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The spleen in surgery in general

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spleen in surgery

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The spleen in surgery in general

  1. 1. t Spleen
  2. 2. Anatomy Develops from mesenchymal cells in the dorsal mesogastrium during the fifth week of gestation.
  3. 3. Anatomy • • The most common anomaly of splenic embryology is the accessory spleen. 80% in the splenic hilum and vascular pedicle
  4. 4. The peritoneum covering the spleen, except in the hilum.
  5. 5. 7cm 150 gr. (80 -300 gr). 12 cm 3 – 4 cm
  6. 6. Ligaments • Gastrosplenic • Splenorenal • Splenophrenic • Splenocolic
  7. 7. Blood supply and venous drainage
  8. 8. 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.
  9. 9. FUNCTIONS 1. 2. 3. 4. Filtration Host defense Storage Cytopoiesis
  10. 10. 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.
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 1. Splenic Trauma/Injury
  17. 17. The spleen is the intra-abdominal organ most frequently injured in blunt trauma.
  18. 18. Mechanism of injury • Blunt abdominal trauma from compression or deceleration (motor vehicle accidents, falls ,direct blow to abdomen,with haematological abnormalities) • Penetrating trauma rare
  19. 19. 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
  20. 20. 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)
  21. 21. The diagnosis is confirmed by ECO - CT (hemodynamic stability) or exploratory laparotomy (hemodynamic instability)
  22. 22. Grade 1
  23. 23. Grade 2
  24. 24. Grade 3
  25. 25. Grade 3
  26. 26. Grade 4
  27. 27. Grade 4
  28. 28. Grade 5
  29. 29. 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.
  30. 30. Surgical treatment of a splenic injury depends on its severit the presence of shock, and associated injuries.
  31. 31. 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)
  32. 32. Grade IV Grade V
  33. 33. Capsular tears of the spleen can be controlled by compression only or by using topical hemostatic agents.
  34. 34. Deeper lacerations can be controlled with horizontal absorbable mattress sutures.
  35. 35. 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.
  36. 36. More extensive injuries involving the hilum or the central portion of the spleen… •Splenectomy.
  37. 37. 2. Splenich abscess
  38. 38. 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
  39. 39. 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
  40. 40. Imaging • • • • Plain photo US CT MRI
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. 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.
  45. 45. Treatment and complication • Splenectomy for most cases • Percutaneous drainage • Complications – Spontaneous rupture – Peritonitis – sepsis
  46. 46. 3. Tumors
  47. 47. Types • Benign – Hemangiomas – Lymphangioma – Hamartoma – Primary cyst echinoccocus cyst
  48. 48. types • Malignant – Lymphomas or myeloprolifrative diseases – Rare site for solid tumors but more common in lung and breast tumors
  49. 49. Thank you

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