Surgery In Splenic
Disorders
Dr. Durga Sai Swaroop Thota,
Final yr post graduate,
Department of General Surgery,
Kamineni Institute of Medical Sciences.
INTRODUCTION
1. When is surgery to spleen considered?
2. Goals of splenectomy
3. Indications of splenectomy
4. Surgical approach to patient with splenic disorders
5. Complications
6. Splenic preservation
When is surgery to spleen
considered?
� When the spleen destroys red blood cells so rapidly
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that severe anemia develops
When the spleen so depletes stores of white blood
cells that infection is likely
When the spleen so depletes stores of platelets that
bleeding is likely
When the spleen is so large that it causes pain or
puts pressure on other organs
When the spleen is so large that parts of it bleed or
die
Goals of splenectomy
1.
Cure or palliation of particular disease causing
splenomegaly
�
2.
3.
Palliation from hypersplenism causing refractory
cytopenias that require frequent transfusion
Relief from symptomatic splenomegaly
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4.
Like early satiety, abdominal pain, and weight loss from mass
effect
Diagnosis of splenic pathology
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5.
Idiopathic (immune) thrombocytopenic purpura (ITP) and
hemolytic anemias
When Malignant tumours like angiosarcomas, malignant fibrous
histiocytomas, and plasmacytomas is suspected
diagnosis of lymphoma
Control of splenic hemorrhage
Indications of splenectomy
BENEFITED (COMMON)
MAY BE BENEFITED(UN
COMMON)
THROMBOCYTOPENIAS
IMMUNE THROMBOCYTOPENIC
PURPURA
THROMBOTIC
THROMBOCYTOPENIC
PURPURA(TTP)
ANEMIAS
HEREDITORY SPHEROCYTOSIS
AUTOIMMUNE HAEMOLYTIC
ANEMIAS
SICKEL CELL ANEMIAS
THALASEMIAS
HEREDITORY ELLIPTOCYTOSIS
MYELOPROLIFERATIVE AND
MYELODYSPLASTIC DISORDERS
CML
POLYCYTHEMIA VERA
MYELOFIBROSIS
ESSENTIAL THROMBOCYTOSIS
MYELOPROLIFERATIVE
DISORDERS
LYMPHOPROLIFERATIVE
DISORDERS
HODGKINS, NON HODGKINS,
CLL, HAIRY CELL LEUKAEMIA
NEUTROPENIAS
FELTYS SYNDROME
NON HAEMATOLOGIC SPLENIC
DISORDERS
SPLENIC MALIGNACIES,
RUPTURE,PARASITIC CYSTS
VASCULAR PROBLEMS� SPLENIC VEIN
THROBOSIS, and PSUEDOCYSTS
SPLENIC ABSCESS
SPLENIC CYSTS
STORAGE DISORDES
THROBOCYTOPENIAS
Idiopathic thrombocytopenic
purpura
� Indications of splenectomy:� if a patient has two relapses on steroid therapy
� refractory thrombocytopenia (thrombocytopenia recurs
while the patient is receiving more than 15 mg of
prednisone per day)
� if the platelet count remains low
� ITP has persisted for more than 6–9 months.
� Up to two-thirds of patients will be cured by surgical
intervention
� 15% will be improved, but no benefit will be derived in
the remainder
THROMBOTIC THROMBOCYTOPENIC
PURPURA(TTP)
� Indications:� In patients who do not respond to medical therapy or
� Those with chronically relapsing disease
� A Retrospective review of 33 patients:- plasmapheresis
dependant patients who underwent splenectomy had
a postoperative relapse rate of 0.07 per patient-year
� Patients who were not continuously dependent on
plasmapheresis, splenectomy reduced the relapse rate
from 0.74 to 1 per patient-year (Br J Heme
2005;130:768).
ANEMIAS
Hereditary spherocytosis
� Splenectomy brings about a return of hematocrit to
normal or near-normal values
� Anemia is usually mild, deferral of operation until
adolescence is preferable, to lessen the risk of
overwhelming postsplenectomy sepsis
� Indications:� Young child who develops frequent hemolytic crises.
� Conjunction with an acute infection.
� Manifested by a profound decrease in hematocrit
necessitating transfusion.
� Who require frequent blood transfusion.
Acquired autoimmune
haemolytic anaemia
� Indications:� Chronic autoimmune hemolytic anemias secondary to antibodies
of the IgG type
� Corticosteroids are ineffective
� Patient is developing complications from long-term steroid
treatment
� If corticosteroids are contraindicated
� Major hemolytic crises, hemoglobinuria, and renal failure
� Eighty per cent of patients respond to splenectomy.
� Splenectomy is not beneficial in patients with IgM-mediated
hemolysis (cold agglutinin disease) because the liver rather than
spleen is the site of red cell sequestration and destruction
Sickle cell disease
� Splenectomy is of benefit in a few patients in whom
excessive splenic sequestration of red cells aggravates
the anaemia.
