Introduction

 Spleen is a lymphatic organ connected to the blood

vascular system
 It acts as a filter for blood and plays an important role
in the immune response of the body
Development
 Cephalic part of dorsal mesogastrium from its left layer
during sixth week of intrauterine life
 Number of nodules –fuse to form a lobulated spleen
 Notching of the superior border of spleen is evidence of
it multiple origin
 The nodules which fail to fuse form accessory spleens
-gastrosplenic ligament , lienorenal ligament
gastophrenic ligament and greater omentum
-broad ligament of uterus
-in the spermatic cord
Location
 Left hypochondrium and
partly in epigastrium
 Wedged between the
fundus of stomach and
diaphragm
 Spleen measures 1x3x5 inches , weighs 7 oz and lies
deep to 9 ,10, 11 ribs
 Spleen lies obliquely along the long axis of the 10th
rib
 Directed downwards, forwards and laterally ,
making an angle of 45 degree with the horizontal
plane
External features
Two ends
1)anterior end is expanded is more like a border, directed
downwards and forwards and reaches the midaxillary
line
2)The posterior end is rounded. It is directed upwards ,
backwards and medially, and rests on the upper pole of
the left kidney
Three borders
1)The superior border is notched near the anterior end
2)The inferior border is rounded
3)The intermediate border is rounded and is directed to
the right
Two surfaces
1)The diaphragmatic surface is convex and smooth
2)Visceral surface is concave and irregular
impressions-gastric impression- fundus
-the renal impression-left kidney
-colic impression-splenic flexure
-pancreatic impression-tail of pancreas
hilum-transmits the splenic vessels and nerves and
provides attachment to the gastrosplenic and
lienorenal ligaments
Relations
Peritoneal relations
 Surrounded by peritoneum and is suspended by
ligaments
1. Gastrosplenic ligament-extends from the hilum to
greater curvature of stomach-contains the short
gastric vessels and associated lymphatics and
sympathetic nerves
2. Lienorenal ligament- from hilum to anterior surface
of left kidney – contains tail of pancreas, the splenic
vessels and associated pancreaticosplenic lymph
nodes , lymphatics and sympathetic nerves
3. Phrenicocolic ligament- not attached to spleen but
supports its anterior end
Visceral relations
1. Visceral surface- fundus of stomach
-anterior surface of left kidney
-the splenic flexure of the colon
-tail of pancreas
2. Diaphragmatic surface
-related to diaphragm
separates spleen from the costodiaphragmatic recess
of pleura , lung and 9th and 10th and 11th ribs .
Blood supply
 Aterial supply – splenic artery
 Venous drainage- splenic vein
Lymphatic drainage
 Several nodes at hilum- pancreaticosplenic nodes –
coeliac nodes

Nerve supply
 Sympathetic fibers from coeliac plexus
Histology
 Supporting tissue-fibroelastic forming the capsule ,
coarse trabeculae and a fine reticulum
 White pulp- lymphatic nodules arranged around an
eccentric arteriole called Malpighian corpuscle
 Red pulp- collection of cells in the interstices of
reticulum, in between the sinusoids
- the cells include-all types of lymphocytes, RBC,
WBC and platelets, macrophages
Palpation of spleen
 Enlarge spleen – felt under the left costal margin
during inspiration .
 Palpation assisted by turning patient to right
Splenic infarction
The smaller branches of splenic artery are end arteries
Their obstruction(embolism) results in splenic
infarction which causes referred pain in the left shoulder
(Kehr’s sign)
Surgical approach
 Splenectomy involves cutting two pedicles
- the splenorenal and gastrosplenic ligaments
 Emergency splenectomy
-after rupture
- the left or posterior layer of the splenorenal ligament is
incised and the spleen turned medially so that the
splenic vessels can be dissected away from the tail of the
pancreas and ligated (arteries before veins)
-the short gastric vessels and the gastrosplenic ligament
are then divided and removal completed
 Elective splenectomy
-the lesser sac is entered by dividing the gastrosplenic
ligament and its vessels
-the splenic vessels are identified and ligated
-the splenorenal ligament is divided
-stomach should not be perforated when ligating the
short gastric vessels
- Avoid damage to pancreas and splenic flexure .
Physiology of spleen
The spleen is a reservoir for storing RBC
 2 separate areas for storing blood-venous sinuses and
red pulp
 Red pulp – concentrated red blood cells
 Expelled into general circulation on sympathetic
stimulation causing contraction of spleen
 As much as 50 ml of concentrated RBC can be released
raising hematocrit 1-2 %
Blood cleansing function of spleen
 Blood cells passing through the splenic pulp before
entering the sinuses undergo through squeezing
 Fragile RBC cannot withstand the trauma
 These are destroyed in the spleen

