Presented by: Dr. Rafiq M. Salhab. Alahli Hospital, Hebron. بسم الله الرحمن الرحيم Al-Quds University Faculty of Medicine Spleen in Surgery Presented by: Dr. Rafiq M. Salhab. Alahli Hospital, Hebron.

Presentation contents Embriology and Anatomy. Physiology and Pathophysiology. Evaluation of Size and Function. Indications for Splenectomy. Preoperative Considerations. Splenectomy Techniques. Splenectomy Outcomes. Dr. Rafiq Salhab 10/10/2011

Embriology and Anatomy Encapsulated mass of vascular and lymphoid tissue. Reticuloendothelial organ ( 25% of the fixed tissue macrophage population in the body). Primitive mesoderm. Differentiation and migration. Accessory spleen.(20%). Dr. Rafiq Salhab 10/10/2011

# Anatomy: Location. Dimensions. Ligaments. Blood supply. Dr. Rafiq Salhab 10/10/2011

Dr. Rafiq Salhab 10/10/2011

# Histology: Red pulp (75%): filtration system. White pulp: lymphocytes and lymphoid follicles. Marginal zone. Trabecular areas. Dr. Rafiq Salhab 10/10/2011

# Histology: Dr. Rafiq Salhab 10/10/2011

Physiology and Pathophysiology a) Storage spleens (many mammals). b) Defense spleens (Humans): Filtration: RBCs, WBCs, Platelets. Host defense: - Humoral (IGM, Tuftsin, Properdin, fibronectin). - Cell-mediated. Storage. Cytopoiesis. Tuftsin stimulates granulocyte and macrophage motility and phagocytosis. Properdin activates the alternative pathway of the complement system, Fibronectin is a macromolecule that appears to have nonspecific stimulatory activity on the processes of fibrosis and wound healing. Dr. Rafiq Salhab 10/10/2011

Splenomegaly: * weight ≥ 500 g. * length ≥ 15 cm. Palpable spleen : double the normal size. Hypersplenism: the presence of cytopenia (one or more blood cell lines) in the context of normally responding bone marrow, and improvement after splenectomy. It has two types: Primary. Secondary. Dr. Rafiq Salhab 10/10/2011

Dr. Rafiq Salhab 10/10/2011

Dr. Rafiq Salhab 10/10/2011

Evaluation of Size and Function Imaging: Preoperative evaluation. Left upper quadrant pain. Delineation of tumors or cysts. Characterization of splenic abscesses. Dr. Rafiq Salhab 10/10/2011

- no ionizing radiation. - sensitivity up to 98 % in expert hand. # Ultrasound (US): - most cost-effective. - rapid. - easy to perform. - not invasive. - no ionizing radiation. - sensitivity up to 98 % in expert hand. Dr. Rafiq Salhab 10/10/2011

- assessment of splenomegaly. - identification of lesions. # CT Scanning: - assessment of splenomegaly. - identification of lesions. - guidance for percutaneous procedure. - use of contrast material increases resolution. - staging. # MRI: more expensive than CT or US and offers no advantage. Dr. Rafiq Salhab 10/10/2011

# Angiography: not helpful as diagnostic: # Radioscintigraphy: demonstrates splenic location and size; helpful in detecting accessory spleens following unsuccessful splenectomy for ITP. # Angiography: not helpful as diagnostic: - embolizing splenic branches in trauma. - limited success in partial embolization for chronic ITP. - treatment of splenomegaly. Dr. Rafiq Salhab 10/10/2011

Dr. Rafiq Salhab 10/10/2011

Indications for Splenectomy Trauma. Pathological disorders. Red cells disorders. Platelet disorders. White cell disorders. Bone marrow disorders (myeloproliferative). Miscellaneous disorders and lesions. Dr. Rafiq Salhab 10/10/2011

Splenectomy: most common indications: Trauma. Staging for Hodgkin’s disease (in the past). ITP. Hereditary spherocytosis. Autoimmune hemolytic anemia (AIHA). Thrombotic thrombocytopenic purpura (TTP). Dr. Rafiq Salhab 10/10/2011

The spleen is the most commonly injured organ after blunt trauma. Splenic trauma: The spleen is the most commonly injured organ after blunt trauma. Splenic injuries are classified as: Class 1: capsular tear. Class 2: lacerations not extending to the hilum. Class 3: open laceration extending to the hilum. Class 4: shattered spleen. Splenectomy was the gold standard for definitive management of splenic injury. Dr. Rafiq Salhab 10/10/2011

