Schwartz’s Principles of Surgery 11th Ed.

THE SPLEEN

dr. Muhammad Fhandeka Israr

Preseptor: dr.
 Historycal Background

 Andriano Zaccavello in 1549 was performed the first human splenectomy on a

middle-aged woman
 In 1866 Dr. Thomas Bryant performed the first splenectomy in a patient with
leukemia, the patient died. He declared that the operation is physiologically
unsound and surgically unsafe for leukemia and should not be performed
 In 1916 Paul Kaznelson  wrote the role played by the spleen in the destruction of
platelets  first splenectomy for a patient with ITP
 Early 1990’s  the advent of minimally invasive surgery and laparoscopic
splenectomy represented a clear advanc, benefitting the patient
 Embryologi and Anatomy

 Development  begins through the formation of the splanchnic

mesodermal plate, derived from the mesoderm, at embryonic day 12
 The spleen  important hematopoetic role until the fifth month of
gestation.
 The most common anomaly  the accessory spleen  occur in up to 30%
patient with hematologic disease
 The average adult spleen is 7-11 cm in lenght and weight 150 g (70-259 g)
 The spleen is suspended in position by several ligaments and peritoneal
folds to the colon, stomach, diaphragm, adrenal gland and tail of the
pancreas.
 The blood supply for the spleen is from the splenic artery, the short gastric
vessel and the splenic vein joins the superior meseneric vein
THE SPLENIC PARENCHYMA IS COMPOSED OF TWO
ELEMENTS:

The Red Pulp The White Pulp

 The mechanical filtration function  Consist of nodules (≤ 1 mm)
 Enabling macrophages to remove
microorganisms, cellular debris,
antigen-antibody complexes, and
senescent erythorcytes from the
circulation
 PHYSIOLOGY AND
PATHOPHYSIOLOGY

 Total splenic inflow of blood  250 – 300 mL/min

 The spleen acts as:
 The major site for clearance from the blood of damaged or aged red blood cells
 The removal of abnormal white blood cells and platelets
 An extra medullary site of hematopoiesis
 Recycling iron
 Plays a key immunologic role in defense against a number of organisms
 Splenomegaly refers simply to abnormal enlargement of the spleen,
described variably as moderate, massive, and hyper (≥500 g in weight, ≥15
cm in length)
 Hypersplenism the presence of one or more cytopenias in the context
of normally functioning bone marrow
 Disorder causing hypersplenism:
 Increased destruction of abnormal blood cells occurs in an intrinsically normal
spleen
 Primary disorder of the spleen resulting in increased destruction of normal
blood cells
 INDICATION FOR SPLENECTOMY

 Indication:
 Benign condition
 Malignant condition
 Miscellaneous condition
 The most common
indication  ITP and AIHA
 BENIGN DISORDER

Red Blood Cell Disorders

 Congenital
 Hereditary Spherocytosis (HS)
 An inherited dysfunction or deficiency in one of the erythrocyte
membrane protein (autosomal dominant)
 Patient may have mild jaundice, splenomegaly, anemia (4-6
g/dl),elevated reticulocyte count, elevated lactate dehydrogenase
level, increased of unconjugated bilirubin, spherocyte on peripheral
blood film
 The mean indication of splenectomy and cholecystectomy are
moderate to severe symtomatic hemolytic anemia, growth
retardation, skeletal changes, leg ulcers, extramedullary
hemopoietic tumors in young patient
 BENIGN DISORDER

Red Blood Cell Disorders

 Congenital
• Red Blood Cells Enzyme Deficiencies
 Classified into two groups:
 Deficiencies of enzymes involved in glycolytic pathways (pyruvte kinase
deficiency)  splenetomy is common for severe case
 Deficiencies of enzyme to protecting from oxidative damage (G6PD) 
splenectomy is not indicated, may be has benefit for patient with
severe hemolytic anemia
 BENIGN DISORDER

Red Blood Cell Disorders

 Acquired
 Antibody Autoimmune Hemolityc Anemia
 Clinically presentation  mild jaundice, anemia, may be a
splenomegaly
 Hemolisis as indicated by anemia, reticulocytosis, products of red
bood cell dedstruction
 Direct Coombs’ test confirms the AIHA diagnosis
 The treatment depends on the severity and whether it is primary or
secondary
 Splenectomy 
 Favorable respon: complete remission of refractory AIHA in patient over 60 years old
 Transient respon are more common
 BENIGN DISORDER

