General Surgery The Spleen Kingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences General Surgery The Spleen Ali Jassim Alhashli

Anatomy What are the functions of the spleen? It functions as an immunologic organ removing bacteria from the blood. Site where old RBCs (120 days) are destroyed. Site where 33% of body platelets are stored. Weight: 100-175 g. Location: LUQ between 9th-11th ribs. Boundaries: Superior: left hemidiaphragm. Inferior: colon, splenic flexure and phrenocolic ligament. Medial: tail of the pancreas and stomach (gastric impression). Lateral: rib cage. Anterior: rib cage and stomach. Posterior: rib cage. Blood supply: Arterial supply: splenic artery (a branch of the celiac trunk). Venous drainage: splenic vein which converges with superior mesenteric vein to form the portal vein draining to the liver.

Anatomy

Splenectomy What are the most common indications for splenectomy? Trauma. Idiopathic Thrombocytopenic Purpura (ITP) not responding to steroids. Mention other indications for splenectomy: Hereditary spherocytosis. Splenic abscess. Symptomatic splenic parasitic/non-parasitic cysts. Thrombotic Thrombocytopenic Purpura (TTP). Notice that treatment of choice is plasmapheresis. Chronic Lymphocytic Leukemia (CLL). Thalassemia. What are the conditions associated with splenic rupture? Blunt trauma to LUQ. Malaria. Mononucleosis. Types of splenectomy: Open. Laparoscopic. What are the complications of splenectomy? Postoperative sepsis (most common organism: S.pneumoniae). Postoperative hemorrhage. Subphrenic abscess. Thrombocytosis. Leukocytosis (increase 50% above the baseline). Injury to the tails of pancreas. Respiratory complications: atelectasis, penumonia or left pleural effusion. Pneumococcal, H.influenzae and N.meningitidis vaccines are needed for patients undergoing splenectomy. Given at day of hospital discharge or 2 weeks post-operatively. Splenectomy

What are you going to look for in physical examination of a patient presenting with splenic injury? Presence of external signs of injury. Presence of left-sided lower rib fractures. Kehr’s sign: pain radiating to the left shoulder due to splenic rupture which is irritating left hemidiaphragm. Balance’s sign: LUQ dullness to percussion Peritoneal signs (rigidity, guarding, rebound tenderness). Treatment: As you receive the patient: start with ABC, hemodynamic monitoring and focused abdominal sonography for trauma. If patient becomes stable → non-operative management: CT-scan: to identify the exact location and extent of injury. Bed rest. NG tube. Hemodynamic monitoring. Serial physical examinations and hematocrits. If patients is unstable or fails non-operative management → exploratory laparotomy Spleen is the major site of hemorrhage: splenectomy. Spleen is NOT the major site of hemorrhage: pack the area and search for more life-threatening injuries. Splenic Injury

Splenic Abscess Definition: it is the collection of pus within the spleen. Causes: Trauma. Sepsis. Infection from adjacent structure. Hematoma. IV drug use. Signs and symptoms: Fever and chills. LUQ pain. Spleen may or may not be palpable. Diagnosis: Labs: CBC (showing leukocytosis). Imaging: Ultrasound. CT-scan (better than ultrasound): areas of lower attenuation than surrounding spleen parenchyma. Treatment: splenectomy Complications: Splenic rupture. Peritonitis.