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

Spleen in Spleen in SurgerySurgery

Presented by:Presented by: Dr. Rafiq M. Salhab Dr. Rafiq M. Salhab..

Alahli Hospital, HebronAlahli Hospital, Hebron..

الرحيم الرحمن الله بسم

Al-Quds University

Faculty of Medicine

Presentation contentsPresentation contents

Embriology and Anatomy.Embriology and Anatomy. Physiology and Pathophysiology.Physiology and Pathophysiology. Evaluation of Size and Function.Evaluation of Size and Function. Indications for Splenectomy.Indications for Splenectomy. Preoperative Considerations.Preoperative Considerations. Splenectomy Techniques.Splenectomy Techniques. Splenectomy Outcomes.Splenectomy Outcomes.

Dr. Rafiq Salhab 10/10/2011

Embriology and AnatomyEmbriology and Anatomy# Embriology:# Embriology:

Encapsulated mass of vascular and lymphoid Encapsulated mass of vascular and lymphoid tissue.tissue.

Reticuloendothelial organ ( Reticuloendothelial organ ( 25% of the fixed 25% of the fixed tissue macrophage population in the body).tissue macrophage population in the body).

Primitive mesoderm.Primitive mesoderm. Differentiation and migration.Differentiation and migration. Accessory spleen.(20%).Accessory spleen.(20%).


# Anatomy:# Anatomy:

Location. Location. Dimensions.Dimensions. Ligaments.Ligaments. Blood supply.Blood supply.



# Histology:# Histology:

1.1. Red pulp (75%): filtration system.Red pulp (75%): filtration system.

2.2. White pulp: lymphocytes and lymphoid White pulp: lymphocytes and lymphoid follicles.follicles.

3.3. Marginal zone.Marginal zone.

4.4. Trabecular areas.Trabecular areas.


# Histology:# Histology:


Physiology and PathophysiologyPhysiology and Pathophysiology

a) Storage spleens (many mammals).a) Storage spleens (many mammals).

b) Defense spleens (Humans):b) Defense spleens (Humans):• Filtration: RBCs, WBCs, Platelets.Filtration: RBCs, WBCs, Platelets.• Host defense: Host defense:

- Humoral (IGM, Tuftsin, Properdin, - Humoral (IGM, Tuftsin, Properdin, fibronectin).fibronectin).

- Cell-mediated.- Cell-mediated.• Storage.Storage.• Cytopoiesis.Cytopoiesis.


Splenomegaly: * weight ≥ 500 g.Splenomegaly: * weight ≥ 500 g.

* length ≥ 15 cm.* length ≥ 15 cm.

Palpable spleen : double the normal size.Palpable spleen : double the normal size.

Hypersplenism:Hypersplenism:

the presence of cytopenia (one or more blood the presence of cytopenia (one or more blood cell lines) in the context of normally responding cell lines) in the context of normally responding bone marrow, and improvement after bone marrow, and improvement after splenectomy. It has two types:splenectomy. It has two types:

Primary.Primary. Secondary.Secondary.




Evaluation of Size and FunctionEvaluation of Size and Function

Imaging: Imaging: Preoperative evaluation.Preoperative evaluation. Left upper quadrant pain.Left upper quadrant pain. Delineation of tumors or cysts.Delineation of tumors or cysts. Characterization of splenic abscesses. Characterization of splenic abscesses.


# Ultrasound (US):# Ultrasound (US):

- most cost-effective.- most cost-effective.

- rapid.- rapid.

- easy to perform.- easy to perform.

- not invasive.- not invasive.

- no ionizing radiation.- no ionizing radiation.

- sensitivity up to 98 % in expert hand.- sensitivity up to 98 % in expert hand.


# CT Scanning:# CT Scanning: - assessment of splenomegaly.- assessment of splenomegaly. - identification of lesions.- identification of lesions. - guidance for percutaneous procedure.- guidance for percutaneous procedure. - use of contrast material increases- use of contrast material increases resolution.resolution. - staging.- staging.

# MRI: more expensive than CT or US and # MRI: more expensive than CT or US and offers no advantage.offers no advantage.


# Radioscintigraphy: demonstrates splenic # Radioscintigraphy: demonstrates splenic location and size; helpful in detecting location and size; helpful in detecting accessory spleens following unsuccessful accessory spleens following unsuccessful splenectomy for ITP.splenectomy for ITP.

# Angiography: not helpful as diagnostic:# Angiography: not helpful as diagnostic:

- embolizing splenic branches in trauma.- embolizing splenic branches in trauma.

