spleen in surgery

1. t
Spleen

2. Anatomy
Develops from
mesenchymal
cells in the dorsal
mesogastrium
during the fifth
week of gestation.

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

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

6. 7cm
150 gr.
(80 -300 gr).
12 cm
3 – 4 cm

7. Ligaments
• Gastrosplenic
• Splenorenal
• Splenophrenic
• Splenocolic

8. Blood supply and venous
drainage

9. Histology
1. 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.

11. FUNCTIONS
1.
2.
3.
4.
Filtration
Host defense
Storage
Cytopoiesis

12. 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.

13. Indications for Splenectomy
A. Red Blood Cell Disorders:
1. Congenital:
a) Hereditary spherocytosis
b) Hemoglobinopathies
i. Sickle cell disease
ii. Thalasemia
iii. Enzyme deficiencies
2. Acquired:
a) Autoimmune hemolytic anemia
b) Parasitic disease

14. Indications for Splenectomy
B. Platelet Disorders:
1. Idiopathic Thrombocytopenic purpura (ITP)
2. Thrombotic thrombocytopenic purpura (TTP)
C. White Blood Disorders:
1. Leukemias
2. Lymphomas
3. Hodgkin’s disease

15. Indications for Splenectomy
D. Bone Marrow Disorders:
1.
2.
3.
4.
5.
6.
Myelofibrosis
Chronic myeloid leukemia
Acute myeloid leukemia
Chronic myelomonocytic leukemia
Essential thrombocythemia
Polycythemia vera

16. Indications for Splenectomy
E.
Miscellaneous disorders:
1.
2.
Infectious/abscess
Storage dse/infiltrate disorder
a)
b)
c)
3.
4.
5.
6.
7.
Gaucher’s disease
Niemann-Pick dse
Amyloidosis
Felty’s syndrome
Sarcoidosis
Cysts & tumors
Portal hypertension
Splenic artery aneurysm

17. vaccination
• Vaccination
Common bacteria:
a) Streptococcus pneumoniae
b) Hemophilus influenzae type B
c) 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

18. 1. Splenic
Trauma/Injury

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

20. Mechanism of injury
• Blunt abdominal trauma
from compression or deceleration
(motor vehicle accidents, falls ,direct blow
to abdomen,with haematological
abnormalities)
• Penetrating trauma rare

21. 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

22. 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)

23. The diagnosis is
confirmed by
ECO - CT
(hemodynamic
stability) or
exploratory
laparotomy
(hemodynamic
instability)

24. Grade 1

25. Grade 2

26. Grade 3

27. Grade 3

28. Grade 4

29. Grade 4

30. Grade 5

31. Nonopertative Treatment
•
•
•
•
70%
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.

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

33. Grade
Injury Description
I
Haematoma: Subcapsular, <10% surface area
Laceration: Capsular tear, <1cm parenchymal depth
II
Haematoma: Subcapsular, 10-50% surface area
Intraparenchymal, <5cm diameter
Laceration: 1-3cm parenchymal depth not involving a parenchymal
vessel.
III
Haematoma: Subcapsular, >50% surface area or expanding.
Ruptured subcapsular or parenchymal haematoma.
Intraparencymal haematoma >5cm
Laceration: >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 spleen
Vascular: Hilar vascular injury which devascularized spleen
From Moore EE, Cogbill TH, Jurkovich GJ, et al: Organ injury scaling: Spleen and liver
(1994 revision). J Trauma 38:323-324, 1995, with permission.
Organ Injury Scaling-American Association
of the Surgery of Trauma (OIS-AAST)

34. Grade IV
Grade V

35. Capsular tears of the
spleen can be controlled
by compression only or by
using topical
hemostatic agents.

36. Deeper lacerations can be controlled
with horizontal absorbable
mattress sutures.

37. 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.

38. More extensive injuries involving the
hilum or the central portion of the
spleen…
•Splenectomy.

39. 2. Splenich
abscess

40. 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

41. 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

42. Imaging
•
•
•
•
Plain photo
US
CT
MRI

43. 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

44. CECT
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)
Diagnostic Imaging : Abdomen

45. 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

46. 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.

47. Treatment and complication
• Splenectomy for most cases
• Percutaneous drainage
• Complications
– Spontaneous rupture
– Peritonitis
– sepsis

48. 3. Tumors

49. Types
• Benign
– Hemangiomas
– Lymphangioma
– Hamartoma
– Primary cyst echinoccocus cyst

50. types
• Malignant
– Lymphomas or myeloprolifrative diseases
– Rare site for solid tumors but more common in
lung and breast tumors

51. Thank you