Red Blood Cell Disorders

 Acquired
 Hemoglobinopathies
 Sickle cell disease 
 An inherited chronic hemolytic anemia, result from the mutant sickle
cell hemoglobin (HbS) within the red blood cell (autosomal dominant
fashion)
 Microvascular congestion may lead to thrombosis, ischemia, and tissue
necrosis  characterized by painful intermittent episodes
 Splenectomy indication recurrent acute crises (rapid painful
enlargement of the spleen), hypersplenism, and splenic abscess
 BENIGN DISORDER

Red Blood Cell Disorders

 Acquired
 Thalassemia
 An inherited disorder of hemoglobin sythesis, classified according to the
hemoglobin chain (α, β, or γ) affected
 A diagnosis made by demonstrating hypochromic microcytic anemia
associated with randomly distorted red bloo cell and target cells on peripheral
blood smear
 Spelenectomy 
 Indcation  excessive transfusion requirements (>200 ml/kg/year), discomfort
due to splenomegaly, or painful spenic infarction
 High risk for pulmonary hypertension after splenectomy
 The increase in infectious complication  consider partial spenectomy in children
 Should be delayed until after the of 4 years unless it is absolutely necessary
 BENIGN DISORDER

Platelet Disorders
 Idiopathic Thrombocytopenic Purpura (ITP)
 An autoimmune disorder characterized by a low platelet count and
mucocutaneous petechial bleeding
 Diagnosis  based on exclusion of other possiblities in the presence
of a low platelet count and mucocutaneous bleeding
 The first line therapy  oral prednisone 1.0 – 1.5 mg/kg/day
 Splenectomy indication:
 Failure of medical therapy
 Prolonged use of steroids with undesirable effects (>10-20 mg/days for -6 month to maintain platelet
>30,000/mm3)
 In selected case after first relapse
 Refractory ITP
 BENIGN DISORDER

Platelet Disorders
 Thrombotic Thrombocytopenic Purpura (TTP)
• Characterized by thrombocytopenia, microangiopathic
hemolytic anema, and neurologic complication
• Clinical features  petechiae, fever, neurologic symptoms,
renal failure, cardiac symptoms (infrequently)
• Diagnosis  peripheral blood smear: schistocytes, nucleated
red blood cells (target cells), and basophilic stippling
• First-line therapy  plasma exchange
• Spelenctomy  for relapse cases or for who require multiple
plasma exchange to control severe symptoms
 MALIGNANT DISORDER

White Blood Cell Disorders

 Hairy Cell Leukemia
 An uncommon blood disorder
 Characterized by splenomegaly, pancytopenia, and large
numbers of abnormal lymphocytes in the bone marrow
 Splenectomy 
 As palliative procedure
 Should be considered after exhaustive systemic therapy
 To treat pregnant woman to delay onset of chemotherapy
 MALIGNANT DISORDER

White Blood Cell Disorders

 Hodgkin’s Lymphoma (HL)

 A disorder of the lymphoid system characterized by

the presence of Reed-Sternberg cells
 Staging laparatomy is less commonly performed in
the current era of minimally invasive surgery and
advanced imaging technique
 MALIGNANT DISORDER

White Blood Cell Disorders

 Non-Hodgkin’s Lymphoma (NHL)

 NHL encompasses all malignancies derived from the

lymphoid system except classic HL
 Clinically classified into nodal or extranodal, as well as
indolent, aggressive, and very aggressive groups
 Splenectomy is indicated in cases where a diagnosis
cannot established by obtaining peripheral tissue and
clinical suspicion remains or for management of
symptoms relate to an enlarged spleen
 MALIGNANT DISORDER

White Blood Cell Disorders

 Chronic Lymphocytic Leukemia (CLL)

 A progressive accumulation of old and nonfunctional

lymphocytes
 The most frequent finding is lymphadenopathy
 Splenectomy is indicated to improve cytopenias and
was shown to be 75% effective in a combined gropu of
patients who had either CLL or nonmalignant HD
 MALIGNANT DISORDER

Bone Marrow Disorders (Myeloproliverative Disorder)

