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Spleen in Surgery Presented by: Dr. Rafiq M. Salhab. Alahli Hospital, Hebron. بسم الله الرحمن الرحيم Al-Quds University Faculty of Medicine.

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Presentation on theme: "Spleen in Surgery Presented by: Dr. Rafiq M. Salhab. Alahli Hospital, Hebron. بسم الله الرحمن الرحيم Al-Quds University Faculty of Medicine."— Presentation transcript:

1 Spleen in Surgery Presented by: Dr. Rafiq M. Salhab. Alahli Hospital, Hebron. بسم الله الرحمن الرحيم Al-Quds University Faculty of Medicine

2 Presentation contents  Embriology and Anatomy.  Physiology and Pathophysiology.  Evaluation of Size and Function.  Indications for Splenectomy.  Preoperative Considerations.  Splenectomy Techniques.  Splenectomy Outcomes. Dr. Rafiq Salhab10/10/2011

3 Embriology and Anatomy # Embriology:  Encapsulated mass of vascular and lymphoid tissue.  Reticuloendothelial organ ( 25% of the fixed tissue macrophage population in the body).  Primitive mesoderm.  Differentiation and migration.  Accessory spleen.(20%). Dr. Rafiq Salhab10/10/2011

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5 # Anatomy:  Location. Location.  Dimensions.  Ligaments. Ligaments.  Blood supply. Dr. Rafiq Salhab10/10/2011

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7 # Histology: 1. Red pulp (75%): filtration system. 2. White pulp: lymphocytes and lymphoid follicles. 3. Marginal zone. 4. Trabecular areas. Dr. Rafiq Salhab10/10/2011

8 # Histology: Dr. Rafiq Salhab10/10/2011

9 Physiology and Pathophysiology a) Storage spleens (many mammals). b) Defense spleens (Humans): Filtration: RBCs, WBCs, Platelets.Filtration: RBCs, WBCs, Platelets. Host defense:Host defense: - Humoral (IGM, Tuftsin, Properdin, fibronectin). - Humoral (IGM, Tuftsin, Properdin, fibronectin). - Cell-mediated. - Cell-mediated. Storage.Storage. Cytopoiesis.Cytopoiesis. Dr. Rafiq Salhab10/10/2011

10  Splenomegaly: * weight ≥ 500 g. * length ≥ 15 cm. * length ≥ 15 cm.  Palpable spleen : double the normal size.  Hypersplenism: the presence of cytopenia (one or more blood cell lines) in the context of normally responding bone marrow, and improvement after splenectomy. It has two types: the presence of cytopenia (one or more blood cell lines) in the context of normally responding bone marrow, and improvement after splenectomy. It has two types:  Primary.  Secondary. Dr. Rafiq Salhab10/10/2011

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13 Evaluation of Size and Function  Imaging:  Preoperative evaluation.  Left upper quadrant pain.  Delineation of tumors or cysts.  Characterization of splenic abscesses. Dr. Rafiq Salhab10/10/2011

14 # Ultrasound (US): - most cost-effective. - most cost-effective. - rapid. - rapid. - easy to perform. - easy to perform. - not invasive. - not invasive. - no ionizing radiation. - no ionizing radiation. - sensitivity up to 98 % in expert hand. - sensitivity up to 98 % in expert hand. Dr. Rafiq Salhab10/10/2011

15 # CT Scanning: - assessment of splenomegaly. - assessment of splenomegaly. - identification of lesions. - identification of lesions. - guidance for percutaneous procedure. - guidance for percutaneous procedure. - use of contrast material increases - use of contrast material increases resolution. resolution. - staging. - staging. # MRI: more expensive than CT or US and offers no advantage. offers no advantage. Dr. Rafiq Salhab10/10/2011

16 # Radioscintigraphy: demonstrates splenic location and size; helpful in detecting accessory spleens following unsuccessful splenectomy for ITP. # Angiography: not helpful as diagnostic: - embolizing splenic branches in trauma. - embolizing splenic branches in trauma. - limited success in partial embolization - limited success in partial embolization for chronic ITP. for chronic ITP. - treatment of splenomegaly. - treatment of splenomegaly. Dr. Rafiq Salhab10/10/2011

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18 Indications for Splenectomy A. Trauma. B. Pathological disorders. 1)Red cells disorders. 2)Platelet disorders. 3)White cell disorders. 4)Bone marrow disorders (myeloproliferative). 5)Miscellaneous disorders and lesions. Dr. Rafiq Salhab10/10/2011

19 Splenectomy: most common indications: 1.Trauma. 2.Staging for Hodgkin’s disease (in the past). 3.ITP. 4.Hereditary spherocytosis. 5.Autoimmune hemolytic anemia (AIHA). 6.Thrombotic thrombocytopenic purpura (TTP). Dr. Rafiq Salhab10/10/2011

