Splenectomy

splenectomy- lap and open
pre and post op
complication

1. SPLENECTOMY Dr MITHUN BENJAMIN

2. The spleen is a large, encapsulated, complex mass of vascular and lymphoid tissue situated in the upper left quadrant of the abdominal cavity between the fundus of the stomach and the diaphragm

3. The adult spleen is usually 9–14 cm long, 6–8 cm wide and 3–5 cm thick, and fits comfortably in the individual’s cupped hand. It reaches its largest dimension in puberty 150 to 350 g A splenic lobule that fails to coalesce with the developing spleen can persist as a supernumerary or accessory spleen

4. It is most frequently located between the 9 and 11 th ribs, with its long axis along the tenth rib Its posterior border is approximately 4 cm from the midline at the level of the tenth thoracic vertebral spine and it extends about 3 cm anterior to the mid-axillary line

5. RELATION The spleen has superolateral diaphragmatic and inferomedial visceral surfaces superior and inferior poles DIAPHRAGMATIC SURFACE- left pleural costodiaphragmatic recess, lower lobe of the left lung and the 9 to 11th left ribs by the underside of the left dome of the diaphragm

6. VISERAL -gastric, renal and colic impressions GASTRIC- Fundus, upper body and upper greater curvature of the stomach. It is separated from the stomach by a peritoneal recess, limited by the gastrosplenic ligament. RENAL- Posteroinferior part of the visceral surface, separated from the gastric impression above by a ridge of splenic tissue and the splenic hilum. Is related to the upper lateral area of the anterior surface of the left kidney and sometimes to the superior pole of the left suprarenal gland COLIC- Inferior pole of the spleen and is related to the splenic flexure of the colon and the phrenicocolic ligament

7. The anterosuperior border separates the diaphragmatic surface from the gastric impression and is usually convex. Inferiorly, it may bear one or two notches that have persisted from the lobulated form of the spleen in early fetal life. The posteroinferior border separates the renal impression from the diaphragmatic surface and is more rounded and blunt than the anterosuperior border The superior pole corresponds to the posterior extremity and usually faces the vertebral column. The inferior pole is longer and less angulated than the superior pole and connects the anterosuperior and posteroinferior borders anteriorly; it is related to the colic impression and often lies adjacent to the splenic flexure and phrenicocolic ligament

8. Blood supply Almost always, the splenic artery arises from the coeliac trunk. However, it may originate from the common hepatic artery or the left gastric artery, or rarely directly from the aorta either in isolation or as a splenomesenteric trunk From its origin, the artery runs a little way inferiorly before turning to the left behind the stomach to run horizontally posterior to the upper border of the body and tail of the pancreas. The splenic artery courses anterior to the left kidney and left suprarenal gland, and runs in the splenorenal ligament behind or above the tail of the pancreas The superior pole of the spleen gains an additional arterial supply, distinct from the splenic hilar vessels, from the short gastric arteries in the gastrosplenic ligament

9. The magistral type, which branches into terminal and polar arteries near the hilum of the spleen; and the distributed type, which, as the name implies, gives off its branches early and distant from the hilum. enter the hilum they divide into four or five segmental arteries that each supply a segment of splenic tissue. There is relatively little arterial collateral circulation between segments, which means that occlusion of a segmental vessel often leads to infarction of part of the spleen

10. Segmental arteries divide within the splenic trabeculae and give rise to follicular arterioles, which are surrounded by a thick lymphoid sheath of white pulp. There is considerable communication between arterioles. lymphatic tissue that continues until the vessels thin to capillaries. These lymphatic sheaths make up the white pulp of the spleen and are interspersed among the arteriolar branches as lymphatic follicles. The white pulp then interfaces with the red pulp at the marginal zone. It is in this marginal zone that the arterioles lose their lymphatic tissue and the vessels evolve into thin-walled splenic sinuses and sinusoids.

