This ppt. Is about the surgical anatomy, physiology,functions of spleen and laparoscopic management of splenic disorder.
Most of the anatomy is depicted pictorial and with suitable diagrams and is recommended for postgraduates only.
Most of Laparoscopic splenectomy has been made understand by diagrams only after consulting different standard surgical books.
2. Contents
1. Surgical anatomy of spleen.
2. Functions of spleen.
3. Indications and contraindications of
laparoscopic management of splenic
disorders.
4. Preoperative workup and
immunization.
5. Approaches of laparoscopic
splenectomy.
3. Surgical anatomy of spleen
The spleen is concealed at the left
hypochondrium and is not palpable
under normal conditions.
It is associated with the posterior
portions of the left 9th, 10th, and 11th
ribs – separated from them by the
diaphragm and the costodiaphragmatic
recess
7. Chief splenic ligaments
At the hilum, the visceral peritoneum
joins the right layer of the greater
omentum and forms the gastrosplenic
and splenorenal ligaments, the two
chief ligaments of the spleen.
These two ligaments form the splenic
pedicle.
10. VASCULAR SYSTEM
OF THE SPLEEN
Splenic artery
The normal course of the splenic artery
crosses the left side of the aorta,
passes along the upper border of the
pancreas reaching the tail in front, and
then crosses the upper pole of the left
kidney.
• Distributed type – 75%.
• Magistral type- 25%.
12. Lymphatic drainage of the
spleen
One of the peculiarities of the spleen is
the lack of provision for lymphatics for
the splenic pulp.
The splenic lymphatic chain is
reported to be formed by
suprapancreatic nodes, infrapancreatic
nodes, and afferent and efferent lymph
vessels.
13. Accessory Spleens
Sites of accessory spleens in order
of frequency:
near the splenic hilum
tail of the pancreas (these contain
86–95% of all accessory spleens).
omentum
along the splenic artery;
splenocolic ligament;
mesentery.
testis or ovary (3–7 are unusual
locations)
16. Physiology
The spleen receives 250 to 300 mL of
blood per minute, which corresponds to
5% of the cardiac output.
At any given time, it contains only 30 to
40 mL of blood.
As the blood enters the spleen, it can
take 2 paths of flow: a fast (closed)
circulation that takes the blood directly
from the arterioles to the venules or a
slower (open) circulation that takes the
blood through the pulp.
The majority (90%) of flow is of the
slow (open) type, which exposes the
circulating cells and erythrocytes to
splenic macrophages in the red pulp
17. Functions
Erythrocyte quality control and removal of defective red cells: : This is achieved
through pitting and culling.
Pitting refers to the removal of rigid structures such as Heinz bodies
(denatured intracellular hemoglobin), Howell-Jolly bodies, and hemosiderin
granules from red cells. The process involves the removal of nondeformable
intracellular substances from deformable cells.
Culling is the term applied to the spleen’s ability to remove red cells that are
aged or abnormal.
Pooling: In health, the spleen does serve as an important reservoir for
blood cells for platelets. Normally, about one-third of the platelet mass is
pooled in the spleen, and this pool exchanges freely with the circulating
platelets that have a life span of about 10 days.
With splenomegaly, a large proportion of platelets are sequestered in the
spleen (up to 80%), and this, coupled with accelerated platelet destruction in
the spleen, accounts for thrombocytopenia. The role of the spleen in platelet
storage also explains the elevation in platelet count that is seen after
splenectomy.
18. Hematopoiesis: The spleen has an important hematopoietic function in fetal life that
ceases by the seventh intrauterine month and does not occur in healthy adults with
exception in certain pathologic conditions where bone marrow is unable to meet the
needs (i.e., extramedullary hematopoiesis).
Filtration: Macrophages residing in the splenic parenchyma capture cellular and non
cellular material from blood, including encapsulated bacteria such as pneumococci, and
destroy them. This function explains the increased risk of infections caused by
encapsulated organisms that is seen after splenectomy.
Antibody synthesis in the white pulp: In addition to the phagocytosis of antibody-
coated cells, the immunologic functions of the spleen include antibody synthesis
(especially immunoglobulin M [IgM]); generation of lymphocytes; and production of
tuftsin, opsonins, properdin, and interferon. Foreign antigens that are filtered in the white
pulp are presented to lymphoid cells. Here the immunoglobulin response is mounted,
leading to release of antibodies.
