Baghdad College of Medicine / 4
th
grade
Student’s Name :
Dr. Mohanned Al-Fallouji
Lec. 3
THE SPLEEN
Tues. 1 / 3 / 2016
DONE BY : Ali Kareem
مكتب
اشور لالستنساخ
2015 – 2016
The Spleen Dr. Mohanned Al-Fallouji
1-3-2016
2
The Spleen
Objectives
To reveal the surgical anatomy and the applied
physiology of the Spleen.
To know clinical differences between the Splenomegaly and tumour of
the left kidney.
To be acquainted with indications for splenectomy.
To be acquainted with post-splenectomy complications.
To sum it up in a clinical scenario of (splenic injury).
Surgical Anatomy: Location
o It lies under the diaphragm in the left hypochondrium.
o It is summarised by (1, 3, 5, 7, 9, 11):
It measures 1 X 3 X 5 inches (2.5 X 7.5 X 12.5 cm).
It weighs 7 ounces (200 gm).
It lies beneath the 9
th
- 11
th
ribs.
Spleen lies at the far left extremity of lesser sac under diaphragm.
It is related:
o to pancreatic tail,
o splenic flexure of the colon,
o left kidney.
o diaphragm.
o 6 short gastric arteries (from splenic artery) supply the fundus of the
stomach.
The Spleen Dr. Mohanned Al-Fallouji
1-3-2016
3
Surgical Physiology : FISH(H)
Spleen is the largest lymphoid organ in the body.
o F: Filtration and removal of old, abnormal, and senescent RBCs and
recycling iron as well as removal of encapsulated microorganisms
مقبرة
الخاليا
.
o I: Immunological functions (production of IgM and Opsonins)
o S: Storage Pool functions (30% of total Platelets are located within spleen:
it also receives 5% of total cardiac output approximately 150-300 ml/min so
that each RBC averages 1000 passes through spleen each day).
o H: Haematopoiesis (usually in the developing foetus, but in adults only
reactivated in myeloproliferative disorders that impair bone marrow to
produce sufficient RBCs).
o H: hormonally active? It has recently been evoked that the spleen has an
endocrine function through the production of an immuno-potentiating
peptide called (tuftsin).
DD of Splenomegaly from Renal tumour
o Palpate from right iliac fossa upwards towards left hypochondrium.
o Splenomegaly may be mistaken for left renal tumour.
o The following points will help in differentiation:
1. A renal tumour is bimanually palpable moving backwards and
forwards between one hand on the loin behind, and the other on the
anterior abdominal wall. Splenomegaly is not palpable bimanually.
2. Fingers can usually be passed between the kidney and the ribs but
not between the ribs and splenomegaly.
3. The spleen has a sharp edge with a notch. The kidney edge always
rounded and has no notch.
4. An enlarged kidney tends to bulge forwards. Peri-nephric abscesses
bulge backwards. Splenomegaly bulges towards RIF.
5. Because of overlying colonic splenic flexure percussion on
splenomegaly may be resonant.
The Spleen Dr. Mohanned Al-Fallouji
1-3-2016
4
Causes of Splenomegaly
o Spleen MUST be enlarged to 3 times its normal size before it becomes
clinically palpable.
o Massive splenomegaly is likely due to malignant disease:
Chronic myeloid leukemia,
Myelofibrosis,
Lymphoma (Hodgkin’s and Non-Hodgkin’s).
o Tropical splenomegaly:
Malaria
Kala-azar
Shistosomiasis
o Infective Splenomegaly :
Bacterial : Typhoid, Paratyphoid, Tuberculosis, Splenic Abscess,
Septicaemia.
Viral: infectious mononucleosis, HIV, psittacosis.
Parasitic: Hydatid cyst, Trypanosomiasis, Syphilis,Weil’s disease.
Hypersplenism : Possible indications for Splenectomy
1. Inherited haemolytic anaemia (Congenital Spherocytosis & Elliptocytosis).
Mechanism: ↑ RBCs fragility (Anaemia).
2. Autoimmune haemolytic anaemias.
Mechanism: Antibodies to RBCs (Anaemia).
3. Thalassaemia and Sickle cell disease.
Mechanism: Abnormal haemoglobins (Anaemia).
4. Immune thrombocytopenic purpura (primary & secondary)
Mechanism: Antibodies to platelets (Thrombocytopenia).
5. Portal Hypertension. Mechanism: ↑splenic venous pressure with delayed
transit of blood (Pancytopenia).
6. Rheumatoid arthritis (Felty’s syndrome)
Mechanism: Uncertain (Leucopenia or pancytopenia).
The Spleen Dr. Mohanned Al-Fallouji
1-3-2016
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Splenectomy: other indications
o Traumatic rupture of spleen
o Iatrogenic splenectomy
o Part of other surgical procedures, e.g. total gastrectomy, distal
pancreatectomy, lower oesophagectomy, left sided renal cell carcinomas
and adrenal cancer, and retroperitoneal sarcoidosis in left upper quadrant.
o Vascular diseases:
splenic vein thrombosis, splenic artery aneurysm.
o Storage disease:
Gaucher disease, Letterer-Siwe disease, amyloidosis.
o Collagen disease: Felty’s syndrome, Still’s disease.
o Cysts, abscesses, primary splenic tumours.
o Diagnostic staging laparotomy with splenectomy is now replaced by CT
abdomen.
o Rare: wandering spleen, splenic ectopic pregnancy (!).
Post-Splenectomy Complications
1. Overwheming post-splenectomy infection (OPSI)
Serious late complicationdue to pneumococci, meningococci and
Haemophilus influenzae. Sepsis into fulminant infection with fever, vomiting,
dehydration and collapse. Prophylactic immunization (pneumovac) 2 week
prior to surgery, antibiotics after emmergency surgery continued for life
(Penicillin V 250 mg b.d.).
2. Unexplained postoperative abdominal pain with fever may herald portal
vein thrombosis (anticoagulant and antibiotic must be given).
3. Others: Acute gastric distension, paralytic ileus, left basal atelectasis,
haematemesis (due to gastric mucosal congestion after vasa brevia ligation),
pancreatic leak, possible abdominal wound dehiscence or persistent hiccup
due to left subphrenic irritation by blood collection or an abscess.
The Spleen Dr. Mohanned Al-Fallouji
1-3-2016
6
A Clinical Scenario of ‘Splenic Injury’ (to sum it up)
o Blunt trauma (slipped and fell on edge of bath-tub) 6 hr ago.
o Severe upper abdominal pain
o Pain in left shoulder (Kehr sign)
o BP 100/60 PR: 100 Temp: 37.3 Resp Rate 18
o Not in shock now - (barely haemodynamically stable)
o Ecchymosis left lower chest wall
o Upper abdominal tenderness
o Otherwise soft abdomen What to do next?
o Chest x-ray (trachea central, chest clear but fractured rib 10)
o FAST (fluid collection peri-splenic area).
CT abdomen:
Stable patients >55y with isolated Grade 1 or 11 injury
can be managed conservatively
The Spleen Dr. Mohanned Al-Fallouji
1-3-2016
7
How to treat?
Laparotomy and Splenectomy
Haemodynamically this patient became unstable.
What is conservative Splenectomy ?
Look for spleniculus or spleniculi.
1. Partial splenectomy. or
2. Splenic repair (as in liver).
3. Splenic Auto-transplantation (splenosis).
END OF THIS LECTURE…