� Indication:� Major episode of "acute splenic sequestration
� A minor episode plus the presence of hypersplenism
� Splenic sequestration
� usually occurring before age 2
� presents as fever, cough, diarrhea, vomiting,
drowsiness, and bone pain
� If shock is present, the episode is considered major
Thalassaemia (synonyms: Cooley
Cooley’’s anaemia
anaemia,,
Mediterranean anaemia
anaemia))
� Indications:� Who require frequent blood transfusion (when blood
transfused reaches a value of 200 ml/kg body
weight/year)
� If hemolytic antibodies have developed as a result
� Severe thrombocytopenia
� Secondary hypersplenism
� Symptomatic splenomegaly.
� Operative morbidity from cerebral or mesenteric
vascular accidents has been lessened by
administration of aspirin and dipyridamole
MYELOPROLIFERATIVE AND
MYELODYSPLASTIC DISORDERS
Chronic myelogenous leukemia
(CML)
� Splenectomy had no effect on survival or disease
progression, but it did increase the rate of thrombosis
and vascular accidents
� Splenectomy is indicated only for palliation of
symptomatic splenomegaly or hypersplenism that
significantly limits therapy
Polycythemia vera and essential
thrombocytosis
� Splenectomy can be required to treat symptomatic
splenomegaly or pain from splenic infarcts
� Splenectomy can result in severe thrombocytosis,
causing thrombosis or hemorrhage, which requires
perioperative antiplatelet, anticoagulation, and
myelosuppressive treatment.
Myelofibrosis and myeloid
metaplasia
� Indications for splenectomy include
� symptomatic splenomegaly and
� transfusion-dependent anemias
� patients are at increased risk for postoperative
hemorrhage and thrombotic complications after
splenectomy
Lymphoproliferative disorders
Chronic lymphocytic leukemia (CLL)
� Indications:� Symptomatic splenomegaly and
� Severe hypersplenism
� One retrospective study demonstrated that early
splenectomy (the majority of which were for
hypersplenism or cytopenias) in some patient
subgroups was associated with improved survival (J
Am Coll Surg 1997;185:237).
Non-Hodgkin and Hodgkins
Lymphomas
� Indications:� For palliation of hypersplenism and
� cytopenias or
� For diagnosis in patients with suspected persistent or
recurrent disease after systemic therapy
� Splenectomy plays an important role in the diagnosis
and staging of patients with isolated splenic
lymphoma
� Improved survival has been shown in patients
undergoing splenectomy (Cancer 1993; 71:207).
NEOPLASMS
� Primary benign
� Primary malignant
� Metastatic
Benign Neoplasms
� Haemangioma
� Littoral cell angioma
� Lymphangioma
� Other rare tumours
� Inflammatory pseudotumor of the spleen
� Hamartomas
� Peliosis
� Angiomyolipoma, lipoma, hemangiopericytoma, and
fibroma.
Haemangioma
� Indications:� Multiple haemangiomas
� Large and symptomatic
� Which have potential to transform into angiosarcoma
� Severe hypersplenism
� Spontaneous rupture(25%)
Littoral cell angioma
� Endothelial cell neoplasm arising from the cells lining
the sinus channels of the splenic red pulp
� Benign neoplasm cured with splenectomy
� Indications:� Association with malignant lymphoma and other
visceral organ cancers
� Recurrent disease
� Evidence of malignant transformation into malignant
littoral cell hemangioendothelioma
Lymphangioma
� Partial splenectomy
� Indications:-
Small in size
� Focal symptomatic lesions
� Total splenectomy:�
� Indications:�
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Large in size
Mass effect
Complicated with bleeding, rupture,
comsumptive coagulopathy and hypersplenism
Diffuse invoLvement of spleen
Generlised lyphagiomatosis with multi visceral
involvement
Primary Malignant Tumors
� Rare
� Angiosarcomas, malignant fibrous histiocytomas, and
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plasmacytomas
Angiosarcoma is the most common nonlymphoid
primary malignant neoplasm of the spleen
primary treatment is splenectomy
Metastasis is frequent and often involves the liver.