- limited success in partial embolization - limited success in partial embolization

for chronic ITP.for chronic ITP.

- treatment of splenomegaly. - treatment of splenomegaly.



Indications for SplenectomyIndications for SplenectomyA.A. Trauma.Trauma.

B.B. Pathological disorders.Pathological disorders.

1)1) Red cells disorders.Red cells disorders.

2)2) Platelet disorders.Platelet disorders.

3)3) White cell disorders.White cell disorders.

4)4) Bone marrow disorders (myeloproliferative).Bone marrow disorders (myeloproliferative).

5)5) Miscellaneous disorders and lesions. Miscellaneous disorders and lesions.


Splenectomy: most common indications:Splenectomy: most common indications:

1.1. Trauma.Trauma.

2.2. Staging for Hodgkin’s disease (in the Staging for Hodgkin’s disease (in the past).past).

3.3. ITP.ITP.

4.4. Hereditary spherocytosis.Hereditary spherocytosis.

5.5. Autoimmune hemolytic anemia (AIHA).Autoimmune hemolytic anemia (AIHA).

6.6. Thrombotic thrombocytopenic purpura Thrombotic thrombocytopenic purpura (TTP). (TTP).


A.A. Splenic trauma:Splenic trauma:

The spleen is the most commonly injured The spleen is the most commonly injured organ after blunt trauma.organ after blunt trauma.

Splenic injuries are classified as:Splenic injuries are classified as:

1.1. Class 1: Class 1: capsular tear.capsular tear.

2.2. Class 2:Class 2: lacerations not extending to the hilum. lacerations not extending to the hilum.

3.3. Class 3:Class 3: open laceration extending to the hilum. open laceration extending to the hilum.

4.4. Class 4:Class 4: shattered spleen. shattered spleen.

Splenectomy was the gold standard for Splenectomy was the gold standard for definitive management of splenic injury. definitive management of splenic injury.


Preservation of all or most of the injured Preservation of all or most of the injured spleen has become the preferred spleen has become the preferred treatment.treatment.

Avoid overwhelming postsplenectomy Avoid overwhelming postsplenectomy infection (OPSI).infection (OPSI).


# Non-operative salvage (observation):# Non-operative salvage (observation):

Blunt injuries (non penetrating).Blunt injuries (non penetrating). Stable patients without associated injuries.Stable patients without associated injuries. Class 1 and 2 (stable grade 3) may be Class 1 and 2 (stable grade 3) may be

observed.observed. Pediatric patients: successful (85 – 90) % Pediatric patients: successful (85 – 90) % Adult patients: successful 70 %.Adult patients: successful 70 %. Non of the class 4 and only 7 % of the class 3 Non of the class 4 and only 7 % of the class 3

can be treated successfully.can be treated successfully.


# Operative salvage:# Operative salvage:

Successful in 50 % of patients after either Successful in 50 % of patients after either

blunt or penetrating trauma.blunt or penetrating trauma. Should be considered in stable patients with Should be considered in stable patients with

few other injuries.few other injuries. The highest success in class 1 and 2 injuries.The highest success in class 1 and 2 injuries. The conservation of the spleen means more The conservation of the spleen means more

blood transfusion (complications). blood transfusion (complications). Unconscious patients should be operated.Unconscious patients should be operated. Patient over than 55 years of age.Patient over than 55 years of age.


Splenectomy is indicated:Splenectomy is indicated:

1.1. Life threatening hemorrhage from the Life threatening hemorrhage from the

spleen (class 3, 4) .spleen (class 3, 4) .

2.2. Multiple injuries in an unstable patient.Multiple injuries in an unstable patient.

3.3. Inexperience of the surgeon.Inexperience of the surgeon.


B. Pathological disorders:B. Pathological disorders:

1.1. Red blood cells disorders:Red blood cells disorders:

AIHA:AIHA: warm antibodies. Splenectomy is warm antibodies. Splenectomy is

indicated for: indicated for:

- failure to respond to steroids.- failure to respond to steroids.

- intolerance to steroids. - intolerance to steroids.

- requirement for excessive doses.- requirement for excessive doses.

- inability to receive steroids.- inability to receive steroids.

* favorable response to splenectomy in 80%.* favorable response to splenectomy in 80%.


