys for successful tx
•Prophylaxis: --> subcutaneous heparin (5000U)

26. SPLENIC
TRAUMA/INJURY

27. The spleen is the
intra-abdominal
organ most
frequently injured in
blunt trauma.

28. MECHANISM OF INJURY
1.Blunt abdominal
trauma from
compression or
deceleration
(motor vehicle
accidents, falls ,direct
blow to abdomen)
•Penetrating trauma
rare

29. Initial shock  Lucid interval  Internal hemorrhage
STAGE OF SHOCK
GENERAL: Tachycardia, Hypotension, Hypothermia,
Decreased urine output
LOCAL:
Inspection: Ecchymosis, Bruises, Fracture of ribs, Abdominal distention
Palpation: Rigidity, Tenderness, Rebound tenderness
Percussion: Shifting dullness
Auscultation:Diminished intestinal sounds
DRE: Fullness in retro-vesical pouch, Douglass pouch
CLINICAL PRESENTATION

30. CLINICAL PRESENTATION
•Kehr’ Sign: Referred pain in Lt shoulder , hyperesthesia from
diaphragmatic irritation
•Balance sign: Shifting dullness on Right side (free blood) +
Fixed Dullness on Left side (clots, hematoma)
•Cullen’s sign: (late) Bluish discolorationaround the umbilicus

31. The diagnosis is
confirmed by
CT scan
(hemodynamic
stability)
OR
exploratory
laparotomy
(hemodynamic
instability)
U/S, CT replaced "DIAGNOSTIC
PERITONEAL LAVAGE" (used
when there's no time)
INITIAL INVESTIGATION – USG ( FAST)

32. Organ Injury Scaling-American Association
of the Surgery of Trauma (OIS-AAST)
Grade Injury Description
I Haematoma: Subcapsular, <10% surface area
Laceration: Capsular tear, <1cm parenchymal depth
IIHaematoma: Subcapsular, 10-50% surface area
Intraparenchymal, <5cm diameter
Laceration: 1-3cm parenchymal depth not involving a parenchymal
vessel.
IIIHaematoma: Subcapsular, >50% surface area or expanding.
Ruptured subcapsular or parenchymal haematoma.
Intraparencymal haematoma >5cm
Laceration: >3cm parenchymal depth or involving trabecular vessels
IVLaceration: Laceration of segmental or hilar vessels producing major
devascularization (>25% of spleen)
V Laceration: Completely shattered spleen
Vascular: Hilar vascular injury which devascularized spleen

33. 70%
CONSERVATIVE
TREATMENT
•3) Absence of other clear indications for exploratory
laparotomy or associated injuries requiring surgical
intervention.
•4) Absence of associated health conditions that carry an
increased risk for bleeding

34. Surgical
treatment of a
splenic injury
depends on its
severity, the
presence of shock,
and associated
injuries.

35. Grade V
Grade IV

36. Capsular tears of the
spleen can be controlled
by compression only
OR
By using topical
hemostatic agents.

37. Deeper lacerations can be controlled
with horizontal absorbable mattress
sutures.
SPLENORRHAPHY

38. Major lacerations involving less than 50% of the splenic
parenchyma and not extending into the hilum can be
treated by segmental or partial splenic resection.
Resection is indicated only if the patient is stable and no other
major injuries are present.
PARTIAL SPLENECTOMY

39. More extensive injuries involving the
hilum or the central portion of the spleen…
SPLENECTOMY

40. Changes in blood after Splenectomy
•Appearance of Howell-Jolly bodies & siderocytes
•Leukocytosis
•Increased platelet counts

41. COMPLICATIONS OF SPLENECTOMY
•Pulmonary complications:
▫a) Left lower lobe atelectasis (most common)
▫b) Pleural effusion
▫c) Pneumonia

•Hemorrhage ----->subphrenic hematoma
•Infectious complication: Subphrenic abscess

42. •Pancreatic complications: due to intra-op
trauma to tail of pancreas
▫ a) Pancreatitis
▫b) Pseudocyts
▫c) Pancreatic fistula
•Thromboembolic phenomena (5-10%)
COMPLICATIONS OF SPLENECTOMY

43. •lifetime risk of severe infection (1-5%)
• incidence similar among children & adult but
mortality is higher in children.
• mortality is highest in hematologic conditions
•infection to encapsulated bacteria or parasites
▫ 1. Streptococcus pneumoniae (most common infection
50-90%)
▫2. Haemophilus influenzae type B
▫ 3. Meningococcus
▫4. Grp A streptococcus
COMPLICATIONS OF SPLENECTOMY-
Overwhelming Postsplenectomy
Infection (OPSI)

44. SPLENIC
ABSCESS

45. Splenic Abscess
•Condition is rare 0.05-0.7% , high mortality
ETIOLOGY :
-Hematogenous Spread >>
-Infected Trauma
-Infected splenic infarction
-Alcoholism,DM,Immunosupression
•PATHOPHYSIOLOGY
-Hematogenous embolization
-Spread from altered splenic architecture
-Contiguous spread

46. CLINICAL PRESENTATIONS
•Fever
•Abdominal Pain
•Shoulder pain (Involvement of the diaphragmatic pleura )
•Pleuritic chest pain
•General malaise
•Dyspeptic symtoms

47. IMAGING
•Plain X-RAY- elevated lt.copula of diaphragm
indentation of fundic air bubble
Obliteration of Lt. psoas shadow
•US
•CT
•MRI

48. COMPUTED TOMOGRAPHY
•NECT :
-Low attenuation,ill-defined lesion within
splenic
Parenchyma
•CECT:
-Low attenuation, nonenhancing complex fluid
collection
May extend to subcapsular location

49. NECT
Nonenhanced CT scan shows a 6-
cm hypoattenuating mass within
the spleen (large arrow), with
inflammatory soft tissue
stranding in the adjacent
extraperitoneal fat (small arrow)

50. Pyogenic splenic abscess on CECT.
Note low attenuation
abscess bulging splenic
parenchyma (arrow).
Pyogenic splenic abscess on
axial CECT.
Note thin septations within
abscess (arrows)
CECT

51. Microabscess of Spleen
Axial CECT of fungal microabscesses.
Note : numerous hypodense lesions.

52. TREATMENT
•Splenectomy for most
cases
•Percutaneous drainage
•COMPLICATIONS
Spontaneous rupture
–Peritonitis
–sepsis

53. SPLENIC TUMORS

54. TYPES
•BENIGN
–Hemangiomas
–Lymphangioma
–Hamartoma
–Primary cyst \ echinoccocus
cyst

55. •MALIGNANT
–Lymphomas or myeloproliferative diseases
–Rare site for solid tumors but more common
in lung and breast tumors