SURGICAL DISEASES

OF THE SPLEEN
Done By: Mohamad Rassoul Abu-Nuwar
Omar Al-Hendi
Ghassan Faraj
 Outline
 Anatomy
 Blood Supply
 Histology
 Function
 Indications for Splenectomy
 Anatomy
 The largest lymphatic organ in the body.
 Normal weight of adult spleen is 75g-250g and measures
approximately 11 cm in length (Not palpable).
 Located in the left upper quadrant, posterior to the 9th, 10th and 11th
ribs and separated from them by the diaphragm and the
costodiaphragmatic recess.
 If one divides the spleen into three parts, the upper third is related to
the lower lobe of the left lung, the middle third to the left
costodiaphragmatic recess, and the lower third to the left pleura and
costal origin of the diaphragm.
 It has a parietal and visceral surface. The convex parietal surface is
related to the diaphragm. The concave visceral surface is related to the
surfaces of the:
 Greater Curvature of the Stomach
 Upper pole of the Left Kidney
 Left splenic fixture of the Colon
 Tail of the pancreas.
 Anatomy
 On the concave side is the Hilum: Its at an angle between the stomach
and kidney, and comes in contact with the tail of the pancreas.
 The hilar surface is the entrance and exit of the splenic vessels.
 The peritoneum covers the entire spleen in a double layer except at
the hilum.
 Associated ligaments of the spleen (double layers of peritoneum) :
 Gastrosplenic Ligament
 Splenorenal Ligament
 Splenocolic Ligament
 Phrenicocolic Ligament
 Pancreaticosplenic Ligament
 Avascular planes run through the spleen functionally dividing the
spleen. Most commonly into 2 segments or lobes (Inferior and
Superior)
 Blood Supply
 Splenic Artery:
 Originates from the Celiac Trunk
 Runs across the border of the body and tail of the pancreas before
entering the Hilum.
 Gives several branches: To the pancreas, short gastric and left
gastroepiploic arteries.
 As well many branches going to different compartments of the
Spleen. (Anastomosis is present)

 Splenic Vein:
 Formed by tributaries draining the hilum.
 Runs behind the pancreas and receives several tributaries from the
pancreas.
 Joins the Superior Mesenteric Vein at neck of pancreas to form
Portal Vein
 Misc.
 Nerves: Sympathetic nerve fibers run from coeliac plexus and
innervate splenic arterial branches.
 Lymphatic:
 Comprises of efferent vessels in the white pulp that run with
arterioles and emerge from nodes at the hilum.
 These nodes are drained via the supra and infrapancreatic
nodes then to the celiac nodes.
 Accessory Spleens:
 Around 20-30% of the population are inflicted.
 60% have one accessory spleen, the rest have 2 or more.
 They are located at or near the hilum, embedded within the
tail of the pancreas, around the splenic artery or within the
omentum
 Histology
 Surrounded by serosa and collagenous capsule that
contains smooth muscle fibers
 Supported by collagenous capsule and reticular
framework
 The parenchyma consists of red and white pulp.
 Red pulp: Composed of sinusoids and splenic cords
containing Macrophages, B & T Cells, plasma cells and
other blood elements.
 White Pulp: Composed of lymphoid tissue and many
lymphocytes. Most importantly produces
immunoglobulins.
 Overall flow rate is 300ml/min.
 Splenic pulp pressure represents the pressure of the portal
system.
 Functions
 Immunological:
 Active immune response through humoral and cell-mediated pathways
(White Pulp) and blood filtration.
 Production of Opsonins, Tuftsin and Properdin.
 Filtration:
 Endothelial macrophages in the cords and sinuses removes cellular and non-
cellular material from plasma(Red Pulp).
 Removes encapsulated bacteria (H. Influenza, pneumococci, meningococci).
 Removes particulate inclusions; such as, Howell-Jolly and Heinz bodies.
 Hematopoietic:
 From the fourth month of intrauterine life to early neonatal period.
 In certain diseases such as thallasemia.
 Reservoir:
 Normally holds 150-250ml of blood or approximately 8% of red cell mass.
 An enlarged spleen can hold up to 1-3L of blood.
 Splenectomy Indications
 Trauma
 Hemolytic anemia
 Hereditary spherocytosis
 Thalassemia etc.
 Idiopathic thrombocytopenic purpura (ITP)
 Hypersplenism
 Proliferative disorders
 Myelofibrosis
 Tumors of the spleen
 Non Hodgkin's lymphoma
 Hemangioma
 Metastasis
 Cysts
 Trauma
 Etiology:
 Can be: Blunt to lower 6 ribs(RTA most common), Penetrating( e.g. Gunshot,
knife), Explosive(in war).
 Preexisting illness can markedly increase the risk & severity of splenic injury(e.g.
Infectious mononucleosis, malaria, and hematologic abnormalities)