19. Splenomegaly
Splenomegaly refers simply to
abnormal enlargement of the spleen.
Splenomegaly is described variably
within the surgical literature as
moderate, massive, and hyper, which
reflects a lack of consensus.
Splenomegaly applies to organs
weighing ≥500 g and/or averaging ≥15
cm in length.
20. Splenomegaly
Massive splenomegaly similarly lacks
a consensus definition but has been
described variably as spleens >1 kg in
mass or >22 cm in length.
Spleens palpable below the left costal
margin are thought to be at least
double normal size, with an estimated
weight of ≥750 g.
21. HACKETT’S GRADING SYSTEM FOR PALPABLE SPLEEN
Grade 0: Normal impalpable spleen
Grade 1: Spleen palpable only on deep
inspiration
Grade 2: Spleen palpable on
midclavicular line half way between
umbilicus and coastal margin
Grade 3: The spleen expands toward
the umbilicus
Grade 4: The spleen goes past the
umbilicus
Grade 5: The spleen expands toward
the symphysis pubis.
23. Indications of Laparoscopic
Splenectomy
Secondary hypersplenism systemic lupus erythematous, leukemias,
lymphomas, myeloid metaplasia, sarcoidosis, Gaucher’s disease
Splenic cysts
Primary splenic neutropenia and pancytopenia
Wandering spleen
Operative staging of Hodgkin’s lymphoma Stage IA or IIA
Benign tumors of the spleen
Splenic artery aneurysm.
24. Relative Contraindications to
Laparoscopic Splenectomy
Splenic abscess (increased chance of perforation or leakage of
abscess and spread of infection, dense perisplenitis)
Ruptured spleen
Secondary hypersplenism in portal hypertension (increased
collateral formation and risk of hemorrhage)
Splenic vein thrombosis (SVT) with left-sided portal
hypertension
Massive splenomegaly (visualization difficult)
Previous upper abdominal surgery (difficult dissection due to
adhesions).
26. CT
A palpable spleen leads to
imaging with ultrasound and/or CT
scan to measure the maximal
craniocaudal length of the spleen
and look for other conditions that
will increase technical complexity
of splenectomy including
perisplenic varices, splenic
infarcts, and hilar
lymphadenopathy.
27. DEGREES OF SPLENOMEGALY BASED ON
CRANIOCAUDAL LENGTH ON COMPUTED
TOMOGRAPHY OR POSTRESECTION WEIGHT
GRADE LENGTH WEIGHT
NORMAL UPTO 13CM <300
MILD >13-15 300-500
MODERATE 16-20 500-1000
MASSIVE >20 >1000
28. ANTIBIOTIC PROPHYLAXIS
Guidelines recommend daily prophylactic antibiotics (benzyl penicillin) for
children under 5, but there is a lack of consensus on when this should be
discontinued.
British guidelines recommend prophylaxis until the age of 16 and suggest
that lifelong prophylaxis be offered for high-risk patients (inadequate
serologic response to pneumococcal vaccination, history of invasive
pneumococcal disease, splenectomy for underlying hematologic malignancy,
ongoing immunosuppression, age >50 or <16 years).
29. VACCINATION
Patients undergoing splenectomy or partial
splenectomy should be vaccinated against
encapsulated organisms with recombinant
polyvalent S pneumoniae, H influenzae
type B, and N meningitides vaccines.
There is significant international variation
between recommendations regarding exact
vaccine type and boosters.
31. TIMING OF VACCINATION
Vaccination should be started at least 2 weeks before planned splenectomy
and ideally when immunosuppressive agents are not used.
Vaccine effectiveness may be reduced in patients who have received the
anti-CD20 antibody rituximab in the previous 6 months.
Guidelines for post splenectomy vaccinations for patients who have
undergone an emergency procedure suggest that waiting until 2 weeks after
splenectomy results in the highest antibody titers for the most common
serotypes.
If there is concern that the person may not return for post splenectomy
vaccinations, vaccines should be given before discharge to improve
vaccination rates, which have been reported to be as low as 26%, even in
more recent literature.
32. Preoperative Splenic Artery
Embolization
SAE has also been used by some as a preoperative intervention to reduce
vascularity and size of massive spleens in preparation for a laparoscopic
approach. Embolization is achieved using microcoils and/or Gelfoam.