 Chronic Myelogenous Leukemia (CML)
 A disorder of the primitive pluripotent stem cells in te
bone morrow, result in significant increase in
erythroid, megakaryotic and pluripotent progenitors in
the peripheral blood smear
 Enlargement of the spleen is found in roughly one-half
patient
 Splenectomy is indicated to relieve symptoms of
massive splenomegaly
 MALIGNANT DISORDER

Bone Marrow Disorders (Myeloproliverative Disorder)

 Acute Myeloid Leukemia (AML)

 AML has a presentation that is more rapid and dramatic

than CML
 Presenting sign and symptoms: viral-like illness, fever,
malaise, bone pain
 Splenectomy is indicared only in the uncommon
circumstance that left upper quadrant pain and early
astiety become unbearable
 MALIGNANT DISORDER

Bone Marrow Disorders (Myeloproliverative Disorder)

 Chronic Myelomonocytic Leukemia (CMML)
• Characterized by a profileration of hematopoietic elements in the
bone marrow and blood
• Splenomegaly occurs in one-half of these patients
• Splenectomy result in symptomatic relief
 Essential Thrombocythemia (ET)
• Represent abnormal growth of the magakaryocyte cell line, increase levls of
platelets
• Splenomegaly occurs in one-third to one-half of patient
• Splenectomy is not to be helpful in early stage and is best for later stages
 MALIGNANT DISORDER

Bone Marrow Disorders (Myeloproliverative Disorder)

 Polycythemia Vera

 Is a clonal, chronic, progressive myeloproliferative disorder

 Characterized by an increase in red blood cell mass, leukocytosis, thrombocytosis,
and splenomegaly
 Physical finding  ruddy cyanosis, conjungtival plethora, hepatomegaly,
splenomegaly, and hypertension
 Splenectomy is not helpful in early stages, and is best for late-stage, myeloid
metaplasia has developed and splenomegaly-related symptoms are severe
 MALIGNANT DISORDER

Tumors and Metastasis

 The most common primary tumors of the spleen are sarcomas
 Lung carcinoma is the most commonly spreads to the spleen
 A laparoscopic splenectomy with intact spleen retrieval may be considered for an
isolated splenic metastasis
 MISCELLANEOUS DISORDER AND LESIONS

Infection and Abscess

 Mostly because of spontaneous splenic rupture (malaria, Listeria infection, fungal
infection, dengue, and Q fever, neoplastic, or noninfectious causes)
 The mechanisms of splenic abscess formation:
 Hematogenous infection
 Contiguous infection
 Imunosuppression
 Trauma
 Diagnosis  ultrasound or CT scan
 Splenectomy is the operation of choice
 Percutaneous and open drainage for patient who either cannot tolerate splenectomy or
where the clinical scenario warrants splenic preservation, particularly in children
 MISCELLANEOUS DISORDER AND LESIONS

Cysts
 Can be categorized according to a number of criteria  parasitic or nonparasitic
 MISCELLANEOUS DISORDER AND LESIONS

Parasitic Infection
 The most common cause  Echinococcus species
 Ultrasound  the presence of a cystic lesion
 Splenectomy is the best treatment for symptomatic parasitic cyst
 Patient should be advised of the risk of cyst rupture
 IMAGING FOR EVALUATION OF SIZE AND
PATHOLOGY
 Indication for splenic imaging:
 Preopertive consideration for patients with splenomegaly
 Trauma
 Investigations of left upper quadrant pain
 Tumors, cysts, abscesses of the spleen
 Guidance for percutaneous procedures
 Imaging modalitites  ultrasound and CT scan, both enabling measurement if
splenic size and volume. MRI not as commonly used
 Volume (cc) = length (cm) x widht (cm) x height (cm) x 0.52
Deep Vein Thrombosis Prophylaxis (DVT)
 Risk of portal vein thrombosis (PVT) may reach 50% in patient with splenomegaly an
myeloproliverative disorders
 Postsplenectomy PVT anorexia, abdominal pain, leukocytosis, and thrombocytosis
 The diagnosis with contrast enhanced CT, and starting anticoagulation immediately for
the treatment
 Patients have risk factor for DVT (obesity, history of previous thromboembolism,
hypercoagulable state, older age)  postoperative antithrombotic regiment of up to
two weeks of LMWH
 SPLENECTOMY TECHNIQUES

