open spenectomy, spleen, splenic trauma, splenomegaly

1. SPLENECTOMY
DR BASHIR YUNUS
SURGICAL RESIDENT
AKTH
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2. Outline
• Definition
• Anatomy
• Indications
• Preoperative preparation
• Anaesthesia
• Positioning
• Pre-incision
• Exposure
• Closure
• Post-op management
• Complications
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3. Definition
• The surgical removal of the spleen
• Anatomy
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4. Relevant Anatomy
• Location
• Size
• Attachment
• Relations
• Blood supply
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5. • The spleen is located in the left upper quadrant. Lies between the 9th -11th
rib and weighs about 150-200g. Measures about 7.5 by 2.5cm.
• Attachement
Laterally; lienorenal ligament
Anteriorly; gastrosplenic ligament (contains short gastric arteries)
Superiorly; splenophrenic ligament
Inferiorly; splenocolic ligament
• Relations
Anteriorly; fundus of the stomach
Medially; tail of the pancreas
Inferiorly; splenic flexure
Superiorly; diaphragm
Posteriorly; upper part of the kidney
• Blood supply; spleen artery, short gastric arteries
• Venous drainage; splenic vein which joins the SMV behind the head of
pancreas to form the portal vein
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6. Functions of the spleen
• Extramedullary haemopoesis
• Filtration of blood
• Host defense
• Storage of blood
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7. Indications
• Pnemonic; TRASH-TV
• TORSION ; wandering spleen
• RUPTURE; trauma
• ADJUNCTIVE TO SURGERY;pancreatectomy, gastrectomy, staging of HL
• SWELLINGS; splenomegaly, hypersplenism, portal hypertension
• HAEMATOLOGICAL DISORDERS; rbc disorders- spherocytosis, HbSS,
thalasaemia, wbc disorders- leukaemia, myelofibrosis, CML, CLL, platelet
disorders- idiopathic thrombocytopenic Purpura. Others felty’s syndrome,
Gauchers disease
• TUMOURS; haemangiomas, haemangiosarcoma,lymphoma, 2° tumours,
• VASCULAR ANORMALIES; aneurysm of the spenic artery, splenic vein
thrombosis
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8. Types
• Emergency or elective
• Open or laparoscopic
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9. Pre-op preparation
• Emergency
• Resuscitate; urgent Hb, U/Ecr, GXM, iv fluids, urethral catheter, NG
tube, antibiotics, analgesics, blood transfusion.
• Elective
• Baseline investigations; correct any derangement
• Pneumococcal vaccine 2weeks prior to surgery (in emergency, it is given too
weeks post op)
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10. • Anaesthesia; general with cuffed ETT
• Position; supine
• Surgeon, assistant and periop. nurse scrub, gown and
gloved. With the surgeon on the right side of the
patient the assistant on the left and the peri-op the left
side of the assistant.
• The skin is prepared from the nipple line to the mid-
thigh and draped
• Incision
• Emergency - upper midline incision
• Elective- left subcostal incision
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11. Procedure (trauma)
• Incision deepened to access the peritoneal cavity.
• Pack the 4 quadrant of the peritoneal cavity
• Suck out all free blood and clot
• Remove packs starting from least area of bleeding.
• Use your fingers to temporarily secure hemostasis at the hilum(to prevent
clamping of the tail of pancreas)
• Place the left hand on the spleen and draw it down to divide the lieno renal
ligament lying posteriorly
• Deliver the spleen into the abdominal incision
• Then a non-crushing clamp is applied at the hilum safeguarding the pancreas
• Examine the spleen for grade of injury
• Ligate and divide; the short gastric arteries, left gastro-epiploic arteries.
Slightly away from the stomach with non absorbable suture
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12. • Gently separate the tail of the pancreas from the splenic vessels
• Separately divide and double ligate the splenic artery and then the
vein.
• Beware ; tail of the pancreas, splenic flexure of the colon, left kidney
and adrenal gland.
• Complete the splenectomy by dividing the splenocolic liagament
• Complete exploratory laparotomy
• Meticulous hemostasis
• Peritoneal saline lavage
• Suction drain on splenic bed- to drain the tail of pancreas
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13. • Closure; abdomen is closed in layers
Peculiarities for elective;
• Subcostal incision
• Splenomegaly, lesser sac is entered to ligate splenic artery to reduce
vascularity. Giant splenomegaly requires bil. Subcostal incision.
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14. Post operative management
• Remove N-G tube and the suction drain when drainage is minimal
(usu 24-48hours)
• Commence oral when bowel activity resumes
• Long term oral penicillin 250mg daily
• Pneumococcal vaccine 2weeks post op
• Anti-malaria prophylaxis
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15. complications
• Early;
• Acute gastric dilatation
• Fundal ischemia- hematemesis, perforation
• Pancreatic fistula
• Portal vein thrombosis
• Reactionary hemorrhage from splenic vessel
• Late ;
• Infection; pneumococcal, viral, OPSI
• thrombocytosis
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