11. The sinusoids then merge into venules, draining into veins that travel along the trabeculae to form splenic veins that mirror their arterial counterparts. The splenic vein leaves the splenic hilum and travels posteriorly to the pancreas, joining with pancreatic branches and often the inferior mesenteric vein to finally receive the superior mesenteric vein, forming the portal vein.

12. RED PULP The red pulp constitutes up to 90% of the total splenic volume and is a unique filtration device that enables the spleen to clear particulate material from the blood as it perfuses the organ. It contains large numbers of venous sinusoids that ultimately drain into tributaries of the splenic vein. The sinusoids are separated from each other by a fibrocellular network of small bundles of collagen fibres, the reticulum, numerous reticular fibroblasts and splenic macrophages- splenic cords

13. Blood from the open ends of the capillaries that originate from penicillar arterioles percolates through the reticular spaces within the splenic cords. Macrophages in the spaces remove blood-borne particulate material, including ageing and damaged erythrocytes. If the number of damaged erythrocytes increases reticular cells proliferate and the red pulp expands, causing the spleen to enlarge

14. White pulp In an adult, white pulp accounts for between 5% and 20% of the splenic tissue. In their terminal few millimetres, their connective tissue adventitia is replaced by a sheath of T lymphocytes, the peri-arteriolar lymphatic sheath (PALS). This is expanded in places by aggregations of B lymphocytes, lymphoid follicles measuring 0.25–1 mm in diameter and visible to the naked eye on the freshly cut surface of the spleen as white semi-opaque dots, in contrast to the surrounding deep reddish purple of the red pulp After antigenic stimulation, they become sites of intensive B-cell proliferation, developing germinal centres similar to those found in lymph nodes; antigen presentation by follicular dendritic cells is involved in this process. Germinal centres regress when the stimulus abates. Follicles tend to atrophy with advancing age and may be absent in the very elderly

15. NERVE SUPPLY The spleen is innervated by both components of the autonomic nervous system; the sympathetic supply is dominant. Postganglionic sympathetic nerves from the coeliac plexus and parasympathetic nerves from the vagal trunks travel with the splenic vessels

16. FUNCTIONS immunological defence metabolism and maintenance of circulating blood elements In the fetus , it is also a major site of haemopoiesis and can resume this role postnatally in certain pathological conditions reservoir -8% red blood cell mass The sequestration of red blood cells (for maturation) and platelets (reservoir). Properdin and tuftsin

17. Kher sign- push up to diaphragm – left shoulder pain Balance sign- non shifting dullness

18. SPLENECTOMY Elective splenectomy is most commonly carried out for idiopathic thrombocytopenic purpura (ITP) and haemolytic anaemia Laparoscopic splenectomy is the standard approach for elective splenectomy ,The advantages of laparoscopic splenectomy include less postoperative pain, more rapid recovery and fewer respiratory complications when compared to open splenectomy Open splenectomy should be reserved for failure of the laparoscopic technique, emergency splenectomy for trauma and when the necessary laparoscopic skills or equipment are not available

19. preparation Vaccinate patients 2 weeks prior to surgery to decrease the risk of post-splenectomy sepsis Immunize against pneumococcal infections (Pneumovax II 0.5 ml IM/SC, Sanofi Pasteur) and Haemophilus influenza type b (Hib) and meningococcus group C infections ( Menitorix 0.5 ml IM, GlaxoSmithKline Pre operative splenic artery embolization, reduced splenic volume and avoidance of the risk of arteriovenous fistula from stapling acrossthe splenic hilum, risk of bleeding or decrease significant splenomegaly Blood product Npo , rt, enema , consent

20. Position the patient in a left lateral position. This position facilitates retraction of the stomach and omentum away from the spleen and improves access Create a pneumoperitoneum using a Veress needle technique at the umbilicus or an open technique at the camera port site Exact port placement depends on the size of the spleen. For a normal sized spleen place the 11-mm camera port above the umbilicus and to the left of the midline. Place a 5-mm port in the epigastrium and a 12-mm port for stapler and retrieval bag in the left lateral position .An additional port for a fan retractor may be necessary.