Hereditary Spherocytosis (HS):Hereditary Spherocytosis (HS):

Autosomic dominant.Autosomic dominant. Fragility test.Fragility test. Splenectomy is curative for typical forms and is Splenectomy is curative for typical forms and is

the sole mode of therapy.the sole mode of therapy. Delay surgery in children (4-6 years).Delay surgery in children (4-6 years). Intractable leg ulcers needs early surgery.Intractable leg ulcers needs early surgery. (severe anemia and hemolysis)(severe anemia and hemolysis) Prophylactic cholecystectomy in children with Prophylactic cholecystectomy in children with

GBS at the time of splenectomy.GBS at the time of splenectomy.


Hemoglobinopathies:Hemoglobinopathies:

Sickle cell disease: splenectomy is indicated: Sickle cell disease: splenectomy is indicated: - hypersplenism.- hypersplenism. - acute sequestration crisis.- acute sequestration crisis. - splenic abscess.- splenic abscess. Thalassemia: splenectomy is indicated for:Thalassemia: splenectomy is indicated for: - excessive transfusion requirements- excessive transfusion requirements .(200cc/kg/year).(200cc/kg/year)

- discomfort due to splenomegaly. - discomfort due to splenomegaly. - painful splenic infarction.- painful splenic infarction.

RBC enzyme Deficiencies:RBC enzyme Deficiencies: G6PD,PK.G6PD,PK.

In PK surgery is indicated for splenomegaly (delayed In PK surgery is indicated for splenomegaly (delayed surgery)surgery)


2.2. Bone marrow disorders: Bone marrow disorders: (myeloproliferative disorders)(myeloproliferative disorders)

AML; CML; CMML; ET; PV; myelofibrosis.AML; CML; CMML; ET; PV; myelofibrosis.

Splenectomy is indicated for: Splenectomy is indicated for:

- - symptomatic splenomegaly: early satiety, symptomatic splenomegaly: early satiety,

poor gastric emptying, LUQ pain, and poor gastric emptying, LUQ pain, and

diarrhea.diarrhea.

- hypersplenism.- hypersplenism.


3.3. White blood cell disorders:White blood cell disorders:

CLL; HCL; NHL; HL.CLL; HCL; NHL; HL.

Splenectomy is indicated for: Splenectomy is indicated for:

- - symptomatic splenomegaly.symptomatic splenomegaly.

- hypersplenism.- hypersplenism.

HL: splenectomy for staging.HL: splenectomy for staging.


4.4. Platelet disorders:Platelet disorders:

# Idiopathic (Immune) thrombocytopenic purpura (ITP):# Idiopathic (Immune) thrombocytopenic purpura (ITP):

-- Affects mainly females between the ages of 15-50 years.Affects mainly females between the ages of 15-50 years.

-The spleen is palpable in less than 10% of patients.-The spleen is palpable in less than 10% of patients.

-Spontaneous regression is seen in more than two thirds of pediatric cases.-Spontaneous regression is seen in more than two thirds of pediatric cases.

-Increased bleeding time.-Increased bleeding time.

-The response to steroids predicts the benefit from splenectomy.-The response to steroids predicts the benefit from splenectomy.

-About 60-80% of patients will benefit from splenectomy.-About 60-80% of patients will benefit from splenectomy.


ITPITP :continue:continueTreatment : to keep PLT > 30,000Treatment : to keep PLT > 30,000

Corticosteroids :1-1,5 mg/kg/day for 3-6 monthsCorticosteroids :1-1,5 mg/kg/day for 3-6 months

Intravenous immune globulin.Intravenous immune globulin.

Splenectomy is indicated for:Splenectomy is indicated for:

- failure of medical therapy.- failure of medical therapy.

- steroids side effects.- steroids side effects.

- relapse.(2 during treatment)- relapse.(2 during treatment)

- life threatening bleeding.- life threatening bleeding.


# Thrombotic thrombocytopenic purpura (TTP):# Thrombotic thrombocytopenic purpura (TTP):

Splenectomy is indicated for:Splenectomy is indicated for:

- relapse.- relapse.

- multiple plasma exchanges.- multiple plasma exchanges.


5.5. Miscellaneous disorders:Miscellaneous disorders:

# Splenic abscess:# Splenic abscess:

Common in tropical locations: sickle cell Common in tropical locations: sickle cell anemia: anemia: - thrombosed splenic vessels.- thrombosed splenic vessels. - splenic infarction.- splenic infarction.

Abscess formation by: Abscess formation by: 1-hematogenous spread. 1-hematogenous spread. 2-contiguous infections.2-contiguous infections. 3-hemoglobinopathy.3-hemoglobinopathy. 4-immunosuppression.4-immunosuppression. 5-trauma.5-trauma.


