postgraduate surgery presentation

1. SPLENECTOMY
PRESENTER: DR PASHI V
MODERATORS: PROF MUNKONGE L/
DR BVULANI

2. HISTORY
• Hua To (115-205 A.D.) Performed possible
splenectomies in China
• Zaccarelli 1549 Performed one of the earliest
splenectomies (many have argued that it was an
ovariectomy instead)
• Rosetti 1590 First successful partial splenectomy
• Matthias 1678 Performed the first successful
splenectomy for trauma
• Smith 1957 Reported the first severe infections
following splenectomy for traumatic rupture
• Carroll et al. 1992 Reported successful
laparoscopic splenectomy

3. Embryogenesis of the Spleen
• The spleen which is the largest of the
lymphatic organs arises from mesoderm
• In the 5th to 6th week there is formation of
greater omentum from the expanding dorsal
mesogastrium
• the embryogenic mechanisms take place on
the left side of the dorsal mesogastrium, at
the left upper quadrant
• The left side of the dorsal mesogastrium gives
rise to the splenic ligaments

4. Embryogenesis of the Spleen
•

5. Embryogenesis of the Spleen
• Development of splenic ligaments
• With the possible rotation of the stomach, the
left surface of the mesogastrium becomes
fused to the peritoneum over the left kidney.
• The splenic artery is found posterior to the
lesser sac and anterior to the left kidney.
• It is enveloped by the splenorenal ligament,
which is the posterior portion of the dorsal
mesogastrium.
• Mesenchymal cells differentiate to form both
the capsule and a connective tissue
framework.

6. Embryogenesis of the Spleen
Development of splenic ligaments

8. Congenital Anomalies
Asplenia
• Asplenia is autosomal recessive, while splenic
hypoplasia is autosomal dominant.
Polysplenia
• It is distinct from accessory spleen, in which the
normal spleen is present but is joined by one, two,
or more splenic nodules of small size that are
completely separated from the main organ.
Wandering Spleen
• The ligaments may be abnormal (too long, too
short, too wide, too narrow, abnormally fused) or
absent.

9. Peritoneal attachments of the spleen

10. GROSS ANATOMY OF THE SPLEEN
• The spleen is located in the left hyponchondrium
• Associated with the posterior portions of the left
9th, 10th, and 11th ribs
• The spleen has two surfaces: parietal and visceral
• The convex parietal surface is related to the
diaphragm
• the concave visceral surface is related to the
surfaces of the stomach, kidney, colon, and tail of
the pancreas.
• A double layer of peritoneum covers the entire
spleen, except for the hilum

11. Location of the spleen

12. Peritoneal covering of the spleen

13. Shape and size
• The size of the spleen in children is dependant
on actual age.
• < 6cm at 3/12, 6.5cm at 6/12, 7cm at 12/12,
8cm at 2yrs, 9cm at 4yrs, 9.5cm at 6yrs, 10cm
at 8yrs, 11cm at 10yrs, 11.5cm at 12yrs, 12cm
at 15yrs or older for girls and 13cm at 15yrs or
older for boys. (Rosenberg HK et al, 1991)

14. shapes
According to Michels, the spleen has three forms

16. Surgical Applications
• A patient with fractures of the left ninth to
eleventh ribs should be observed closely
• In a child, the spleen may rupture without rib
fractures
• In splenomegaly, the spleen is always located in
front of the splenic flexure of the colon
• Adhesions are almost always present and are
sometimes vascular
• In elective splenectomies, intestinal preparation is
essential if splenomegaly is present
• The size of the spleen will dictate the type of
incision

17. Segmental Anatomy
• Important for segmental resection
• There is no consistent segmental arterial
anatomy
• The spleen is formed by the fusion of
vascularized, isolated mesenchymal aggregates.
• Segmentation of the spleen appears to be
variable
• Gupta et al. reported that the spleens
examined had two lobes or three lobes

18. Segmental Anatomy
• Bifurcation of the splenic artery into inferior
and superior segments

19. Segmental Anatomy

20. Segmental Anatomy

21. 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 gastrosplenic ligament contains the short
gastric arteries above and the left
gastroepiploic vessels below
• The splenorenal ligament envelops the splenic
vessels and the tail of the pancreas

22. Chief splenic ligaments

23. Minor splenic ligaments
• The spleen has several minor ligaments, and
their names indicate their connections

24. Minor splenic ligaments

26. Histology and physiology

28. PATHOLOGIES OF THE SPLEEN
Hypersplenism
• This is a term applied to splenomegaly
associated with the following:
1. any combination of anaemia, leucopaenia, or
thrombocytopaenia;
2. compensatory bone marrow hyperplasia; and
3. improvement after splenectomy.