20 A. Splenic trauma: Splenic trauma: Splenic trauma:  The spleen is the most commonly injured organ after blunt trauma.  Splenic injuries are classified as: 1.Class 1: capsular tear. 2.Class 2: lacerations not extending to the hilum. 3.Class 3: open laceration extending to the hilum. 4.Class 4: shattered spleen.  Splenectomy was the gold standard for definitive management of splenic injury. Dr. Rafiq Salhab10/10/2011

21  Preservation of all or most of the injured spleen has become the preferred treatment.  Avoid overwhelming postsplenectomy infection (OPSI). Dr. Rafiq Salhab10/10/2011

22 # Non-operative salvage (observation):  Blunt injuries (non penetrating).  Stable patients without associated injuries.  Class 1 and 2 (stable grade 3) may be observed. observed.  Pediatric patients: successful (85 – 90) %  Adult patients: successful 70 %.  Non of the class 4 and only 7 % of the class 3 can be treated successfully. Dr. Rafiq Salhab10/10/2011

23 # Operative salvage:  Successful in 50 % of patients after either blunt or penetrating trauma. blunt or penetrating trauma.  Should be considered in stable patients with few other injuries.  The highest success in class 1 and 2 injuries.  The conservation of the spleen means more blood transfusion (complications).  Unconscious patients should be operated.  Patient over than 55 years of age. Dr. Rafiq Salhab10/10/2011

24  Splenectomy is indicated: 1.Life threatening hemorrhage from the spleen (class 3, 4). spleen (class 3, 4). 2.Multiple injuries in an unstable patient. 3.Inexperience of the surgeon. Dr. Rafiq Salhab10/10/2011

25 B. Pathological disorders: 1. Red blood cells disorders:  AIHA: warm antibodies. Splenectomy is indicated for: indicated for: - failure to respond to steroids. - failure to respond to steroids. - intolerance to steroids. - intolerance to steroids. - requirement for excessive doses. - requirement for excessive doses. - inability to receive steroids. - inability to receive steroids. * favorable response to splenectomy in 80%. Dr. Rafiq Salhab10/10/2011

26  Hereditary Spherocytosis (HS):  Autosomic dominant.  Fragility test.  Splenectomy is curative for typical forms and is the sole mode of therapy.  Delay surgery in children (4-6 years).  Intractable leg ulcers needs early surgery. (severe anemia and hemolysis) (severe anemia and hemolysis)  Prophylactic cholecystectomy in children with GBS at the time of splenectomy. Dr. Rafiq Salhab10/10/2011

27  Hemoglobinopathies:  Sickle cell disease: splenectomy is indicated: - hypersplenism. - hypersplenism. - acute sequestration crisis. - acute sequestration crisis. - splenic abscess. - splenic abscess.  Thalassemia: splenectomy is indicated for: - excessive transfusion requirements.(200cc/kg/year) - excessive transfusion requirements.(200cc/kg/year) - discomfort due to splenomegaly. - discomfort due to splenomegaly. - painful splenic infarction. - painful splenic infarction.  RBC enzyme Deficiencies: G6PD,PK. In PK surgery is indicated for splenomegaly (delayed surgery) In PK surgery is indicated for splenomegaly (delayed surgery) Dr. Rafiq Salhab10/10/2011

28 2. Bone marrow disorders: (myeloproliferative disorders) AML; CML; CMML; ET; PV; myelofibrosis. AML; CML; CMML; ET; PV; myelofibrosis.  Splenectomy is indicated for: - symptomatic splenomegaly: early satiety, - symptomatic splenomegaly: early satiety, poor gastric emptying, LUQ pain, and poor gastric emptying, LUQ pain, and diarrhea. diarrhea. - hypersplenism. - hypersplenism. Dr. Rafiq Salhab10/10/2011

29 3. White blood cell disorders: CLL; HCL; NHL; HL. CLL; HCL; NHL; HL.  Splenectomy is indicated for: - symptomatic splenomegaly. - symptomatic splenomegaly. - hypersplenism. - hypersplenism.  HL: splenectomy for staging. Dr. Rafiq Salhab10/10/2011

30 4. Platelet disorders: # Idiopathic (Immune) thrombocytopenic purpura (ITP): -Affects mainly females between the ages of years. - Affects mainly females between the ages of years. -The spleen is palpable in less than 10% of patients. -The spleen is palpable in less than 10% of patients. -Spontaneous regression is seen in more than two thirds of pediatric cases. -Spontaneous regression is seen in more than two thirds of pediatric cases. -Increased bleeding time. -Increased bleeding time. -The response to steroids predicts the benefit from splenectomy. -The response to steroids predicts the benefit from splenectomy. -About 60-80% of patients will benefit from splenectomy. -About 60-80% of patients will benefit from splenectomy. Dr. Rafiq Salhab10/10/2011

