surgical disease of spleen part 1

Surgical Diseases of Spleen

Outlines

1. Anatomy of the spleen2. Function of the spleen3. Splenic trauma4. Cyst, abscess5. Splenectomy

Anatomy

• Lies in the left hypochondrium between the left hemidiaphragm and the gastric fundus.

• Soft, encapsulated, oval organ of variable size, measures about 12 cm (5 in.) in length, weight about 75–250 g.

• The upper border is marked along the upper border of the ninth rib; the lower border, along the 11th rib. The medial end lies 5 cm from the midline. The lateral extension ends at the midaxillary line. **{Trauma}

• The hilum sits between the stomach and the kidney and is in contact with the tail of the pancreas.

• There is a notch on its inferolateral border.• It is usually not palpable, but may be felt in

children, adolescents, and some adults, especially those of weak build.

• A palpable spleen usually means the presence of significant splenomegaly. As a general rule, a spleen has to be doubled in size before it becomes palpable.

P.S.

• Some people have an accessory spleens (10-20%) usually seen at the hilum, greater omentum, and ligaments of the spleen.

Splenic artery• It arises from the celiac trunk and runs along

the upper border of the body and tail of the pancreas.

• It divides into superior and inferior branches, which in turn divide into several segmental branches.

Branches from the splenic artery:- Gastroepiploic artery- Pancreatic branches

splenic vein• The splenic vein is formed from several

tributaries that drain the hilum. The vein runs behind the pancreas, receiving several small tributaries from the pancreas before joining the superior mesenteric vein at the neck of the pancreas to form the portal vein.

• Proper splenic tissue has no lymphatics; however, some arise from the capsule and trabeculae and drain to the pancreaticosplenic lymph nodes.

Histology1- White pulp (lymphatic tissue)

lymphocytes Immunologic function

• The white pulp comprises a central trabecular artery surrounded by nodules with germinal centres and periarterial lymphatic sheaths that provide a lymphocytes and macrophages.

2- Red pulp Blood-filled venous sinuses and splenic cords. Contains RBC, macrophages, B & T lymphocytes, plasma cells Function: filtering RBCs & platelets. Bacteria that are filtered: encapsulated (streptococcus, H.

influenza, E.coli, GBS…).

Function1. Immune function (Immunoglobulins, Filtration).• The spleen processes foreign antigens• is the major site of specific immunoglobulin M (IgM)2. Reservoir

150-200 ml normally >> the spleen can contract in danger cases like shock to save the body.

3. Hematopoieses, in neonatal life.4. Filter function:• Macrophages in the reticulum capture cellular and non-cellular

material from the blood and plasma.• This process takes place in the sinuses and the splenic cords by the

action of the endothelial macrophages.

Splenic Trauma

Splenic Trauma

• Types :– Blunt (e.g RTA, falls)– Penetrating (e.g gunshot, knife)– Iatrogenic (e.g CPR)

Case

A 29-year old male presented with pain in the left hypochondrium for one day. This followed a road traffic accident the previous day. On examination, he was pale and the abdomen was tender with guarding.

How to approach this patient ?

• History• Physical examination• Investigation

History

• Mechanism of injury (IMPORTANT) :In RTA, note : • Position of the victim in the car• Velocity of the impact• Type of accident ( front, lateral, etc)• Information about damage to the vehicle• Whether a passenger died• Whether t person was ejected from the vehicle• The presence of alcohol or drug use.

In a fall, note:– The distance fallen– The site of anatomic impact

Clinical presentation • Pain in LUQ, produced by stretching the

splenic capsule ( most common symptom in stable pt)

• Kehr’s sign (left shoulder pain in splenic rupture ), blood irritates the diaphragm i.e referred pain >> splenic rupture.

• Peritoneal irritation (diffuse pain, rebound tenderness) is caused by extravasated blood

• Signs of shock ; hypotension, tachycardia, restlessness, anxiety. (if massive bleeding).

Physical examination

• Vital signs – vary depending on associated blood loss, not specific for injuries to the spleen

• Abdominal exam – skin abrasions, tenderness, guarding, rebound, rigidity

**a large number of pt with significant splenic injury exhibit no signs or symptoms at all

Delayed rupture of spleen : On initial presentation, no evidence of intra abdominal injury, rupture occurs > 48 hrs after trauma. It is a rare complication.

Investigation

• Labs — Hematology and chemistry laboratory tests are of limited use in the management of the acutely traumatized patient. Baseline values. ( Hb every 6 hour)

• CT scan• FAST exam• Diagnostic Peritoneal Lavage (DPL)• MRI

Focused Assessment with Sonography for Trauma (FAST)

• It is used in evaluation of the 4 acoustic window o 4P’s – pericardiac, perisplenic, perihepatic, pelvic.

• In spleen trauma the US examination focuses on dependent intra peritoneal sites where blood is most likely to accumulate:

o the hepatorenal space (ie, Morrison's pouch),o the splenorenal recess, o the inferior portion of the intraperitoneal cavity

(including pouch of Douglas).

Fluid is Anechoic

• In general, FAST is done by the doctor in the emergency room, it’s a rush procedure to discover if there is intraperitonial bleeding after the trauma.

• Since that, we couldn’t depend totally on it .. “because the patient may be hemodynamically unstable, and FAST exam results be normal !” >> so it’s not 100% sensitive.

Rx

• Hemodynamically stable pt with –ve FAST close observation, serial abdominal exam, and follow up FAST exam consider CT scan if pt is intoxicated or has other associated injuries

• Hemodynamically unstable pt with –ve FAST DPL, exploratory laparotomy

Diagnostic Peritoneal lavage (DPL)

• DPL accurately determines the presence of intraperitoneal hemorrhage in hemodynamically unstable patients and remains a valuable diagnostic tool in such cases, particularly when ultrasound is unavailable or the results of the FAST examination are equivocal.

• We insert the catheter, inject normal saline through the catheter and see the fluid that is coming out.

• put urinary cath before to avoid bladder injury.

• Grossly positive DPL > 10 mL of blood in catheter aspiration. It indicates significant hemoperitoneum

• Positive by cell count> 100,000 RBC/mm cubic

• The important note here is that those days we don’t use DPL any more because we have CT which is more diagnostic and applicable.

CT

• CT is used as golden standard diagnostic tool is Splenic trauma ..

Grading of splenic trauma“Depending in CT findings”

Notes about treatment

• If the patient come to the ER unstable, we should directly take him to the operating theater.

• If was stable, we do FAST and CT, admit his to the ICU, and put him under carful observation, so if turned unstable, to take him to the theater as fast as possible

Treatment• Non operative “conservative “

ICU – complete rest, under observation: monitor vital sign, repeat physical examination, Hct and Hb, frequent US and CT-scan.

• Operative -conservative splenorrhaphy (repair and wound suturing) -Partial splenectomy -Total splenectomy: open or laparoscopic

Hemisplenectomy with preservation of greater than 50% of splenic parenchyma.

Operative vs. non-operative

• Non-operative treatment should be considered only when:

1. Hemodynamically stable patient. 2. Grade I –II splenic injury on CT scan staging. 3. No free fluid or small amount in the abdominal

cavity. 4. No associated injuries requiring surgeries.5. No severe head injury.

• Non operative management is most successful in grade I to III, operative intervention for grade IV and V.

• Contraindicated if unstable, persistent coagulopathy, other injury requiring surgery.