Avoid overwhelming postsplenectomy infection (OPSI). Preservation of all or most of the injured spleen has become the preferred treatment. Avoid overwhelming postsplenectomy infection (OPSI). Dr. Rafiq Salhab 10/10/2011

# Non-operative salvage (observation): Blunt injuries (non penetrating). Stable patients without associated injuries. Class 1 and 2 (stable grade 3) may be observed. Pediatric patients: successful (85 – 90) % Adult patients: successful 70 %. Non of the class 4 and only 7 % of the class 3 can be treated successfully. Dr. Rafiq Salhab 10/10/2011

# Operative salvage: Successful in 50 % of patients after either blunt or penetrating trauma. Should be considered in stable patients with few other injuries. The highest success in class 1 and 2 injuries. The conservation of the spleen means more blood transfusion (complications). Unconscious patients should be operated. Patient over than 55 years of age. Dr. Rafiq Salhab 10/10/2011

Splenectomy is indicated: Life threatening hemorrhage from the spleen (class 3, 4) . Multiple injuries in an unstable patient. Inexperience of the surgeon. Dr. Rafiq Salhab 10/10/2011

B. Pathological disorders: Red blood cells disorders: AIHA: warm antibodies. Splenectomy is indicated for: - failure to respond to steroids. - intolerance to steroids. - requirement for excessive doses. - inability to receive steroids. * favorable response to splenectomy in 80%. Dr. Rafiq Salhab 10/10/2011

Hereditary Spherocytosis (HS): Autosomic dominant. Fragility test. Splenectomy is curative for typical forms and is the sole mode of therapy. Delay surgery in children (4-6 years). Intractable leg ulcers needs early surgery. (severe anemia and hemolysis) Prophylactic cholecystectomy in children with GBS at the time of splenectomy. Dr. Rafiq Salhab 10/10/2011

RBC enzyme Deficiencies: G6PD,PK. Hemoglobinopathies: Sickle cell disease: splenectomy is indicated: - hypersplenism. - acute sequestration crisis. - splenic abscess. Thalassemia: splenectomy is indicated for: - excessive transfusion requirements.(200cc/kg/year) - discomfort due to splenomegaly. - painful splenic infarction. RBC enzyme Deficiencies: G6PD,PK. In PK surgery is indicated for splenomegaly (delayed surgery) Dr. Rafiq Salhab 10/10/2011

Bone marrow disorders: (myeloproliferative disorders) AML; CML; CMML; ET; PV; myelofibrosis. Splenectomy is indicated for: - symptomatic splenomegaly: early satiety, poor gastric emptying, LUQ pain, and diarrhea. - hypersplenism. Dr. Rafiq Salhab 10/10/2011

White blood cell disorders: CLL; HCL; NHL; HL. Splenectomy is indicated for: - symptomatic splenomegaly. - hypersplenism. HL: splenectomy for staging. Dr. Rafiq Salhab 10/10/2011

- Affects mainly females between the ages of 15-50 years. Platelet disorders: # Idiopathic (Immune) thrombocytopenic purpura (ITP): - Affects mainly females between the ages of 15-50 years. -The spleen is palpable in less than 10% of patients. -Spontaneous regression is seen in more than two thirds of pediatric cases. -Increased bleeding time. -The response to steroids predicts the benefit from splenectomy. -About 60-80% of patients will benefit from splenectomy. Splenectomy remains the principal treatment for ITP. Platelet counts rise to adequate levels in 60% to 80% of patients who undergo the procedure. Ninety percent of patients who have had good responses to corticosteroids have improved platelet counts after splenectomy. Of patients who do not respond to corticosteroids, about 60% respond to splenectomy. Splenectomy is effective by virtue of its ability to remove the site of platelet destruction. Because the spleen is the site of most platelet sequestration in ITP, splenectomy should eliminate this source of platelet consumption. Furthermore, splenectomy removes a significant source of antiplatelet IgG production. Dr. Rafiq Salhab 10/10/2011

Treatment : to keep PLT > 30,000 ITP :continue Treatment : to keep PLT > 30,000 Corticosteroids :1-1,5 mg/kg/day for 3-6 months Intravenous immune globulin. Splenectomy is indicated for: - failure of medical therapy. - steroids side effects. - relapse.(2 during treatment) - life threatening bleeding. Splenectomy remains the principal treatment for ITP. Platelet counts rise to adequate levels in 60% to 80% of patients who undergo the procedure. Ninety percent of patients who have had good responses to corticosteroids have improved platelet counts after splenectomy. Of patients who do not respond to corticosteroids, about 60% respond to splenectomy. Splenectomy is effective by virtue of its ability to remove the site of platelet destruction. Because the spleen is the site of most platelet sequestration in ITP, splenectomy should eliminate this source of platelet consumption. Furthermore, splenectomy removes a significant source of antiplatelet IgG production. Dr. Rafiq Salhab 10/10/2011