Reticuloendothelial cells of the spleen

 Pulp of spleen and venous sinuses contain large
phagocytic reticuloendothelial cells .
 They remove debris , bacteria , parasites .
 Therefore spleen enlarges during infection
SPLENIC INJURY
Blunt splenic injuries
Pathophysiology
 Direct compression of the organ in the left upper
quadrant of the abdomen
 Deceleration mechanism that tears the splenic capsule
or parenchyma , mainly at areas fixed or tethered to the
retroperitoneum.
Penetrating splenic injuries
 Are less common
Clinical features
 Splenic rupture manifests in three types
1)The patient succumbs rapidly
-tearing of splenic vessels – internal haemorrhage
2)There are immediate signs of rupture
-commonest group
-after moderate intra-abdominal hemorrhage , adequate
clotting occurs to control the hemorrhage temporarily
-Local signs
1. Tenderness and muscle guarding over left upper
abdomen
2. Abdomen distension -3-4 hrs after the
accident(paralytic ileus)
3. Kehr’s sign- pain in left shoulder due to irritation of
the left half of diaphragm by splenic blood
4. Balance’s sign – persistent dullness on the left side of
the abdomen due to early coagulation of splenic
blood
5. Rectal examination- tenderness and sometimes a
soft swelling due to presence of blood or clot in the
rectovesical pouch
6. Saegesser’s splenic point- is the point in the lower
part of the posterior triangle of neck between the left
sternomastoid and the scalenus medius muscles
above the clavicle
3)Delayed type
 No symptoms for 15 days or more.
 Patient develops sings of internal hemorrhage
 Causes-
1. the coagulum which was sealing the rent suddenly
gives way (reactionary hemorrhage)
2. Infection may lyse the coagulum to cause
hemorrhage (secondary hemorrhage)
3. The greater omentum which may shut off the rent
gives way
4. A subcapsular hematoma – may burst
INVESTIGSTIONS
 In an unstable patient splenic injury may be identified
during emergency laprotomy
 Stable patients- abdominal CT with iv contrast
 Splenic injury appears
 disruption in normal splenic parenchyma ,
 surrounding hematoma
 free intra-abdominal blood
 Active extravasation of contrast , identified as a high-
density blush
 Straight x-ray abdomen
-obliteration of splenic outline
-obliteration of left psoas shadow
-elevation of the left side of the diaphragm
-fracture of one or more ribs on the left side
-indentation of the gastric fundal gas shadow from the
left
-presence of free fluid between gas-filled intestinal coils
-downward displacement of splenic flexure
 USG-surrounding hematoma –
 Four quadrant peritoneal aspiration-frank blood
 Angiography – can identify specific areas of bleeding
 American association for the surgery of trauma –
spleen organ injury scale
INJURY INJURY TYPE DESCRIPTION OF INJURY
GRADE
1 HEMATOMA Subcapsular tear <10% surface area
LACERATION Capsular tear <1 cm parenchymal depth
2 HEMATOMA Subcapsular tear 10-50%, intraparenchymal ,<5cm in dia
LACERATION Capsular tear ,1-3 cm parenchymal depth that does not
involve a trabecular vessel
3 HEMATOMA Subcapsular tear >50% , ruptured subcapsular or
parenchymal hematoma, intraparenchymal hematoma
>5cm or expanding
LACERATION >3cm parenchymal depth or involving trabecular vessels
4 LACERATION Laceration involving segmental or hilar vessels
producing major devascularization(>25% of spleen)

5 HEMATOMA Completely shattered spleen

LACERATION Hilar vascular injury devascularizes spleen
Grade 4 splenic rupture Grade 3 splenic injury with active
bleeding
Treatment
 Angioembolization
 Emergency splenectomy
 Steps
1. Midline incision
2. - the left or posterior layer of the splenorenal
ligament is incised and the spleen turned medially
so that the splenic vessels can be dissected away
from the tail of the pancreas and ligated (arteries
before veins)
3. -the short gastric vessels and the gastrosplenic
ligament are then divided and removal completed
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