the spleen in surgery in general

Spleent

Anatomy

Develops from mesenchymal

cells in the dorsal mesogastrium during the fifth

week of gestation.

Anatomy

• The most common anomaly of splenic embryology is the accessory spleen.

• 80% in the splenic hilum and vascular pedicle

The

peritoneum covering the

spleen, except in the hilum.

7cm

12 cm

3 – 4 cm

150 gr. (80 -300 gr).

Ligaments • Splenophrenic • Splenocolic

• Gastrosplenic• Splenorenal

Blood supply and venous drainage

Histology1. 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.

2. White pulp:– Periarticular lymphatic sheaths– Comprised T lymphocytes and

intermittent aggregations of B lymphocytes or lymphoid follicles.

FUNCTIONS

1. Filtration2. Host defense3. Storage4. Cytopoiesis

Indications for Splenectomy

• 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

A. Red Blood Cell Disorders:1. Congenital:

a) Hereditary spherocytosisb) Hemoglobinopathies

i. Sickle cell diseaseii. Thalasemiaiii. Enzyme deficiencies

2. Acquired:a) Autoimmune hemolytic anemiab) Parasitic disease

Indications for Splenectomy

B. Platelet Disorders:1. Idiopathic Thrombocytopenic purpura (ITP)2. Thrombotic thrombocytopenic purpura (TTP)

C. White Blood Disorders:1. Leukemias2. Lymphomas3. Hodgkin’s disease

Indications for Splenectomy

D. Bone Marrow Disorders:1. Myelofibrosis2. Chronic myeloid leukemia3. Acute myeloid leukemia4. Chronic myelomonocytic leukemia5. Essential thrombocythemia6. Polycythemia vera

Indications for Splenectomy

E. Miscellaneous disorders:1. Infectious/abscess2. Storage dse/infiltrate disorder

a) Gaucher’s diseaseb) Niemann-Pick dsec) Amyloidosis

3. Felty’s syndrome4. Sarcoidosis5. Cysts & tumors6. Portal hypertension7. Splenic artery aneurysm

vaccination

• VaccinationCommon bacteria:

a) Streptococcus pneumoniaeb) Hemophilus influenzae type Bc) Meningococcus

• Vaccination against encapsulated bacteria 2 wks before surgery.

• in emergency splenectomy, trauma, give vaccine 3rd day• booster injections every 5 – 6 yrs regardless of the reason

for splenectomy for pneumococcal• annual influenza immunization

1. Splenic Trauma/Injury

The spleen is the intra-abdominal

organ most frequently

injured in blunt trauma.

Mechanism of injury

• Blunt abdominal trauma from compression or deceleration (motor vehicle accidents, falls ,direct blow

to abdomen,with haematological abnormalities)

• Penetrating trauma rare

Presentation

• Clinical symptoms vary • Pt may present with lt upper abdominal

or flank pain• Reffered pain to lt shoulder (kehr sign)• Some may be asymptomatic

Signs• Physical examination is insensitive and

non specific.• Pt may have signs of lt upper quadrant

tenderness or signs of generalized peritoneal irritation.

• May present with tachycardia ,Tachypnea, anxiety , Hypotension (shock)

The diagnosis is confirmed by

ECO - CT (hemodynamic

stability) or exploratory laparotomy

(hemodynamic instability)

Grade 1

Grade 2

Grade 3

Grade 3

Grade 4

Grade 4

Grade 5

70%Nonopertative Treatment

• Hemodynamic stability. • Normal abdominal examination.• Absence of contrast extravasation on CT. • Absence of other clear indications for exploratory

laparotomy or associated injuries requiring surgical intervention.

• Absence of associated health conditions that carry an increased risk for bleeding (coagulopathy, hepatic failure, use of anticoagulants, specific coagulation factor deficiency)

• Injury grade I to III.

Surgical treatment of a

splenic injury depends on its

severit the presence of shock, and

associated injuries.

Organ Injury Scaling-American Association of the Surgery of Trauma (OIS-AAST)

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Grade Injury Description

I Haematoma: Subcapsular, <10% surface areaLaceration: Capsular tear, <1cm parenchymal depth

II Haematoma: Subcapsular, 10-50% surface area Intraparenchymal, <5cm diameterLaceration: 1-3cm parenchymal depth not involving a parenchymal vessel.

III Haematoma: Subcapsular, >50% surface area or expanding. Ruptured subcapsular or parenchymal haematoma. Intraparencymal haematoma >5cmLaceration: >3cm parenchymal depth or involving trabecular vessels

IV Laceration: Laceration of segmental or hilar vessels producing major devascularization (>25% of spleen)

V Laceration: Completely shattered spleenVascular: Hilar vascular injury which devascularized spleen

Grade V

Grade IV

Capsular tears of the spleen can be controlled

by compression only or by

using topical hemostatic agents.

Deeper lacerations can be controlled with horizontal absorbable

mattress sutures.

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.

More extensive injuries involving the hilum or the central portion of the

spleen…

• Splenectomy.

2. Splenich abscess

Spleen Abcess

• Epid : rare 0.05-0.7% , high mortality• Etiology :

- Hematogenic Spread >>- Infected Trauma- Infected spleenic infarction- Alcoholism,DM,Immunosupressan, drug abuser >>

• Pathophysiology- Hematogenous embolization- Spread from altered splenic architecture- Contiguous spread

Clinical Presentations

• Fever• Abdominal Pain (punctum maximum in the

left hypochondrium )• Shoulder pain (Involvement of the

diaphragmatic pleura )• Pleuritic chest pain • General malaise• Dyspeptic symtoms

Imaging

• Plain photo• US• CT• MRI

Computed Tomography

• NECT :- Low attenuation, ill-defined lesion within splenic

parenchyma- May rarely contain gas bubbles or air-fluid levels

• CECT: - Low attenuation, nonenhancing complex fluid

collection- May extend to subcapsular location

Diagnostic Imaging : Abdomen

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

Diagnostic Imaging : Abdomen

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)

RadioGraphics 1994; 14:307-332

Microabcess of Spleen

Axial CECT of fungal microabscesses. Note : numerous hypodense lesions.

Axial CECT demonstrates splenic microabscesses. Note small < 1 cm lesions diffusely throughout the spleen.

Treatment and complication

• Splenectomy for most cases• Percutaneous drainage

• Complications – Spontaneous rupture– Peritonitis– sepsis

3. Tumors

Types

• Benign – Hemangiomas – Lymphangioma– Hamartoma – Primary cyst \ echinoccocus cyst

types

• Malignant – Lymphomas or myeloprolifrative diseases– Rare site for solid tumors but more common in

lung and breast tumors

Thank you