2. INTRODUCTION
The spleen was regarded by Galen as “an organ of
mystery,” ; By Aristotle as unnecessary, and By
Pliny as an organ that might hinder the speed of
runners
The term ‘hypersplenism’ first appeared in the
thesis of Anatole Chauffard in 1907 and
subsequently in the study of Morawitz and
Denecked
3. ANATOMY
Spleen is located in the Left Upper Quadrant(LUQ).
Lies between the 9th -11th rib
weighs about 150gm( 75-250gm ).
Measures about 13 x 7 x 3 cms.
4. Attachement :-
Laterally- Lienorenal
Ligament
Anteriorly-
Gastrosplenic
Ligament (Contains
Short Gastric Arteries
and Left Gastro
Epiploic artery)
Superiorly-
Splenophrenic
Ligament
Inferiorly- Splenocolic
Ligament
5. RELATIONS
Anterior-fundus of
the stomach
Medially- tail of
the pancreas
Inferiorly- splenic
flexure
Superiorly-
diaphragm
Posteriorly- upper
part of the kidney
6. Arterial supply- Splenic artery,
Short Gastric arteries
Distributed type- the most
common (70%) and is
distinguished by a short trunk
with many long branches.
Magistral type of splenic
artery (30%) has a long main
trunk dividing near the hilum
into short terminal branches.
Splenic vein joins the Superior
Mesenteric Vein to form the
Portal Vein and
accommodates the major
venous drainage of the
Spleen.
7. EMBRYOLOGY
Spleen is the largest reticulo-
endothelial organ in the body.
Developed from the primitive
mesoderm of dorsal mesogastrium by
fifth week of gestation.
The most common variation of
Splenic embryology is the
accessory spleen (10-29 % of
the population.)
8. HISTOLOGY AND FUNCTION OF SPLEEN
Red pulp(90%)- Cords and sinuses - Phagocytosis
White pulp- Periarticular lymphatic sheets -
Immunoglobulins.
9. Reservior for platelets,monocytes,Factor VIII etc.
Haematopoiesis in fetus
Repairs and destruction of RBC’s by pitting & culling.
Immune function: produces IgM ,properidin,tuftsin
Prevention of infection- By capsulated organism
(H.influenza etc) , role in phagocytosis.
10. HYPERSPLENISM
Clinical syndrome characterized by:
Splenomegaly
Pancytopenia or a reduction in the number of one or
more types of blood cells
Improvement of cytopenias Post-Splenectomy
Hyperplasia of the precursor cells in the marrow or so
called maturation arrest
Decreased RBC/platelet survival
11. In Hypersplenism, Splenic function accelerates,
and begins automatically to remove cells that may
still be normal in function.
Sometimes, the spleen will temporarily sequestrate
90% of the body platelets and 45% of the red cells.
12. Classification of Hypersplenism
Hypersplenism can be classified into three categories by its
etiology as follows.( Yunfu et al., 2016)
Primary hypersplenism
Cause is not clear.
1. Primary splenic hyperplasia
2. Non-tropical idiopathic splenomegaly
3. Primary splenic granulocytopenia
4. Primary splenic pancytopenia
5. Splenic Anemia or thrombocytopenia
13. Secondary hypersplenism
Cause is clear
A. Infections - viral hepatitis, brucellosis, subacute or chronic diseases,
infectious mononucleosis syndrome and malaria.
B. Alcohol
C. Portal hypertension (PH) - liver cirrhosis of various causes including
Post-hepatitic Cirrhosis, Alcoholic Cirrhosis, Biliary Cirrhosis, Fatty Liver
Cirrhosis, Post-hepatitic Autoimmune Cirrhosis, Schistosomiasis-induced
Cirrhosis, & Drug-induced Cirrhosis, as well as Hemosiderosis And
Portal Vein Thrombosis.
D. Granulomatous inflammation - Systemic Lupus Erythematosus,
Rheumatoid Arthritis, Chronic Syphilis, Chronic Tuberculosis, Felty's
Syndrome, & Sarcoidosis.