It is generally agreed that SAE is not helpful in laparoscopic cases where the
spleen measures less than 20 cm in length.
Some studies have shown that preoperative SAE can lead to reduced
intraoperative blood loss in cases of large spleens, they reported no
significant differences in conversion rates, incidence of postoperative
complications, or length of hospital stay.
Complications have been reported in up to 20% of cases and include
catheter site hematoma and pseudoaneurysm, pancreatitis, splenic abscess
or rupture, peritonitis, and postembolization syndrome (ie, pain, fever, ileus,
and/or pleural effusion).
33. Anterior vs. posterolateral
approach of splenectomy
Easier exploration of the entire peritoneal
cavity for detection of accessory splenic
tissue, staging of lymphoma and trauma.
Ability to perform concomitant surgical
procedures.
Allows rapid performance of traditional
midline incision if necessary.
Easy access to lesser sac for early splenic
artery ligation or accessory spleen detection.
Improved exposure and midline incision for
extraction causes less pain in patients with
massive splenomegaly.
DISADVANTAGE:
poor visualization of the splenic hilum, which
may increase the risks of bleeding and
bleeding-associated complications especially
when performed by less experienced
surgeons.
Enhanced retraction:
The colon, stomach, and small bowel are drawn out of
the operative field by gravity.
– Less manipulation of the spleen decreases the
chances of trauma and bleeding. Gentle elevation of
the inferior pole is sufficient.
Enhances exposure:
– The tail of pancreas is well visualized, enabling
dissection and avoidance of injury.
– Lower pole splenic vessels are well visualized.
– After dividing the splenocolic ligament and elevating
the lower pole of spleen, the splenogastric ligament
and splenic pedicle is tented and easily divided.
The splenic pedicle can be approached both anteriorly
and posteriorly.
• Enhanced ease of operation:
– Trocar position entails superior operative ergonomics
with less fatigue for the surgeon.
– Intraoperative bleeding is more easily managed as
the splenic pedicle is hanging and exposed can be
approached anteriorly or posteriorly.
– Control of short gastric vessels does not require wide
opening of the lesser sac.
34. ORIGINAL ARTICLES
Lateral Versus Anterior Approach Laparoscopic Splenectomy: A
Randomized-controlled Study
Fathi, Adel MD, PhD; Eldamshety, Osama MD, PhD; Bahy, Osama
MSc; Denewer, Adel, PhD; Setit, Ahmed MD, PhD
Author InformationSurgical Laparoscopy, Endoscopy & Percutaneous
Techniques 26(6):p 465-469, December
2016. | DOI: 10.1097/SLE.0000000000000339
35. Technique of Laparoscopic Splenectomy
There are eight steps to LS:
Positioning and safe access to establish pneumoperitoneum
Diagnostic laparoscopy, including a search for accessory spleens
Mobilization of the spleen with dissection of splenic ligaments
Division of the splenic vessels, including splenic hilum and short
gastric vessels
Division of remaining attachments completely detaching the spleen
and spleen placement within a specimen bag
Extraction of the spleen within the specimen bag from the peritoneal
cavity.
Inspection of the operative field for hemostasis, pancreatic injury,
etc.
Removal of trocars, abdomen desufflation, and port site closure
50. OPSI
OPSI is the most common fatal late complication of
splenectomy.
Infection may occur at any time after splenectomy.
Most infections occurred more than two years after
splenectomy and 42% occurred more than five years
after splenectomy, with the overall incidence reported to
be 3.2% to 3.5%.
For those who acquire OPSI, the mortality is between
40% and 50%.
OPSI is typically caused by polysaccharide
encapsulated organisms, such as S. pneumoniae, N.
meningitidis, and H. influenzae with S. pneumoniae
estimated to be responsible for between 50% and 90%
of cases.
The risk for fatal OPSI is estimated to be 1/300 to 350
patient-years of follow-up for children and 1/800 to 1000
patient-years of follow-up for adults.
52. SYMPTOMS
flue-like symptoms
characterized by fever, rigors, chills, and
other nonspecific symptoms, including
sore throat, malaise, myalgias, diarrhea,
and vomiting.
multiorgan system failure with the
development of hypotension,
disseminated intravascular coagulation,
respiratory distress, coma, and death
within hours of presentation or within 24
to 48 hrs.