 Patient Preparation
 Assessment of the potential need for transfusion of blood products
 Anemic patient  transfused before surgery to a hemoglobin level of 10 g/dl
 2-4 units of cross-matched blood should be availabe at time of surgery for complex cases
 Optimization of preoperative coagulation status
 Thrombocytopenic patient  <30 x 109/L of platelet count  require a IV immunoglobulin
or oral corticosteroid before the surgery
 Patient with maintained on corticosteroid therapy preoperatively should receive parenteral
corticosteroid therapy perioperatively
 All splenectomy patient do receive DVT prophylaxis
 NGT is inserted for stomach decompression after endotracheal intubation
 Open Splenectomy (OS)
 The most common indication  traumatic rupture of the spleen
 Patiens is placed in the supine position with the surgeon situated at the patient’s right
 A left subcostal incision paralleling the left costal margin and lying two finger-breadths
below it  for elective splenectomy
 A midline incision  for exposure when the spleen is ruptured or massively enlarged
 Ligating the splenic artery in continuity along the superior border of the pancreas  in
patient with significant splenomegaly
Continue...

 Spleenocolic ligament is divided at the beginning of open splenectomy

 Individual ligation and sequential division of the short gastric vessels, reduce
the risk of retracting an bleeding
 Splenic hilar dissection then takes place
 Ligate the splenic artery and vein before dividing them
 The tail of pancreas lies within 1 cm of th splenic hilum in 75% patient
 The spleen is excised  hemostasis is secure by irrigating, suctioning, and
scrupulously inspecting the bed of dissection
 Laparoscopic Splenectomy (LS)

 Laparoscopic splenectomy  the procedure of choice, the gold standard for elective
splenectomy in patients with normal-sized spleen
 LS procedures are performed with the patient in the right lateral decubitus position
Continae...

 The double-access technique  the patient is in a 450 right

lateral decubitus position, requires the placement of 5 or 6
trocars
 Placement of trocars in the left upper quadrant should be
performed under laparoscopic visualization  can significantly
reduce the available operating space
 The splenocolic ligament an the lateral eritoneal attachemnts
are divided
 With the lowe pole of spleen gently retracted, he splenic hilum
is accessible
 The splenic artery and vein are divided separetly when possible
Continue...

 A blunt instrument should be used to remove the spleen

  Hand-Assisted Splenectomy (HALS)

 As an alternative to the LS approach

 HALS may benefit to the spleen greater than 22 cm in craniocaudal lenght, or 19 cm
in width
 HALS techniques has been reported the reduction of average operative time for
patient with massive splenomegally
 HALS require small incision (7-8 cm) for hand insertion and specimen extraction
 Patient positioning is similar to that of LS
Continue...

 Right-hand dominant surgeon  the hand assist device

can be placed in midline position
 Left-hand dominant surgeon  the hand assist device can
be placed in subcostal position
 A 7-8 cm incision should be made 2-4 cm caudal to the
inferior pole of the enlarged spleen
 The non-dominant hand  provides medial retraction and
rotation of the spleen
 The dominant hand  carries out the dissection using
laparoscopic instruments
 Single-Incision Laparoscopic Surgery Splenectomy (SILS)

 Use a one small transabdominal incision that can be hidden periumbilically, and is
used as the specimen extraction site
 As a solid organ, the spleen cannot be grasped and retraction may be more
challenging
 Periumbilical port position may result in technical challanges when dealing with high
body mass index or tall patient
 Other alternatives to single port placement have been reported, although to date,
no proven benefits of SILS spelenectomy habe been demonstrated
 Robotic Splenectomy

 The da Vinci surgical robot  has been applied to clinical practice for abdominal
procedures include splenectomy
 Some advantages:
 Increased degrees of freedom as compared to standard “straight-stick” laparoscopy
 Improved optics  three-dimensional imaing of the operative field
 Improved instrument stabilization
 Reduction in hand tremor
 Purpoted ergonomic and comfort factors for the operating surgeon
 Robotic splenectomy has been performed in the pediatric population
 Partial Splenectomy

 Particularly indicated to minimize the risk of postsplenectomy sepsis in children

 Partial splenectomy to treatment patient with:
 Certain lipid storage disorder leading to splenomegaly (e.g Gaucher’s disease)
 Some forms of traumatic splenic injury (blunt and penetrating)
 Spherocytosis in children
 Focal benign splenic lesions
  Inadvertent Intraoperative Splenic Injury