 Presentation:
 LUQ pain and tenderness
 Left shoulder pain(Kehr’s sign).
 Diffuse abdominal pain, peritoneal irritation, and rebound tenderness with free
intraperitoneal blood.
 If the intra-abdominal bleeding exceeds 5-10% of blood volume, clinical signs of
early shock may manifest.
 Abdominal exam : skin abrasions, decrease movement with respiration, (rebound)
tenderness, guarding, & rigidity.

*A large number of patients with significant splenic injury exhibit no signs or symptoms
at all
 Trauma
 Classification:
 Grade I - Subcapsular hematoma of <10% of surface area.
Capsular tear of <1 cm in depth
 Grade II - Subcapsular hematoma of 10-50% of surface area.
Intraparenchymal hematoma of < 5 cm in diameter. Laceration
of 1-3 cm in depth and not involving trabecular vessels.
 Grade III - Subcapsular hematoma of > 50% of surface area or
expanding, ruptured subcapsular or parenchymal hematoma.
Intraparenchymal hematoma of > 5 cm or expanding. Laceration
of > 3 cm in depth or involving trabecular vessels.
 Grade IV - Laceration involving segmental or hilar vessels with
devascularization of > 25% of the spleen.
 Grade V - Shattered spleen or hilar vascular injury.
 Trauma
 Management:
 History & Examination
 Diagnostic Peritoneal Lavage(DPL)
 Positive results :>10mL blood aspirated by catheter, or after
infusion of 1L crystalloid fluid, there is >100,000 RBC/mm3,
>500WBCs/ml, amylase >200 units, presence of bile, bacteria .
 It is very accurate, sensitive and specific

 Focused Assessment with Sonography for Trauma (FAST)

 Performed by ER physician or surgeon.
 Rapid, portable, noninvasive.
 Can identify as little as 70ml of fluid/blood in peritoneal
cavity.
 FAST has replaced DPL in many institutions
 Trauma
 Management:
 CT Scan(with contrast)
 Detect IA fluid/air.
 Identifies the presence and severity of solid organ injury.
 Have the capability to determine source of
hemorrhage(unlike DPT or FAST).

Unstable patients can be assessed by FAST or DPL in

addition to clinical examination but should not
undergo CT scanning of the abdomen for
diagnosis
 Trauma
 Treatment:
 Can be: Non-operative or operative
 Non-operative management is most successful in
grades I-III, whereas operative intervention for grades
IV-V.

 Non-Operative:
 Observe patient in ICU, complete rest, frequent US and
CT to make sure the patient is under control
 Operative:
 Conservative : Partial Splenectomy, splenorrhaphy
 Total Splenectomy : Open vs. laparoscopic
 Hereditary Spherocytosis
 Autosomal Dominant Disease.
 RBC’s are spherical, fragile and destroyed in the
spleen.
 Diagnosed by osmolarity fragility test.
 Results in anemia, jaundice, and splenic enlargement.
 Disease of remission and relapse that requires
repeated blood transfusions.
 30-60% have pigment gallstones.
 Splenectomy indicated when health is impaired
(presence of severe hemolytic crisis and gallbladder
disease are present).
 Acquired Hemolytic Anemia
 Excess hemolysis due to exposure to chemicals,
drugs, infection or even immune mediated.
 In autoimmune hemolysis RBC’s are coated
with auto antibodies.
 Coombs Test is positive.
 Autoimmune hemolytic anemia more common
in middle aged women and causes severe
hemolytic crisis.
 Treatment is steroid therapy initially; however,
Splenectomy is indicated if steroids fail.
 Idiopathic Thrombocytopenic Purpura (ITP)