29. Pathologies of the spleen
Splenomegaly
• The causes of splenomegaly are numerous but
may be grouped together under the following
headings:
1. congestion;
2. infection;
3. haematological disorders;
4. immune disorders;
5. storage disorders; and
6. amyloid.

30. SURGERY OF THE SPLEEN
Twelve Principles of Splenic Surgery
1. Know surgical anatomy.
2. Know clinical and surgical pathology.
3. Know surgical procedures.
4. Perform a physical examination.
5. Assess the diseased spleen.
6. Know how to treat a ruptured spleen.
7. Perform adequate preoperative preparations.
8. Adhere to operating room rules.
9. Place the patient in a convenient position.

31. Twelve Principles of Splenic Surgery
10. Choose an incision.
11. Assess congenital anomalies and variations.
12. Provide optimal postoperative care.

32. Trauma with ?Splenic injury

34. Preoperative Preparation
• Consent
• FBC, U&E, G&H (consider Xmatch)
• Platelets may be required
• Peri-operative antibiotics – usually IV cefazolin
at Induction, to continue for 24hours
• Pneumococcal vaccine 2weeks prior to surgery
(in emergency, it is given 2 weeks post op)

35. Consent
• Laparoscopic splenectomy, where possible, is
now the standard of care. Alternatively open
(left subcostal incision)
• Wound infection, incisional hernia,
haemorrhage, subphrenic abscess, pancreatic
pseudocyst, gastric fistula/perforation
• Those with myeloproliferative disorders have
higher risk of bleeding and thrombosis
• Overwhelming post splenectomy infection

36. Infection Risk in Splenectomised
patients
The risk of post-splenectomy sepsis is greatest in
the following groups:
• younger children
• early in the post-operative course (up to 2 years)
• individuals with an underlying haematologic
disorder
• immune suppressed children - eg cancer disease
• Streptococcus pneumoniae (pneumococcus) is the
commonest pathogen

37. Immunisations
• No vaccines are contraindicated for
splenectomised /hyposplenic patients.
• Ensure patient is up to date with routine
immunisations according to National
Immunisation
• Schedule, especially pneumococcal,
Haemophilus influenzae type b (Hib)

38. Immunisation
• Additional immunisations are recommended
for asplenia/hyposplenia; commence
immunisation programme as soon as
condition is recognised.
• For elective splenectomy extra immunisations
should be commenced as soon as possible and
at least 2 weeks pre-operatively
• For emergency splenectomy commence
immunisations 2 weeks post-operatively

39. Antibiotic prophylaxis
• Some children may require long term
antibiotic prophylaxis against pneumococcal
infection (with amoxicillin, penicillin or
erythromycin if beta lactam allergy)

40. TECHINIQUE
• 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

41. TECHINIQUE
Splenectomy Due to Hemorrhage Secondary to
Trauma
Step 1. Make an incision.
Step 2. Mobilize the spleen.
Step 3. Ligate the vessels.
Step 4. Divide the hilum.
Step 5. Obtain hemostasis.
Step 6. Provide drainage.
Step 7. Close the wound.

42. TECHINIQUE
Splenectomy Due to Hematological Disorders
(Hypersplenism)
Step 1. Make an incision.
Step 2. Ligate the arteries.
Step 3. Mobilize the spleen.
Step 4. Divide the hilum.
Step 5. Obtain hemostasis.
Step 6. Search for accessory spleens.
Step 7. Provide drainage.
Step 8. Close the wound.