# Cyst and tumors:# Cyst and tumors:

Parasitic cyst(hydatid cyst). Or non-parasiticParasitic cyst(hydatid cyst). Or non-parasitic

(pseudocyst, dermoid, epidermoid, epithelial)(pseudocyst, dermoid, epidermoid, epithelial) Primary tumors (Sarcoma, NHL) or Primary tumors (Sarcoma, NHL) or

metastatic tumors (lung).metastatic tumors (lung).

# Storage diseases and infiltrative disorders:# Storage diseases and infiltrative disorders:

- Gaucher’s disease.- Gaucher’s disease.

- Niemann-Pick disease.- Niemann-Pick disease.

- Amyloidosis.- Amyloidosis.


# Felty’s syndrome: RA, splenomegaly, # Felty’s syndrome: RA, splenomegaly, neutropenia.neutropenia.

# Sarcoidosis.# Sarcoidosis.

# Portal hypertension.# Portal hypertension.

# Splenic artery aneurysm.# Splenic artery aneurysm.


Preoperative ConsiderationsPreoperative Considerations Splenic artery embolization.Splenic artery embolization. Vaccination: Vaccination:

- - encapsulated bacteria: S.pneumonia, encapsulated bacteria: S.pneumonia,

H.Influenza type B, Meningococcus.H.Influenza type B, Meningococcus.

- 2 weeks before planned splenectomy.- 2 weeks before planned splenectomy.

- in emergency is given post operatively - in emergency is given post operatively

as soon as possible.as soon as possible.

- booster injections every 5 - 6 years.- booster injections every 5 - 6 years.

- annual influenza immunization.- annual influenza immunization.


DVT prophylaxis: patients with MPD.DVT prophylaxis: patients with MPD. Adjustment of anemia.Adjustment of anemia. Adjustment of coagulation profile.Adjustment of coagulation profile. Adjustment of thrombocytopenia.Adjustment of thrombocytopenia. Antibiotic. Antibiotic.


Splenectomy TechniquesSplenectomy Techniques

A.A. Laparoscopic:Laparoscopic: more tendency. more tendency.

B.B. Open Technique:Open Technique:1.1. Traumatic rupture.Traumatic rupture.

2.2. Massive splenomegaly.Massive splenomegaly.

3.3. Ascites.Ascites.

4.4. Portal hypertension.Portal hypertension.

5.5. Multiple prior operations.Multiple prior operations.

6.6. Extensive splenic radiation.Extensive splenic radiation.

7.7. Splenic abscess.Splenic abscess. Dr. Rafiq Salhab 10/10/2011

Splenectomy OutcomesSplenectomy Outcomes

Hematologic outcomes:Hematologic outcomes:

- appearance of Howel-Jolly bodies and - appearance of Howel-Jolly bodies and

siderocytes.siderocytes.

- leukocytosis: within 1 day.- leukocytosis: within 1 day.

- thrombocytosis: within 2 days, peak (7 days).- thrombocytosis: within 2 days, peak (7 days).

- increased hemoglobin level. - increased hemoglobin level.


Complications:Complications:

1.1. Pulmonary:Pulmonary:

- left lower lobe atelectasis.- left lower lobe atelectasis.

- left pleural effusion.- left pleural effusion.

- pneumonia.- pneumonia.

2.2. Hemorrhagic:Hemorrhagic:

- intraoperatively.- intraoperatively.

- subphrenic hematoma.- subphrenic hematoma.


3.3. Infectious:Infectious: - subphrenic abscess.- subphrenic abscess. - wound infection.- wound infection.4.4. Pancreatic:Pancreatic: - pancreatitis.- pancreatitis. - pseudocyst.- pseudocyst. - fistula.- fistula.

5.5. Thromboembolic phenomena:Thromboembolic phenomena: - DVT.- DVT. - PVT.- PVT.


Overwhelming post splenectomy infection:Overwhelming post splenectomy infection:

Incidence 1 – 5 %.Incidence 1 – 5 %. Caused by encapsulated bacteria.Caused by encapsulated bacteria. Mortality > 50 %.Mortality > 50 %. More common in children and Immuno- More common in children and Immuno-

compromised patients.compromised patients. Occurs more frequently during the first 5 Occurs more frequently during the first 5

years of life.years of life. The risk is greatest within 2 years of surgery.The risk is greatest within 2 years of surgery. Risk factors: cause of splenectomy, immunity Risk factors: cause of splenectomy, immunity

status, interval from the date of surgery.status, interval from the date of surgery.



Spleen position







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

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