21. Perform a systematic exploration looking for splenunculi (small nodules of splenic tissue away from the main body of the spleen), which may be found anywhere in the abdominal cavity, but are commonly located at the hilum of the spleen and adjacent to the tail of the pancreas Use open Johannes forceps to gently retract the spleen medially. Divide splenic attachments about 1 cm away from the spleen and use these attachments to retract the spleen

22. Continue the dissection, using the harmonic scalpel or hook diathermy, from the inferior pole of the spleen to the superior pole and spleen can be moved medially to expose the back of the splenic hilum . It is important to clear the back of the splenic hilum carefully at this stage and identify the tail of the pancreas to avoid damaging it at a later stage Return to the lower pole of the spleen and begin the medial dissection by dividing the serosa over the hilar vessels Pass towards the upper pole of the spleen you will encounter the short gastric vessels. Divide these now with the harmonic scalpel. Alternatively, they can be divided together with the hilar vessels using a vascular stapler. A fan retractor may be used by the first assistant from the right upper quadrant position to retract the splenic flexure and, later in the procedure, to retract the stomach away from the spleen.

23. Once a clear view in front and behind the hilum is obtained, place a vascular stapler across the vessels at the hilum of the spleen and divide the splenic artery and vein. Take care to remain close to the spleen as straying medially may damage the tail of the pancreas. Once all the vessels are divided, lift the spleen anteriorly to allow division of any remaining posterior attachments using a harmonic scalpel The splenophrenic ligaments at the top of the spleen to stop it falling into the abdominal cavity: these are divided once the spleen has been placed in the retrieval bag

24. Partially withdraw the bag through the 12-mm port and use a finger or sponge holding forceps through the port site to break down the spleen whilst it is still intra-abdominal. Remove the spleen piecemeal from the bag using a combination of sponge holding forceps and a sucker.

25. Open splenectomy Make an upper midline or left subcostal incision through the abdominal wall In elective cases, anterior approach is ideal; in trauma and emergency situation, posterior approach is the preferred one, Make a careful search for splenunculi . Ligate the splenic artery at the beginning of the operation if the spleen is very large or prior to infusing platelets in patients with ITP . the lesser sac entered by dividing 10 cm of the gastrocolic omentum using diathermy or a harmonic scalpel. Incise the peritoneum at the superior border of the pancreas to identify the tortuous splenic artery. Use a right angle forceps to pass a ligature behind the splenic artery and ligate it in continuity with a large non-absorbable suture

26. left hand to draw the spleen medially and have your assistant retract the abdominal wall laterally. Incise the peritoneum that attaches the spleen to the lateral sidewall . Extend this incision up along the lateral border of the spleen towards the diaphragm. Because of its position this cannot always be achieved under direct vision. Extend this incision downwards around the lower pole of the spleento identify the splenic flexure and separate it from the spleen

27. Dividing lateral attachment allows your left hand to gently move the spleen medially and upwards into the abdominal wound and divide the adhesions from the upper pole of the spleen to the diaphragm Divide the peritoneum over the front of the splenic hilum from the lower pole to the upper pole. The short gastric arteries are divided Divide the splenic vessels between large clips. Several clips may be required to take all the vessels. Be careful not to injure the tail of the pancreas at this point

28. CONSERVATIVE SPLENECTOMY Immediately remove a spleen that is either fragmented or avulsed from its vascular pedicle. Under these circumstances consider auto transplantation of splenic tissue by suturing a piece of omentum around a sliver of removed splenic pulp to encourage splenic regeneration( splenosis ) If the extent of the damage and bleeding is less severe, gently mobilize the spleen into the wound after dividing its peritoneal attachments. Remove attached clot and examine the organ thoroughly. Decide whether topical haemostatic agents, partial splenectomy or some form of splenic repair is feasible, with or without ligation of the splenic artery or its branches

29. Capsular tears and other minor injuries can often be controlled by application of a haemostatic agent Deeper or more extensive lacerations may still be suitable for repair. Mobilize the spleen, at least in part. Use synthetic absorbable sutures on a long blunt needle. Take deep bites of splenic tissue on either side of the tear, and tie the sutures snugly. Use omentum or Teflon buttresses to prevent the stitches cutting through, together with a topical haemostatic agent to control surface bleeding.

