SPLENECTOMY

PRESENTER: DR PASHI VMODERATORS: PROF MUNKONGE L/

DR BVULANI

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

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

Embryogenesis of the Spleen

•

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.

Embryogenesis of the SpleenDevelopment of splenic ligaments

Congenital AnomaliesAsplenia• 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.

Peritoneal attachments of the spleen

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

Location of the spleen

Peritoneal covering of the spleen

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)

shapesAccording to Michels, the spleen has three forms

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

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

Segmental Anatomy• Bifurcation of the splenic artery into inferior

and superior segments

Segmental Anatomy

Segmental Anatomy

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

Chief splenic ligaments

Minor splenic ligaments

• The spleen has several minor ligaments, and their names indicate their connections

Minor splenic ligaments

Histology and physiology

PATHOLOGIES OF THE SPLEENHypersplenism• This is a term applied to splenomegaly

associated with the following:1. any combination of anaemia, leucopaenia, or

thrombocytopaenia;2. compensatory bone marrow hyperplasia; and3. improvement after splenectomy.

Pathologies of the spleenSplenomegaly• 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; and6. amyloid.

SURGERY OF THE SPLEENTwelve Principles of Splenic Surgery1. 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.

Twelve Principles of Splenic Surgery10. Choose an incision.11. Assess congenital anomalies and variations.12. Provide optimal postoperative care.

Trauma with ?Splenic injury

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)

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

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

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)

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

Antibiotic prophylaxis

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

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

TECHINIQUESplenectomy Due to Hemorrhage Secondary to TraumaStep 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.

TECHINIQUESplenectomy 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.

Abdominal incisions

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

Total splenectomy• Total open splenectomy (the removal of the

spleen in toto) can be performed by an anterior approach or a posterior approach

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

Ligation of the Splenic Pedicle: Anterior Approach

IncisionClamp, 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

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.

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.

Ligation of the Splenic Pedicle: Posterior Approach

Hold the spleen medially.Divide the splenorenal, splenophrenic, and

splenocolic ligamentsLift the spleen outside the peritoneal cavity,

being particularly careful with the tail of the pancreas.

Dissect rapidly and mobilize the bleeding spleen immediately.

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.

Medial position of the spleen

Compression of splenic vessels

Ligation of splenic vessels

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

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.

• 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.

Effects of splenectomyHaematological 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

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

• 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

Summary of immunisation

Summary of immunisation

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