Surgical Diseases of

Spleen

Outlines
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Anatomy of the spleen

Function of the spleen
Splenic trauma
Cyst, abscess
Splenectomy

Anatomy
Lies in the left hypochondrium between the
left hemidiaphragm and the gastric fundus.
Soft, encapsulated, oval organ of variable
size, measures about 12 cm (5 in.) in
length, weight about 75250 g.
The upper border is marked along the upper
border of the ninth rib; the lower border,
along the 11th rib. The medial end lies 5 cm
from the midline. The lateral extension ends
at the midaxillary line. **{Trauma}

 The hilum sits between the stomach

and the kidney and is in contact with
the tail of the pancreas.
There is a notch on its inferolateral
border.
It is usually not palpable, but may be
felt in children, adolescents, and
some adults, especially those of weak
build.
A palpable spleenusuallymeans the
presence of significant splenomegaly.
As a general rule, a spleen has to be
doubled in size before it becomes

P.S.

Some people have an accessory

spleens (10-20%) usually seen at the
hilum, greater omentum, and
ligaments of the spleen.

Splenic artery
It arises from the celiac trunk and
runs along the upper border of the
body and tail of the pancreas.
It divides into superior and inferior
branches, which in turn divide into
several segmental branches.

Branches from the splenic artery:

- Gastroepiploic artery
- Pancreatic branches

splenic vein
The splenic vein is formed from
several tributaries that drain the
hilum. The vein runs behind the
pancreas, receiving several small
tributaries from the pancreas before
joining the superior mesenteric vein
at the neck of the pancreas to form
the portal vein.

 Proper splenic
tissue has no
lymphatics;
however, some
arise from the
capsule and
trabeculae and
drain to the
pancreaticosple
nic lymph nodes.

Histology
1- White pulp (lymphatic tissue)
lymphocytes
Immunologic function
The white pulp comprises a central trabecular artery
surrounded by nodules with germinal centres and
periarterial lymphatic sheaths that provide a lymphocytes
and macrophages.

2- Red pulp
Blood-filled venous sinuses and splenic cords.
Contains RBC, macrophages, B & T lymphocytes,
plasma cells
Function: filtering RBCs & platelets.
Bacteria that are filtered: encapsulated
(streptococcus, H. influenza, E.coli, GBS).

Function
1. Immune function (Immunoglobulins, Filtration).
The spleen processes foreign antigens
is the major site of specific immunoglobulin M (IgM)
2. Reservoir
150-200 ml normally >> the spleen can contract in
danger cases like shock to save the body.
3. Hematopoieses, in neonatal life.
4. Filter function:
Macrophages in the reticulum capture cellular and noncellular material from the blood and plasma.
This process takes place in the sinuses and the splenic
cords by the action of the endothelial macrophages.

Splenic Trauma

Splenic Trauma
Types :
Blunt (e.g RTA, falls)
Penetrating (e.g gunshot, knife)
Iatrogenic (e.g CPR)

Case
A 29-year old male presented with pain
in the left hypochondrium for one day.
This followed a road traffic accident
the previous day.
On examination, he was pale and the
abdomen was tender with guarding.

How to approach this patient ?

History
Physical examination
Investigation

History
Mechanism of injury (IMPORTANT) :
In RTA, note :

Position of the victim in the car

Velocity of the impact
Type of accident ( front, lateral, etc)
Information about damage to the vehicle
Whether a passenger died
Whether t person was ejected from the vehicle
The presence of alcohol or drug use.

In a fall, note:
The distance fallen
The site of anatomic impact

Clinical presentation
Pain in LUQ, produced by stretching the
splenic capsule ( most common symptom
in stable pt)
Kehrs sign (left shoulder pain in splenic
rupture ), blood irritates the diaphragm i.e
referred pain >> splenic rupture.
Peritoneal irritation (diffuse pain, rebound
tenderness) is caused by extravasated
blood
Signs of shock ; hypotension, tachycardia,
restlessness, anxiety. (if massive
bleeding).

Physical examination
Vital signs vary depending on associated
blood loss, not specific for injuries to the spleen
Abdominal exam skin abrasions, tenderness,
guarding, rebound, rigidity
**a large number of pt with significant splenic injury
exhibit no signs or symptoms at all
Delayed rupture of spleen : On initial presentation,

no evidence of intra abdominal injury, rupture

occurs > 48 hrs after trauma. It is a rare
complication.

Investigation
LabsHematology and chemistry
laboratory tests are of limited use in the
management of the acutely traumatized
patient. Baseline values. ( Hb every 6
hour)
CT scan
FAST exam
Diagnostic Peritoneal Lavage (DPL)
MRI

Focused Assessment with

Sonography for Trauma (FAST)
It is used in evaluation of the 4 acoustic window
o 4Ps pericardiac, perisplenic, perihepatic, pelvic.

In spleen trauma the US examination focuses on

dependent intra peritoneal sites where blood is
most likely to accumulate:
o the hepatorenal space (ie, Morrison's pouch),
o the splenorenal recess,
o the inferior portion of the intraperitoneal cavity
(including pouch of Douglas).

Fluid is Anechoic

 In general, FAST is done by the doctor in

the emergency room, its a rush
procedure to discover if there is
intraperitonial bleeding after the trauma.
Since that, we couldnt depend totally on
it .. because the patient may be
hemodynamically unstable, and FAST
exam results be normal ! >> so its not
100% sensitive.

Rx
Hemodynamically stable pt with
ve FAST
close observation, serial abdominal
exam, and follow up FAST exam
consider CT scan if pt is intoxicated
or has other associated injuries
Hemodynamically unstable pt
with ve FAST DPL, exploratory
laparotomy

Diagnostic Peritoneal
lavage (DPL)
DPL accurately determines the presence of
intraperitoneal hemorrhage in
hemodynamically unstable patients and
remains a valuable diagnostic tool in such
cases, particularly when ultrasound is
unavailable or the results of the FAST
examination are equivocal.
We insert the catheter, inject normal saline
through the catheter and see the fluid that is
coming out.
put urinary cath before to avoid bladder injury.

 Grossly positive DPL

> 10 mL of blood in catheter
aspiration. It indicates significant
hemoperitoneum
Positive by cell count
> 100,000 RBC/mm cubic

 The important note here is that those

days we dont use DPL any more
because we have CT which is more
diagnostic and applicable.

CT
CT is used as golden standard
diagnostic tool is Splenic trauma ..

Grading of splenic trauma

Depending in CT findings

Notes about treatment

If the patient come to the ER
unstable, we should directly take him
to the operating theater.
If was stable, we do FAST and CT,
admit his to the ICU, and put him
under carful observation, so if turned
unstable, to take him to the theater
as fast as possible

Treatment
Non operative conservative
ICU complete rest, under observation:
monitor vital sign, repeat physical examination,
Hct and Hb, frequent US and CT-scan.
Operative
-conservative splenorrhaphy (repair and
wound suturing)
-Partial splenectomy
-Total splenectomy: open or laparoscopic

Hemisplenectomy with preservation of

greater than 50% of splenic
parenchyma.

Operative vs. nonoperative

Non-operative treatment should be
considered only when:
1. Hemodynamically stable patient.
2. Grade I II splenic injury on CT scan
staging.
3. No free fluid or small amount in the
abdominal cavity.
4. No associated injuries requiring surgeries.
5. No severe head injury.

 Non operative management is most

successful in grade I to III, operative
intervention for grade IV and V.
Contraindicated if unstable,
persistent coagulopathy, other injury
requiring surgery.