30. mesh In open method in trauma, absorbable mesh is wrapped around completely. It is partly haemostatic and creates tamponade also. Diff erent methods are there to place the mesh as a wrap. Mesh may be wrapped around completely and at the hilar level it is bunched loosely using purse string suture. Another method, a large absorbable mesh is taken. At its centre, a circular gap is made through which poles of the spleen are slid and mesh is wrapped from hilum outwards; mesh margins are sutured on the parietal surface of the spleen .

31. For partial splenectomy, fully mobilize the organ and carefully dissect in the splenic hilum to identify and ligate the segmental arteries and veins. Incise the capsule of the spleen at the line of ischaemia and use a finger-fracture technique to resect the upper or lower pole. Secure haemostasis by means of synthetic absorbable sutures or with argon coagulation. Preserve at least 30% of the spleen volume to maintain adequate splenic function .

32. Marsupialization (Greek: maryp (p)ion ¼ a pouch; removing the top) of a thin-walled congenital or traumatic cyst avoids splenectomy but there is a risk of recurrence

33. POST OPERATIVE Check the haemoglobin, white cell and platelet counts postoperatively. Leucocytosis and thrombocythaemia nearly always ensue, with peaks at 7–14 days. Persistent leucocytosis and pyrexia suggest the possibility of a subphrenic abscess. Consider antiplatelet medication such as aspirin if the platelet count exceeds 1000X per litre After an emergency splenectomy, vaccinate the patient once fully recovered Monitor the haemoglobin level and remove the drain, if used, when it ceases to function  

34. COMPLICATION Intra operative - bleeding. Small splenic tears may be controlled with compression by surrounding tissues and haemostatic diathermy or get control of the hilar vessels Postoperative haemorrhage is reported to occur in 2–5% of patients after splenectomy bleeding. The usual sites are the hilar or short gastric vessels: require re laparotomy Thrombocytosis can occur following splenectomy, leading to deep venous thrombosis and pulmonary emboli Respiratory complications such as pneumonia, atelectasis, and pleural effusion are by far the most common morbidity following open splenectomy, occurring in 20–40% of patients

35. Injury to adjacent organs: the splenic flexure of the colon, the greater curvature of the stomach and the tail of the pancreas are all susceptible to damage during splenectomy. Undetected pancreatic injury may later present as pancreatic ascites, a subphrenic collection or pancreatic fistula. Accessory spleens are noted in 15–30% of patients and account for late failure of splenectomy in ITP.

36. Subphrenic collection: this may develop due to minor bleeding or serous oozing from the raw area in the diaphragm and retroperitoneum. If this happens, carefully monitor the platelet count and clotting parameters. A CT (computed tomography) scan is often required to confirm the diagnosis trauma. A subphrenic collection can usually be drained percutaneously with antibiotic cover but may occasionally require a laparotomy. 4%

37. Overwhelming post-splenectomy infection (OPSI) As there is reduced IgM, tuftin , properdin and other antibodies, phagocytosis of encapsulated bacteria is defective. So, the postsplenectomised patient is more prone for Pneumococcal septicaemia (commonest), N. meningitides, H. infl uenzae and Babesia microti infections Splenectomy there is a 1–2.5% risk of developing overwhelming septicaemia from encapsulated bacteria, usually within 2 years of operation. The risk is higher in young children (4–10%) and after splenectomy for haematological disease adults. The mortality rate of post-splenectomy sepsis is higher in children (50%) Features—Prodromal phase—fever, chills, sore throat; hypotension, shock; DIC; respiratory distress, coma, death

38. PREVENTION Prompt medical attention, particularly for respiratory illness. Patients should be advised regarding immunization and foreign and to carry an information card at all times. All patients should be advised to have yearly influenza immunization. Vaccination

39. Thank you