14. Malignancies - Splenic lymphosarcoma, leukemia, and cancer
metastasis.
Chronic hemolytic diseases - hereditary spherocytosis,
autoimmune hemolytic anemia and thalassemia.
Lipidosis - Gaucher's disease, and Niemann-Pick disease.
Myeloproliferative disorders- Polycythemia Vera, Chronic Myeloid
Leukemia, Myelofibrosis
15. OCCULT HYPERSPLENISM
Sometimes due to benign bone marrow hyperplasia and
sufficient bone marrow compensation, peripheral
cytopenias may not occur.
In this case, hypersplenism becomes occult with no
symptoms.
Bone marrow hematopoietic function is suppressed by
factors such as infection or drugs, peripheral cytopenia
occurs, accompanied by clinical symptoms, which is not
classified as occult hypersplenism.
16. DEGREES OF SPLENOMEGALY BASED ON CRANIO-CAUDAL LENGTH
ON CT OR POST-RESECTION WEIGHT
SPLENIC LENGTH (CM) SPLENIC WEIGHT
(GM)
Normal spleen Up to 13 <300
Mild splenomegaly 13–15 300–500
Moderate splenomegaly 16–20 500–1000
Massive splenomegaly >20 >1000
gm with etiological di
agnosis
17. HACKETT’S GRADING SYSTEM FOR PALPABLE
SPLENOMEGALY
MILD-palpable <3cms below LCM
MODERATE-4-7 below LCM
SEVERE- >7cms below LCM
19. CLINICAL FEATURES
Abdominal pain/tenderness.
Early satiety due to splenic encroachment.
Symptoms of anemia due to accompanying cytopenia.
Febrile illness (infectious).
Pallor, dyspnea, bruising, and/or petechiae (hemolytic
process).
20. History of liver disease (congestive).
Weight loss, constitutional symptoms (neoplastic).
Pancreatitis (splenic vein thrombosis).
Alcoholism, hepatitis (cirrhosis).
Examination
Inspection may reveal fullness in the LUQ.
Palpation.
Percussion- Nixon, Castell, Percussion of Traube's
semilunar space.
Auscultation- may reveal a venous hum or friction rub
21. INVESTIGATION
Ultrasound -
The spleen is considered to be normal in size if its length is
<13 cm or its thickness is ≤5 cm
Plain film
The spleen is normal in size if it is
not seen on the abdominal plain
film.
It is considered enlarged
( if >6cm wide or >13.6 cm long) .
22. CT Scanning-
In general, the
spleen can be
considered
enlarged if its
craniocaudal length
is more than 10cm .
Spleen that extends b
elow the lower th
ird pole of the kidn
ey
is also indicative of
splenomegaly
23. LiverSpleen Colloid Scanning-
A splenic length of greater than 14 cm is considered enlarged on
liverspleen scan .
Erythrocytes are labeled with chromium51, mercury197 ,
rubidium81
Bone marrow examination is useful in diagnosis of
histiocytoses, lysosomal storage disorders, and some
infections(e.g., disseminated histoplasmosis).
.
24. MRI/ Doppler USG- portal/splenic vein thrombosis -
cavernomas
MRI scan- liver hemangiomas hemochromatosis
erlenmeyer flask sign(Gaucher)
PET scan - Dx & staging of lymphomas - determine
metabolic cells in spleen
Splenectomy and Splenic Biopsy
25. LABORATORY STUDIES
Complete blood cell count (CBC) with differential.
Liver function testing
Hepatitis B and C testing
Lactate dehydrogenase (LDH)
Erythrocyte sediumentation rate (ESR)
Peripheral blood smear for RBC morphology & signs of myelopr
oliferative disorders underlying bone marrow disorders.