 Auto antibodies causes premature removal of the platelets

 Associated with increased megakaryocytes in the bone
marrow.
 Purpura, epistaxis, and gingival bleeding are common.
 Rarely GI, GU, and intracranial hemorrhage.
 Platelet count under 50k & Spleen enlarged in 2-3% of
patients.
 The acute form is often found in children, where at least 70%
patients have spontaneous remission within 6 months
 The chronic form (adults) characterized by a course of
remission and relapse over years.
 Initial therapy is steroids but Splenectomy is indicated if
steroid therapy does not result in rapid remission.
 Hypersplenism
 Syndrome consist of splenomegaly, pancytopenia, normal
bone marrow and absence of autoimmune disorder
 May be secondary to a number of disorders e.g.
rheumatoid arthritis, malaria, tuberculosis.
 Hypersplenism  increase blood volume needed to fill
the vascular spaces  increase blood pooling in spleen 
increase destruction.
 In peripheral blood, there is anemia, thrombocytopenia,
and leucopenia.
 Bone marrow turnover is increased with reticulocytosis
and leucoerythrombocytosis
 Increased amounts of urobilinogen in the urine.
 Splenectomy relieves the pancytopenia.
 Myelofibrosis
 Proliferation of a abnormal Bone Marrow stem
cell resulting in fibrosis or replacement of
marrow with collagen CT.
 Pancytopenia develops thus Extra Medullary
hematopoiesis occurs at the liver and spleen.
 Resulting in splenomegaly which eventually
causes blood sequestration and blood
transfusion proves unhelpful.
 Splenectomy reduces the transfusion
requirement and relieves the symptoms.
 Tumors
 Non-Hodgkin’s lymphoma (most common)
 Splenectomy is indicated if primary neoplasm is
confined to the spleen.
 Hemangioma
 Rare but most common of the benign neoplasms
 Enlargement is indicative for surgery.
 Splenic rupture may occur in about 25% cases
 Metastasis (Not uncommon)
 Normally comes from melanoma, breast, lung,
renal, and ovarian carcinomas.
 Cysts
 Uncommon, usually single but occasionally multiple.
 If a small cyst it is usually removed under
laparoscope.
 If large and the spleen is highly affected, total
splenectomy is indicated.
 Can be:
 Congenital cyst: Dermoid
 Degenerative cyst from liquefaction or infarct
 Parasitic cyst (Hydatid cysts  Echinococcus Granulosus)
 Normally affects the liver and lungs rarely the spleen
 Pre-Op Preparations
 Blood components:
 Full blood count and coagulation status
 Bleeding tendencies may need a blood transfusion, FFP, or
Platelets.
 In Thrombocytopenia platelets are needed during and
postoperatively.
 Decompression of stomach to facilitate handling of short gastric
vein.
 Vaccination:
 Tripivax (H. influenza, pneumococci, & meningiococci) is given
2-3 weeks before operation.
 This is to prevent Post-Splenectomy Overwhelming Sepsis
(PSOS).
 Post-Op Complications
 Left Lower Lobe Atelactasis (most common)
 Hematologic changes : Howell-Jolly bodies,
Siderocytes, Leucocytosis(neutrophillia) & increased
platelets.
 Hemorrhage
 Acute Gastric dilatation
 Iatrogenic Trauma
 Thrombosis
 Infections
 Post Splenectomy Overwhelming Sepsis
(PSOS)
 Caused by encapsulated bacteria ( Strep Pneumoniae,
Meningiococcus, H. Influenza). Bacteria cannot be
opsonized.
 Begins with mild, non-specific influenza like symptoms
and progress to high fever, devastating bacteremia,
thrombosis, DIC, shock and finally death.
 Greatest risk in the first 2 yrs of life.
 Prevention : vaccine, prophylactic antibiotics until 18
y/o in children and 2-3 years in adults.
 Acute Management: Cefotaxime or Ceftriaxone IV
usually with Vancomycin.
 IV Levofloxacin can be used in cases of allergies.
THANK YOU