Spontaneous rupture has been reported and is
associated with a dismal outcome
Metastatic Tumors
� Lung, stomach, pancreas, breast, melanoma, and
colon
� Isolated splenic metastasis is unusual� associated
with colorectal, ovarian, endometrial, and renal
carcinoma
� Indications:� No other sites of disease found on thorough evaluation
Non-hematologic splenic
disorders
Splenic cysts
Splenic cysts
Non-Parasitic
cysts
True
cysts(primary)
Deroofing and
spleenectomy
parasitic cysts
Pseudocysts
(secondary)
Hydatid
cysts(majority)
Aspiration and
injection of
hypertonic saline
splenectomy
Splenic abscess
� Eitiology:� Infected splenic embolus or
� in association with typhoid and paratyphoid fever,
� osteomyelitis,
� otitis media and puerperal sepsis
� Pathophysiology:- abscess may rupture � left subphrenic
abscess �peritonitis
� Initial management:� treatment involves that of the underlying cause and
� drainage of the splenic abscess by percutaneous means under
radiological guidance
� Treatment of choice � Splenectomy
� Difficult in patients with extensive parasplenic inflammation
and adhesions� operative splenectomy may be performed after
preliminary aspiration of the abscess
30
Gaucher
Gaucher’’s disease
� Associated with Enormous splenic enlargement
� Splenectomy is indicated only for severe symptoms
related to the splenomegaly
� Partial splenectomy may be considered as a
temporizing procedure in young children
� Partial splenectomy has been performed in an
attempt to lessen the risk of postsplenectomy
infection
� After partial splenectomy, symptomatic splenic
enlargement and worsening hypersplenism recur after
3 to 8 years and necessitate later total splenectomy.
OTHER INDICATIONS FOR
SPLENECTOMY
� Occult Rupture of the Spleen
� Congestive splenomegaly
� Wandering spleen
� splenunculi
Occult Rupture of the Spleen
� True rupture:� True "spontaneous rupture" of a normal-sized spleen is
rare.
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Mechanisms:�
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repeated vomiting and retching� producing
increased traction on the lienogastric ligament
abnormal splenic mobility and torsion
degenerative changes in intrasplenic arteries
acute or chronic splenic congestion
� Splenic rupture secondary to underlying splenic
pathology
� Much more commoner than true rupture
� Eitiology:�
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Infective� eg., infectious mononucleosis
Neoplasms(primary and metastatic)
Infiltrative conditions:- sarcoidosis, amylodosis, gauchers
disease
Haemolytic anemias
Some external factors� eosion associated with gastric ulcer
and pancreatitis
vascular, thrombotic and haemostatic disorders
Congestive Splenomegaly
� Indications:� Left-sided portal hypertension
� Hypersplenism resulting from splenic vein thrombosis
� Persistent severe thrombocytopenia after a portalsystemic shunt
� Splenectomy alone for the management of
thrombocytopenia associated with hepatic cirrhosis
and bleeding esophageal varices is inappropriate
because platelet counts usually rise to safe levels after
one of the portal-systemic shunting procedures
Wandering spleen
� Due to increased splenic mobility on an elongated splenic
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pedicle
Results from congenital weakness or atresia of the lienorenal
ligament as a result of failure of fusion of the dorsal
mesogastrium, from which the spleen develops embryologically
Present as an asymptomatic abdominal mass or, more
commonly, as an abdominal mass with associated intermittent
abdominal pain
A more serious situation is presentation as an acute abdomen
resulting from persistent splenic torsion and infarction
Nonemergency situation, splenopexy deserves more serious
consideration in the young child, who is more susceptible to
postsplenectomy sepsis.
Indiations:� Acute splenic torsion
� Infarction
Splenunculi
� Supernumerary or accessory spleens or splenules
� Small nodules of spleen that are detached from the
rest of the organ
� They are benign and asymptomatic present
� Near the splenic hilum (most common)
� Gastrosplenic ligament
� Splenorenal ligament
� Pancreatic tail
� Greater omentum
� Small bowel mesentery
� Stomach or bowel wall
� Scrotum
� If accessory splenic
tissue is found, reexploration should be
considered, although
long-term response to
removal of an
accessory spleen is
uncommon in cases of
ITP (N Engl J Med
2002;346:995).