Prothrombin time (INR) and activated partial
thromboplastin time (aPTT)
27. MEDICAL TREATMENT
Whole blood transfusion
For anemia and leucopenia
Platelet transfusion
Correction of coagulopathy
Pre-operative nutritional optimisation
Treatment of underlying cause- portal hypertension, liver
transplant for liver cirrhosis, anti-malarials for tropical
splenomegaly
28. Transcatheter embolisation method
It includes embolisation of certain
branches of splenic artery
leading to infarction of part of spleen.
PVA, gelatin sponge are used for
embolisation
Hypersplenism is relieved if
>50% of splenic area is embolised
Partial splenic embolisation
29. Role in reducing portal pressure in
hypersplenism due to portal
hypertension
Contraindications - pyemia,
splenic abscess, coagulopathy
Complications- post-embolisation
syndrome (fever, abdominal pain,
vomiting), lung atelectasis,
pleural effusion, splenic abscess,
deranged liver or renal function,
portal vein thrombosis
31. Blood grouping and Cross matching
Platelets should not be administered preoperatively in
patient with ITP
In myeloproliferative disorders - Low-dose heparin
and aspirin on the day before surgery upto 5 days
postoperatively.
Orogastric tube is used during the operation.
Preoperative embolization(massive spleen)
Perioperative steroids are usually given if a patient
had prolonged steroid treatment
32. INDICATION OF SPLENECTOMY
Absolute
Bleeding varices due to splenic vein thrombosis
Hereditary spherocytosis
Massive splenic trauma
Primary splenic malignancy
Relative
Autoimmune hemolytic anemia
Hypersplenism due to portal HTN
Idiopathic thrombocytopenic purpura (ITP)
Leukemia (chronic myeloid leukemia )
34. SURGICAL TECHNIQUE
Open Splenectomy
- in blunt abdominal trauma, staging of Hodgkin disease
an upper midline incision given.
- In hematological disorder, a left oblique subcostal
incision approximately two finger breadths below the costal
margin given.
-Preoperative angiographic embolization can be
considered to reduce bleeding in cases of massive
splenomegaly
35. Splenectomy starts with mobilization and dissection down to
an ultimate pedicle of Splenic Artery and Vein.
Transection of the ligamentous attachments, including the
splenophrenic ligament at the superior pole and the
splenocolic and splenorenal ligaments at the inferior pole.
36. After the ligamentous attachments are transected, two to six
gastric vessels should be ligated in continuity and divided
37. After these maneuvers are completed, the spleen can be
delivered into the wound by blunt dissection of the posterior
attachments.
Care should be taken not to divide the posterior
attachments too far medially to avoid entering the splenic
vein.
Dissection is carried out at the hilus as close to the spleen
as possible to avoid injury to the Pancreas.
38. Splenic artery ligation is managed by double ligation and
suture ligature, where as the splenic vein can be doubly
ligated and divided.
Ligation of the splenic artery and splenic vein in relation to the hilus
39. Three major areas to be inspected for bleeding:-
(a) the inferior surface of the diaphragm.
(b) the greater curvature of the stomach and region of the
short gastric vessels.
(c) the region of the hilus.
An integral part of splenectomy for haematological disease is
a thorough exploration to detect any accessory spleens.
40. PREOPERATIVE SPLENIC ARTERY EMBOLIZATION
(SPIGOS ET AL, 1979, )
Embolization is achieved using microcoils and/ or Gelfoam.
To reduce vascularity and size of massive spleen in
preparation for a laparoscopic approach.
Applied in the treatment of PH and bleeding
esophagogastric varices.
41. Merit
Faster Increase in platelet and leukocyte counts.
Reduces splenic size, improves pancytopenia, and
stimulates the immune system
RISKS
•Post-embolization syndrome: pain, fever, ileus, pleural
effusion
•Pancreatitis
•Splenic abscess or rupture
•Peritonitis
42. LAPAROSCOPIC SPLENECTOMY
Laparoscopic techniques is mostly preferred for elective
splenectomy.
The complicating factors are a large spleen (>500 g),
suspected perisplenitis ( infections or portal hypertension)
and previous gastric surgery.
ITP patients and staging laparotomy is suited ideally for
laparoscopic approaches as well.