Splenectomy is indicated for: - relapse. - multiple plasma exchanges. # Thrombotic thrombocytopenic purpura (TTP): Splenectomy is indicated for: - relapse. - multiple plasma exchanges. thrombocytopenia, microangiopathy, hemolytic anemia, fluctuating neurologic abnormalities, progressive renal failure, and fever. The cause is unknown, and the prognosis is very poor: survival is less than 10%. Treatment is generally focused on the removal of the plasma constituents that lead to platelet aggregation. Plasmapheresis is particularly effective and has decreased the 1-year mortality rate of 50% to 80% to about 10%.   Dr. Rafiq Salhab 10/10/2011

Miscellaneous disorders: # Splenic abscess: Common in tropical locations: sickle cell anemia: - thrombosed splenic vessels. - splenic infarction. Abscess formation by: 1-hematogenous spread. 2-contiguous infections. 3-hemoglobinopathy. 4-immunosuppression. 5-trauma. Dr. Rafiq Salhab 10/10/2011

Parasitic cyst(hydatid cyst). Or non-parasitic # Cyst and tumors: Parasitic cyst(hydatid cyst). Or non-parasitic (pseudocyst, dermoid, epidermoid, epithelial) Primary tumors (Sarcoma, NHL) or metastatic tumors (lung). # Storage diseases and infiltrative disorders: - Gaucher’s disease. - Niemann-Pick disease. - Amyloidosis. Dr. Rafiq Salhab 10/10/2011

# Felty’s syndrome: RA, splenomegaly, neutropenia. # Sarcoidosis. # Portal hypertension. # Splenic artery aneurysm. Dr. Rafiq Salhab 10/10/2011

Preoperative Considerations Splenic artery embolization. Vaccination: - encapsulated bacteria: S.pneumonia, H.Influenza type B, Meningococcus. - 2 weeks before planned splenectomy. - in emergency is given post operatively as soon as possible. - booster injections every 5 - 6 years. - annual influenza immunization. Dr. Rafiq Salhab 10/10/2011

DVT prophylaxis: patients with MPD. Adjustment of anemia. Adjustment of coagulation profile. Adjustment of thrombocytopenia. Antibiotic. Dr. Rafiq Salhab 10/10/2011

Splenectomy Techniques Laparoscopic: more tendency. Open Technique: Traumatic rupture. Massive splenomegaly. Ascites. Portal hypertension. Multiple prior operations. Extensive splenic radiation. Splenic abscess. Dr. Rafiq Salhab 10/10/2011

Splenectomy Outcomes Hematologic outcomes: - appearance of Howel-Jolly bodies and siderocytes. - leukocytosis: within 1 day. - thrombocytosis: within 2 days, peak (7 days). - increased hemoglobin level. Dr. Rafiq Salhab 10/10/2011

- left lower lobe atelectasis. - left pleural effusion. - pneumonia. Complications: Pulmonary: - left lower lobe atelectasis. - left pleural effusion. - pneumonia. Hemorrhagic: - intraoperatively. - subphrenic hematoma. Dr. Rafiq Salhab 10/10/2011

Thromboembolic phenomena: - DVT. - PVT. Infectious: - subphrenic abscess. - wound infection. Pancreatic: - pancreatitis. - pseudocyst. - fistula. Thromboembolic phenomena: - DVT. - PVT. Dr. Rafiq Salhab 10/10/2011

Overwhelming post splenectomy infection: Incidence 1 – 5 %. Caused by encapsulated bacteria. Mortality > 50 %. More common in children and Immuno- compromised patients. Occurs more frequently during the first 5 years of life. The risk is greatest within 2 years of surgery. Risk factors: cause of splenectomy, immunity status, interval from the date of surgery.

Dr. Rafiq Salhab 10/10/2011

Spleen position Dr. Rafiq Salhab 10/10/2011

Dr. Rafiq Salhab 10/10/2011

Dr. Rafiq Salhab 10/10/2011

Dr. Rafiq Salhab 10/10/2011

Dr. Rafiq Salhab 10/10/2011

Dr. Rafiq Salhab 10/10/2011

Dr. Rafiq Salhab 10/10/2011