31 ITP :continue ITP :continue Treatment : to keep PLT > 30,000 Corticosteroids :1-1,5 mg/kg/day for 3-6 months Corticosteroids :1-1,5 mg/kg/day for 3-6 months Intravenous immune globulin. Intravenous immune globulin.  Splenectomy is indicated for: - failure of medical therapy. - failure of medical therapy. - steroids side effects. - steroids side effects. - relapse.(2 during treatment) - relapse.(2 during treatment) - life threatening bleeding. - life threatening bleeding. Dr. Rafiq Salhab10/10/2011

32 # Thrombotic thrombocytopenic purpura (TTP):  Splenectomy is indicated for: - relapse. - relapse. - multiple plasma exchanges. - multiple plasma exchanges. Dr. Rafiq Salhab10/10/2011

33 5. Miscellaneous disorders: # Splenic abscess:  Common in tropical locations: sickle cell anemia: anemia: - thrombosed splenic vessels. - thrombosed splenic vessels. - splenic infarction. - splenic infarction.  Abscess formation by: 1-hematogenous spread. 1-hematogenous spread. 2-contiguous infections. 2-contiguous infections. 3-hemoglobinopathy. 3-hemoglobinopathy. 4-immunosuppression. 4-immunosuppression. 5-trauma. 5-trauma. Dr. Rafiq Salhab10/10/2011

34 # Cyst and tumors:  Parasitic cyst(hydatid cyst). Or non-parasitic (pseudocyst, dermoid, epidermoid, epithelial) (pseudocyst, dermoid, epidermoid, epithelial)pseudocyst  Primary tumors (Sarcoma, NHL) or metastatic tumors (lung). # Storage diseases and infiltrative disorders: - Gaucher’s disease. - Gaucher’s disease. - Niemann-Pick disease. - Niemann-Pick disease. - Amyloidosis. - Amyloidosis. Dr. Rafiq Salhab10/10/2011

35 # Felty’s syndrome: RA, splenomegaly, neutropenia. # Sarcoidosis. # Portal hypertension. # Splenic artery aneurysm. Dr. Rafiq Salhab10/10/2011

36 Preoperative Considerations  Splenic artery embolization.  Vaccination: - encapsulated bacteria: S.pneumonia, - encapsulated bacteria: S.pneumonia, H.Influenza type B, Meningococcus. H.Influenza type B, Meningococcus. - 2 weeks before planned splenectomy. - 2 weeks before planned splenectomy. - in emergency is given post operatively - in emergency is given post operatively as soon as possible. as soon as possible. - booster injections every years. - booster injections every years. - annual influenza immunization. - annual influenza immunization. Dr. Rafiq Salhab10/10/2011

37  DVT prophylaxis: patients with MPD.  Adjustment of anemia.  Adjustment of coagulation profile.  Adjustment of thrombocytopenia.  Antibiotic. Dr. Rafiq Salhab10/10/2011

38 Splenectomy Techniques A. Laparoscopic: more tendency. B. Open Technique: 1.Traumatic rupture. 2.Massive splenomegaly. 3.Ascites. 4.Portal hypertension. 5.Multiple prior operations. 6.Extensive splenic radiation. 7.Splenic abscess. Dr. Rafiq Salhab10/10/2011

39 Splenectomy Outcomes  Hematologic outcomes: - appearance of Howel-Jolly bodies and - appearance of Howel-Jolly bodies and siderocytes. siderocytes. - leukocytosis: within 1 day. - leukocytosis: within 1 day. - thrombocytosis: within 2 days, peak (7 days). - thrombocytosis: within 2 days, peak (7 days). - increased hemoglobin level. - increased hemoglobin level. Dr. Rafiq Salhab10/10/2011

40  Complications: 1. Pulmonary: - left lower lobe atelectasis. - left lower lobe atelectasis. - left pleural effusion. - left pleural effusion. - pneumonia. - pneumonia. 2. Hemorrhagic: - intraoperatively. - intraoperatively. - subphrenic hematoma. - subphrenic hematoma. Dr. Rafiq Salhab10/10/2011

41 3. Infectious: - subphrenic abscess. - subphrenic abscess. - wound infection. - wound infection. 4. Pancreatic: - pancreatitis. - pancreatitis. - pseudocyst. - pseudocyst. - fistula. - fistula. 5. Thromboembolic phenomena: - DVT. - DVT. - PVT. - PVT. Dr. Rafiq Salhab10/10/2011

42  Overwhelming post splenectomy infection:  Incidence 1 – 5 %.  Caused by encapsulated bacteria.  Mortality > 50 %.  More common in children and Immuno- compromised patients. compromised patients.  Occurs more frequently during the first 5 years of life. years of life.  The risk is greatest within 2 years of surgery.  Risk factors: cause of splenectomy, immunity status, interval from the date of surgery. status, interval from the date of surgery.

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