43. Abdominal incisions

44. 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

45. Total splenectomy
• Total open splenectomy (the removal of the
spleen in toto) can be performed by an
anterior approach or a posterior approach

46. • a well-developed presplenic fold, six sheets of
peritoneum, fat, lymph nodes, and pancreas
fused into a single mass

47. Ligation of the Splenic Pedicle:
Anterior Approach
Incision
Clamp, incise, and ligate the left part of the
gastrocolic ligament and the gastroepiploic
artery and vein.
Locate the splenic artery at the superior
border of the body of the pancreas. Carefully
ligate the artery in continuity and doubly, with
ligatures being placed as distally as possible

49. Clamp, divide, and ligate the short gastric arteries
and veins, one at a time.
Mobilize the spleen by dividing the several
ligaments with scissors. Insert the index finger
deeply to separate the spleen from the renal
covering. With the use of sharp and blunt
dissection, clamp, divide, and ligate the
splenocolic and splenophrenic ligaments.
Elevate the spleen, tail, and part of the body of
the pancreas, being particularly careful with the
tail of the pancreas. The spleen is now outside the
peritoneal cavity and is attached only by one of
the branches of the splenic arteries and veins.

50. Close to the hilum, clamp, divide, and ligate all
branches of the splenic artery, the splenic vein
should not be clamped. Ligate and divide the
splenic vein and branches in continuity with
2–0 silk.
Inspect the site for bleeding, beginning with
the diaphragm and continuing to the greater
curvature of the stomach, pancreatic tail,
gastrosplenic ligament, splenorenal ligament,
splenocolic ligament, and splenic bed and
other ligaments.

52. Ligation of the Splenic Pedicle:
Posterior Approach
Hold the spleen medially.
Divide the splenorenal, splenophrenic, and
splenocolic ligaments
Lift the spleen outside the peritoneal cavity,
being particularly careful with the tail of the
pancreas.
Dissect rapidly and mobilize the bleeding
spleen immediately.

53. Bleeding can be controlled by manually
compressing the splenic artery and vein and
the tail of the pancreas between the thumb
and index finger or with a noncrushing clamp
Ligate the arterial and venous branches close
to the hilum using 2–0 and 3–0 ligatures.
Doubly ligate the splenic artery
Ligate the short gastric vessels.
Remove the spleen and secure any bleeding
points.
Close the abdominal wall.

54. Medial position of the spleen

55. Compression of splenic vessels

56. Ligation of splenic vessels

57. Partial splenectomy
• Decision is based upon the age of the patient,
the condition of the patient, and the condition
of the spleen.
• Procedure of choice:
• Splenorrhaphy
• Splenorrhaphy with omental fixation
• Debridement, perhaps with partial
splenectomy and omental fixation
• Splenic mesh wrap
• Autotransplantation

58. Technique of Intrasplenic Dissection
• With scalpel, make a superficial anterior
incision of the splenic capsule on the viable
side of the line of demarcation.
• Using the scalpel handle, gradually deepen the
incision until the entire spleen has been
divided.
• Ligate all vessels with hemoclips or with
figure-of-eight 4–0 silk.

59. • In partial splenectomy or a deeply lacerated
spleen, use absorbable mesh.
• Observe the splenic remnant for 10 min to
ascertain the completeness of hemostasis.
• The surgeon should determine whether
drainage is required.

64. Effects of splenectomy
Haematological effects
• capacity of the spleen to remove immature or
abnormal red cells from the circulation reduces
• The red cell count does not change, but red cells
with cytoplasmic inclusions increases
• Target cells, reticulocytes and siderocytes appear
within a few days of operation.
• Granulocytosis occurs immediately after
splenectomy
• The platelet count is usually increased

65. Postsplenectomy sepsis
• the younger the patient undergoing splenectomy
and the more severe the underlying condition,
the greater is the risk of developing
overwhelming postsplenectomy sepsis
• Streptococcus pneumoniae, Haemophilus infl
uenzae and meningococci are the most common
pathogens.
• The risk of fatal sepsis is less after splenectomy
for trauma.
• For planned procedures a polyvalent
pneumococcal vaccine should be given prior to
splenectomy

66. • The vaccine is only effective against 80% of
pneumococcal organisms.
• it is recommended that prophylactic penicillin
be given for two years after splenectomy
• Antibiotic prophylaxis is essential in children
under two years of age.
• Some authorities believe that antibiotic
prophylaxis should be continued for life.
• Vaccination against H. influenzae type b (HiB)
and meningococci A and C should also be
given

67. Summary of immunisation

68. Summary of immunisation

69. References
• Andrew T Raftery, applied basic sciences for
basic surgical training, second edition, 2008
• Skandalakis L. Skandalakis J. Surgical anatomy
and techinique, fourth edition, 2014
• Skandalakis’ surgical anatomy, skandalakis
TOC.mht
• www.slideshare.com