 Intraoperative injury to the sleen has been link with numerous operations
 Improper traction on the spleen against its peritoneal attachments is the most
common mechanism
 Capsular tears are the most common type of injury, the lower pole is more
commonly injured
 Control of bleeding  compression of the spleen, compression of the vessels at the
splenic hilum, pressure on the splenic artery at superior pancreatic margin
 Hilar injury  managed by splenectomy
PREOPERATIVE GRADING SCORE TO PREDICT TECHNICAL
DIFFICULTY IN LAPAROSCOPIC SPLENECTOMY
 SPLENECTOMY OUTCOMES

 Overwhelming Postsplenectomy Infection

 Considering that the spleen is the site for special adaption macrophages that
targeted encapsulated organisms
 Asplenic patient are at highest risk for infection with encapsulated organism
(Streptococus pneumoniae, Haemophilus influenza, Neiseria meningitides)

 Complications
• Complications of splenectomy  hemorrhagic, infectious,
pancreatic
Continue...

 Hematologic Outcome

 Divided into intial and long-term response

 For thrombocytopenia, the initial response is defined as a rise in platelet count within
several days
 A long-term platelet response in approximately 80% of individuals with ITP
 Chronic hemolytic anemia  splenectomy has been reported to successful for the
majority of patient with chronic hemolytic anemia
 The laparoscopic approach typically result in longer operatives times, shorter hospital
stays, lower morbidity rates, similar blood loss, and similar mortality rates compared
with OS
Continue...

 Cancer

 A Taiwanse population-based study  splenectomy have higher risk of developing

certain type of cancer (esophagus, stomach, liver, other head and neck, non-Hodkin’s
lymphoma, and leukemia cancers)
 The possible association is unclear  splenectomy may impair immune surveillance in
the host
 ULTRASOUND
 The first imaging modality used to evaluate the spleen in trauma patient, routine
diagnostic purpose, or for preoperative planning
 A normal spleen  differentiation between red and white pulp is not possible, a
homogeneous acoustic echotexture should be visualized
 Splenic artery anatomy has been classified commonly into two patterns:
distributed and magistral
 Percutaneous ultrasound-guide procedures for splenic disease, avoided due to the
risk of hemorrhage and other complication
 COMPUTED TOMOGRAPHY
 CT has become an invaluable tool in the evaluation and managemnt of the blunt
trauma, standardized scoring systems for splenic trauma
 Non-trauma spleen  identification of solid and cyst lesions, guidance of
percutaneous procedures
 Splenic abscess  a contrast-enhanced CT should be utilized
 PLAIN RADIOGRAPHY

 Rarely is plain radiography used for primary splenic imaging

 Plain films may demonstrate splenic calcifications
 Splenic calcifications can indicate a number of benign, neoplastic, or infectious
processes

 Magnetic Resonance Imaging

• MRI can be a valuable adjunct to the more commonly used imaging
techniques when splenic disease is suspected but not definitively
diagnosed
 ANGIOGRAPHY

 Angiography of the spleen most commonly refers to invasive arterial imaging

 Angiography combined with therapeutic splenic arterial embolization (SAE) in patient
with cirrhosis or portal and sinistral hypertension

Nuclear Imaging
• Radioscintigraphy with technetium-99m sulfur colloid  for splenic
location and size
• Especially helpful in locating accessory spleens after unsuccessful
splenectomy for ITP
 Antibiotics and The Asplenic Patient

 Antibiotic therapy for the asplenic patient can be considered in three context:
 Therapy for established or resumed infections
 Prophylaxis in anticipation of invasive procedure
 General prophylaxis
 The treatment OPSI  use of a broad-spectrum intravenous antibiotics, ideally
after the collection of blood cultures
 Vancomycin  broad-spectrum gram-positive (S penumonia)
 Ceftriaxone should be added to include gram-negative coverage
 Education
 Risk management strategies to patient following splenectomy:
 Wearing a medical bracelet
 Carrying a laminatedmedical alert card
 Possessing a medical letter with specific empiric therapy instruction
 Keeping a-5 day supply of standby antibiotics
 A high index of suspicion, prompt action, and aggressive education of the patient, family
and medical providers