Surge - Spleen 2008

SPLEEN EMMANUEL G. DIAZ, MD, MHA, FPCS, FPSGS Department of Surgery De La Salle University Medical Center

SU RGI CAL ANA TOM Y    

Located at the left upper quadrant Arise from the mesoderm Evident during the 5th week of pregnancy Has a notch at the anterior border

SU RGI CAL ANAT OM Y 7 – 11 cms in length 150 gm average weight Wedge-shaped with colic, gastric, renal & pancreatic impressions  diaphragm separates it from left lower lung & left 9th – 11th ribs   

SU RGI CAL ANAT OM Y 4 Suspensory ligaments of Spleen 1. 2. 3. 4.

Splenocolic Gastrosplenic ** Phrenosplenic Splenorenal

SU RGI CAL ANAT OM Y Vascular supply Splenic artery Short gastric vessels Splenic vein

HI STO LOGY 3 Elements of Splenic Parenchyma 1. Outer red pulp – cords & sinuses 2. Middle marginal zone – plasma cell 3. Inner white pulp – lymphoid tissues

PH YSI OL OGY Basic functions of the Spleen 1. 2. 3. 4.

Filtration Immunologic Storage Cytopoiesis

Di agnost ic Procedures for Spleni c Imagin g 1. 2. 3. 4.

Ultrasound ( US ) Computed Tomography ( CT ) Magnetic Resonance Imaging ( MRI ) Radioscintigraphy

Di agnost ic test s for Spleni c Di sor ders      

Angiography Plain & contrast radiography Diagnostic Peritoneal Lavage ( DPL ) Bone marrow cytology Coomb’s test Laparoscopy

INDI CA TIONS FOR SP LENECT OMY 1. Red cell disorders 2. White cell disorders 3. Platelet disorders 4. Bone marrow disorders 5. Various diseases – abscess, cysts, tumors, trauma, portal hypertension, vascular diseases

SPL ENI C ABSCESS  Becoming rare occurrence  Routes of Infection 1. 2. 3. 4. 5.

hematogenous ( 75% ) direct contiguous trauma immunosuppression hemoglobinopathy

SPL ENI C ABSC ESS Clinical Manifestations -

LUQ pain fever leukocytosis painful splenomegaly

SPL ENI C ABSCESS  Diagnosis - US , CT Scan  Treatment - broad spectrum antibiotics - percutaneous drainage - splenectomy

SPL ENI C CYST Classification 1. Primary ( True ) a. Parasitic b. Non-parasitic 2. Secondary ( False ) a. Traumatic b. Inflammatory

SPL ENI C CYST Clinical Manifestations due to : 1. mass effect 2. pressure & adhesion 3. complications

SPL ENI C CYST Diagnosis -

History & physical examination US CT Scan MRI

Treatment - Splenectomy

SPL ENI C TUM ORS     

Poor medium for malignant cell growth Metastatic lesions from lung, breast Non-Hodgkin’s lymphoma Angiosarcoma Hemangiomas

SPL ENI C TU MO RS Clinical Manifestations -

anorexia weight loss body weakness splenomegaly

SPL ENI C TU MO R  Diagnosis - US - CT Scan - Peripheral smear - Percutaneous biopsy - Laparoscopy  Treatment - Splenectomy

SPL ENI C ARTE RY ANE URY SM    

most common visceral artery aneurysm 4x more common in elderly females 2 cm size is indication for surgery presence of circular calcification at LUQ on x-ray is diagnostic

Treatment - excision or ligation

SPL ENI C INJURY increasing incidence young male > females blunt abdominal trauma ** - most common  Iatrogenic injuries result from undue traction during surgery   

SPL ENI C INJURY Clinical Manifestations - signs & symptoms of hypovolemia - Kehr’s sign , Ballance sign - peritoneal irritation - left lower rib fracture - hematuria

SPL ENI C INJ URY Diagnosis - History & PE - anemia & decreasing hematocrit - leukocytosis - US , CT Scan , DPL - laparoscopy

SPL ENI C INJ URY  Treatment depends on extent of injury  Splenic Injury Scale ( AAST 1994 ) Grade I – subcapsular hematoma < 10% laceration < 1 cm Grade II – subcapsular hematoma 10 – 50% laceration 3 cm Grade III – subcapsular hematoma > 50% laceration > 3cm Grade IV – deep hilar laceration Grade V – shattered spleen

SPL ENI C INJURY Treatment Options : 1. Non-operative management 2. Operative management

SPL ENI C INJ URY Criteria for Non-operative management 1. 2. 3. 4. 5.

Hemodynamic stability Negative abdominal examination CT Scan injury grade I, II or III Younger age group No liver pathology

SPL ENI C INJ URY Clinical signs of failure of non-operative management : 1. 2. 3. 4. 5.

persistent tachycardia hypotension worsening abdominal findings falling hematocrit persistent ileus

SPL ENI C INJ URY Delayed splenic rupture - latent period of Baudet - occurs 2 – 7 days post trauma - minor capsular or parenchymal hemorrhage or laceration - diagnosis & treatment as above

SPL ENI C INJ URY Operative management -

salvage vs splenectomy midline laparotomy incision packing with hemostatic pads fibrin glue , cautery , coagulator Splenorrhaphy , partial splenectomy Splenectomy ( open or laparoscopic )

SPL ENI C INJURY Complications of Splenectomy 1. 2. 3. 4. 5.

Pulmonary Hemorrhagic Infectious Pancreatic Thromboembolic

SPL ENI C INJ URY Overwhelmimg Postsplenectomy Sepsis ( OPSS / OPSI ) - highest incidence in children - causative agents: S. pneumonia H. influenza E. coli N. meningitidis

OP SS / OPSI Clinical Manifestations - fever - muscle & headaches - vomiting & diarrhea - abdominal pain - septic shock - DIC

OP SS / OPSI     

Uncommon but fatal No current diagnostic test Risk remains until 2 years postoperative Polyvalent vaccine Penicillin administration

TH ANK Y OU