Dr.P.THAMILSELVAM.

MS
SENIOR LECTURER, IMU
GENERAL & LAPARASCOPIC
SURGEON
• Dear students, This is only for your
revision and NOT A FULL TEXT.
 Spleen
Organum Plenum Mysterium

Anatomy,
Functions,
Rupture &
Hypersplenism.
 Largest lymphoid organ
• Shape-Like a segment of orange
Devoleped from dorsal mesogastrium
• diaphragm superiorly.
• Transverse colon-Inferiorly
• gastric impression-Anterirly.
• Kidney-Posteriorly
SPLEEN
SPLEEN IN SITU
SPLEEN
Normal Appearance
 Functions of the spleen

1.Immune function —immunoglobin M (1gM)

production. The nonspecific opsonins ,tuftin and
properdin are synthesised.
2.Filter function —macrophages pneumococci.
3 •Removal of effete, platelets and red cells —this
process is called ‘culling’.
4• Pitting —removing particulate inclusions from
red cells and returning the repaired red cell to the
circulation.
malarial parasites can be removed by this process
without destroying the cell.
 Functions of the spleen.cont

5•Iron reutilisation —
return the iron to the plasma.
6•Pooling — up to 30—40 per cent of blood
platelets are sequestered within the spleen.
platelet destruction,
-thrombocytopenia.
7•Reservoir function —in animals,
-not occur in humans.
8.Haematopoiesis—occurs up to the fifth intra-
uterine month and thereafter in certain
disease states.
 Trauma

Blunt
Penetrating
 Trauma to Spleen

• Presentation :
• History / Assymptomatic
• Abd. Pain
• # Ribs
• Ref. pain – Lt. shoulder KEHR’S SIGN
• Progressive Anaemia – serial HCT
• Shock
 Grading – Splenic Injuries
• Grade 1 – Minor subcapsular tear or
haematoma
• Grade 2 – Parenchymal injury not
extending to the hilum
• Grade 3 – Major parenchymal injury
involving vessels and hilum
• Grade 4 – Shattered spleen
Sub capsular injury

Capsular injury
Parenchymal injury

Simple type
Transection

Complex type
Hilar vessel injury

Appendix
 Diagnosis
Serious Injury
Less Acute Injury
TC Increased

Imaging- P Abd. Film

U/S - FAST
CT + Contrast
DPL
 Plain X-ray of the abdomen

• — obliteration of the spleenic outline;

• — obliteration of the psoas shadow;
• — indentation of the left side of the
gastric air bubble;
• — fracture of one or more lower ribs of the
left side;
• — elevation of the left hemidiaphragm;
• -free fluid between gas-filled intestinal
coils.
• - Downward displacement of spleenic
flexure
 USG ABDOMEN
• SOLID ORGAN INJURY(SPLEEN OR
LIVER)
• FREE FLUID COLLECTION
PERISPLEENIC AREAS AND
PERITONEAL CAITY
• OTHER ASSOSIATED INJURIES
Some time CT , MRI are indicated
Rupture of a malarial spleen

In tropical countries this is not an

infrequent catastrophe.
The delayed type of rupture (following
‘trivial’ injury) is also very common
Target should be perfect
Splenectomy-Indication in general

• Trauma Gr. IV & V

• Removal en bloc –
Radical
Gastrectomy
• Spherocytosis / ITP
• Hypersplenism
• PHT in association
with shunt or
Variceal Surgery
• Staging Laparotomy
Splenectomy - Indication in trauma

• Penetrating injury
• Irreparable injury Gr.IV / Gr.V
• HD instability
• Coagulpathy, HT, premorbids that
precludes lengthy surgery
• Polytrauma – no time for repair
Splenectomy
Splenectomy
Laparascopic Splenectomy
Splenectomy – the only option ?

• Non operative management

• Spleen preserving procedures
• Minor Lacerations - Haemostatic gel
,Abs. Mesh
• Larger Injuries – Debridement & suture
repair
• Wrap – absorbable mesh
• Autotransplantation – Omentum
Non operative
Splenic haematoma - initial
Regression of haematoma
Partial Splenectomy
 Delayed Splenic Rupture

• IP Hge contained by peritoneal folds /

omentum
• Breakdown of haematoma &
liquefaction of cells – expanding the
size – Incr. pressure – leading to
rupture & haemorrhage .
• Incidence – 5 %
• 2-3 weeks , months or years later
 Survey Centers as to
Protocol for Immunization
• >2 weeks before splenectomy
– Pneumococcal
– H. flu
– Meningococcal
• EDUCATION
• Antibiotic prophylaxis
– Variable compliance
 Splenectomy – Complications

• Bleeding
• Atelectasis /Pneumonia /Pleural effusion
• Pancreatitis Gastric injury / Fistula
• Thrombocytosis
• Subphrenic Abscess
• OPSI
 OPSI
(Overwhelming Post- Splenectomy Infection)

• 80 % - young children
• Mortality – 50% to 80%
• Capsulated bacteria – filter lost
• Site of maturation of NK cells, T helper
& T cytotoxic suppressor cells
• Def. prod. – opsonins , properdin &
tuftsin
• IgM & IgG – levels decrease
 Prevention
• Preserve as much as possible
• Pneumovax
• Prophylactic Antibiotics – prolonged
• Patients are cautioned to report in the
presence of suspected infections
 Vaccine
• As early , after splenectomy , repeated
every 4to5 yrs
• Elective 1/52 before
• Effective against only 80 % , prophylactic
antibiotics for prolonged period to prevent
infection
 Hypersplenism
• This is a pancytopenia occurring in
patients an enlarged spleen
• - due to large numbers of cells being
pooled and destroyed
• the spleen's reticuloendothelial system,
and haemodilution because of an
increased plasma volume.
• It can present with symptoms of
anaemia, infection, or bleeding
 Hypersplenism
• Bone marrow biopsy shows normal or
hyperplastic marrow.
• Splenic sequestration crisis may
develop in young children with sickle
cell anaemia
• can precipitate hypovolaemic shock
and death, and is an indication for
splenectomy
 Splenomegaly

• Tropical splenomegaly
• portal hypertension
• Felty’s syndrome –Arthritis with Neutropenia
• Tuberculosis
• Schistosomiasis- Schistosoma mansoni
Schistosoma haematobium
• Neoplasms
• Porphyria -a hereditary error
• Gaucher’s disease-storage of abnormal lipoids,
• Leukaemia
• Abscess of the spleen
Splenomegaly