43. Position- right side down
Ports-
1. At midline and 4 cm below the spleen tip,
2. Near the tip of the 11th rib along the posterior axillary line
3. Half way between the other two, along the anterior axillary
line. Occasionally, a fourth port may be required.
Scissors with cautery or preferably the harmonic Scalpel can
be used to take down the lateral peritoneal attachments and
can be used to ligate short gastric vessels.
44.
45. Ligation and division of the short gastric vessels then splenic
artery and vein secured
Specimen delivery - morselization of the spleen in a bag or port
site can be enlarged to facilitate removal
If the spleen is too large, a small Pfannenstien incision and
removing the spleen through a suprapubic area may be more
cosmetically satisfactory.
46. HAND-ASSISTED SPLENECTOMY
Hand-assisted laparoscopic surgery (HALS )
As an alternative to the LS approach with same positioning
Spleen greater than 22 cm in craniocaudal length or 19 cm in
width may benefit.
Merit
Marked reduction in average operative time.
This technique allows for a tactile feedback and atraumatic
manipulation of the enlarged spleen.
Demerit
Require a small incision (7–8 cm) for hand insertion and
specimen extraction.
47.
48. SINGLE-INCISION LAPAROSCOPIC SURGERY
(SILS)
One small transabdominal incision
Incision -periumbilical and is used as the specimen
extraction site.
Theoretical benefits of less pain and better cosmetic.
Technical challenging for solid organs- since all
instruments are closely aligned together.
Limited degrees of movement
49. ROBOTIC SPLENECTOMY
Unique three-dimensional visualization of the surgical field.
Facilitates movement with higher precision than standard
laparoscopy.
Robotic splenectomy is very similar to standard laparoscopy,
although not as cost effective.
No clear benefit of robotic versus laparoscopic splenectomy.
50. POST OPERATIVE MANAGEMENT
Remove NG tube and suction drain when drainage
is minimal (usually 24 - 48hours)
Commence oral when bowel activity resumes.
Long term oral penicillin 250mg daily.
Pneumococcal vaccine 2 weeks post op.
Anti-malaria prophylaxis.
51. COMPLICATIONS
Early
Acute gastric dilatation
Fundal ischemia- hematemesis, perforation
Pancreatic fistula
Portal vein thrombosis
Reactionary hemorrhage from splenic vessel 4% to 16% of
patients
The most common site of bleeding is the short gastric
vessels
Late
Infection; pneumococcal, viral, OPSI
Thrombocytosis
52. OVERWHELMING POSTSPLENECTOMY INFECTION (OPSI)
Incidence - 4%.
Due to reduced IgM, tuftin, properdin and other antibodies,
phagocytosis of encapsulated bacteria is defective.
Post-splenectomised patient is more prone for
Pneumococcal septicaemia (commonest), N. meningitides,
H. influenzae, Babesia microti infections.
Common in first two years after splenectomy but life long
risk present.
54. Treatment of OPSI
Antibiotics like Cefoperazone, Ceftazidime, Amikacin
Ventilatory support—ICU care.
Blood transfusion.
Immunoglobulin transfusion.
Nutrition (TPN) and maintaining of urine output.
55. PREVENTION
Pneumococcal vaccine should be given to all
splenectomised patients.
Polyvalent pneumo-vac is given 2-3 weeks prior to surgery
and repeated once in 5 years (>2 yr of age).
meningococcal vaccine (only to those who travel with high-
risk), H. influenzae ‘B’ vaccine (to all whatever the age,
once in 10 years).
In malaria endemic areas, anti-malarial prophylaxis is given
for patients after splenectomy
56. Management and treatment should therefore be
administered taking into account the specific etiology and be
individualized for each patient.
Surgical outcome following Splenectomy is usually
satisfactory.
Continuous basic and clinical studies will advance our
understanding of the underlying mechanisms of the
development of hypersplenism, and provide better
management strategies for the treatment of patients with
hypersplenism.
CONCLUSION