Surgical approach to patient with
splenic disorders
� Preoperative considerations in splenectomy
� Open splenectomy
� Laproscopic spleenectomy
� Staging laprotomy
Preoperative Considerations in
Splenectomy
� Vaccinations
� Polyvalent pneumococcal vaccine (Pneumovax)
� Meningococcal vaccine
� Haemophilus influenzae type B
� Considerations for Transfusion
� Patients with hematologic disease
� Patients with severe thrombocytopenia
� Preoperative imaging
� Other consideration
� Counseling of patients for conversion from laproscopic
to open splenectomy or a hand assisted approach
Open splenectomy
Step 1:-selection of incision
Step 2:-division of short gastric
vessels
Step3:-division of splenic
attachments
Step 4:- control of splenic
hilum
Step 1:-Selection of incision
Step 2:-Division of short gastric
vessels
Step3:-Division of splenic
attachments
Step 4:- Control of splenic hilum
Laproscopic splenectomy
Step 1
• Patient positioning and theatre set-up
Step 2
• Port placement
Step 3
• Exposure
•The vascular attachments are divided next using a 30- or 45-mm
Step 4 endoscopic linear cutting stapler
Step 5
• The spleen is next placed in a large specimen retrieval
bag
Step 6
• Morcellation of the spleen
Patient positioning and theatre setup
Port placement
Exposure
The vascular attachments are divided next using
a 30- or 45-mm endoscopic linear cutting stapler
The spleen is next placed in a large
specimen retrieval bag
Morcellation of the spleen
Hand-assisted laparoscopic
splenectomy (HALS)
Contraindications to Laparoscopic
Splenectomy
� Absolute contraindications:� Massive splenomegaly (>30 cm length)
� Portal hypertension
� Splenic trauma, unstable patient
� Relative contraindication:� Moderate splenomegaly (>20–25 cm)
� Severe uncorrectable cytopenia
� Splenic vein thrombosis
� Splenic trauma, stable patient
� Bulky hilar adenopathy
� Morbid obesity
OPERATIVE STAGING OF PATIENTS
WITH LYMPHOMA
� Hodgkin's disease
� Indications:�
�
to define more accurately the extent of disease
to tailor subsequent radiotherapy to involved areas
� Diagnosis is made usually by excision of an enlarged
cervical, axillary, or inguinal lymph node
� Once a histologic diagnosis has been made, a
diagnostic evaluation is carried out to determine the
clinical stage of the disease
� Based on clinical stage, which patients should be
considered for possible operative staging
� Procedure:� Long vertical abdominal incision,
� Splenectomy,
� wedge biopsy of the liver,
� Systematic biopsy of iliac and para-aortic lymph nodes,
and
� wedge biopsy of left iliac crest bone and marrow
Complications of splenectomy
complications
intraoperative
Early post operative
Late post
operative
complications
Intra-operative
Complications
pancreatic
injury
vascular
stomach
bowel
colon
Diaphragmatic
injury
Intra-operative Complications
� pancreatic injury:� 0% to 6%
� A closed suction drain should be placed adjacent to the
pancreas, and a drain amylase obtained prior to
removal after the patient is eating a regular diet
� Vascular injury:�
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Haemorrhage(MC)
2-3%� Open splenectomy
5%� laproscopic splenectomy
Bleeding during laparoscopic splenectomy may
necessitate conversion to a hand-assisted or open
procedure
� Bowel injury:� Because of the close proximity of the splenic flexure to
the lower pole of the spleen, it is possible to injure the
colon during mobilization
� Stomach:� Gastric injuries can occur by direct trauma or can result from
thermal injury during division of the short gastric vessels.
Use of energy devices too close to the greater curvature of
the stomach can result in a delayed gastric necrosis and
perforation
� Diaphragmatic injury:� during the mobilization of the superior pole especially
with perisplenitis
� careful dissection of the splenophrenic ligament can
minimize its occurrence
Early Postoperative Complications
Pulmonary (10%)
Subphrenic abscess(2-3%)
Wound problems(4-5%)
Thrombocytosis and thrombotic
complications(8-10%)
Ileus
Early Postoperative Complications
� Pulmonary complications:� 10%
� Atelectasis to pneumonia and pleural effusion
� Subphrenic abscess:� 2% to 3%
� uncommon after laparoscopic splenectomy (0.7%)
� Treatment:-percutaneous drainage and the intravenous
antibiotics
� Wound problems:� 4% to 5%
� hematomas, seromas, and wound infections
� Thrombocytosis and thrombotic complications:� Due to occurrence of thrombocytosis, alterations in
platelet function, and a low-flow stasis phenomenon in
the ligated splenic vein.
Late Postoperative Complications
� Overwhelming postsplenectomy infection (OPSI):� Nonspecific flulike symptoms rapidly progressing to
fulminant sepsis, consumptive coagulopathy,
bacteremia, and ultimately death within 12 to 48 hours
� Organisms:- Encapsulated bacteria especially
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Streptococcus pneumoniae,
H. influenzae type B, and
Neisseria meningitidis
� Treatment:- early supportive care and high-dose third-
generation cephalosporins
� Prevention:- immunization
Splenosis
� Presence of disseminated intra-abdominal splenic
tissue, which usually occurs after splenic rupture or
marcellation of spleen during laproscopic
splenectomy
� Prevention:� care should be taken during splenic morcellation to
avoid bag rupture and spillage of splenic tissue.
Splenic preservation
� Partial splenectomy:� Indications:�
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As a palliation for severe splenomegaly causing mass effect
Young patients
� Splenic replantation :� Placing small fragments of splenic tissue with in the
omentum
� This “omental omelet” of multiple splenic fragments
measuring no more than 1 cm in size is constructed
� The splenic omelets uniformly survive and take up
isotope, but the histology of these surviving segments
shows that the perifollicular lymphoid tissue is absent.
� The patients with splenic replantation do not respond
in the same way as patients with splenic salvage in the
normal position with maintained splenic blood flow.