Abdominal - Spleen Flashcards
What are the three approaches to a splenectomy?
Laparoscopic , Hand-assisted, and Open
The spleen span which set of ribs and in what anatomic position
Spans 9-11 along the mid to posterior axillary line and abuts the curvature of the stomach and tail of the pancreas.
What other structures does the spleen attach to and by which ligament(s)?
Fundus of the stomach, the left kidney, and colon; via gastrosplenic ligament (stomach), splenorenal ligament (left kidney), two avascular ligaments (splenocolic and gastrocolic ligaments).
What vascular structures are found within the splenorenal ligament?
Splenic artery and vein
What vascular structures are found within the gastrosplenic ligament?
the left gastroepiploic artery and short gastric arteries (supply the greater curvature of the stomach)
What preoperative preparation do patients need to undergo prior to elective splenectomy?
Receive vaccinations 1 week prior to procedure.
What vaccinations should patients receive preoperatively before an elective splenectomy?
Polyvalent pneumococcal, meningococcal, and Haemophilus vaccines are suggested
Describe a Grade I Splenic Laceration
- Subcapsular hematoma less than 10% of surface area
- Capsular laceration less than 1 cm in depth
What Grade?
- Subcapsular hematoma less than 10% of surface area
- Capsular laceration less than 1 cm in depth
Grade I laceration
Describe a Grade II Splenic Laceration
- Subcapsular hematoma 10% to 50% of surface area
- Intraparenchymal hematoma less than 5 cm in diameter
- Laceration 1 to 3 cm in depth not involving trabecular vessels
What grade Splenic laceration?
- Subcapsular hematoma 10% to 50% of surface area
- Intraparenchymal hematoma less than 5 cm in diameter
- Laceration 1 to 3 cm in depth not involving trabecular vessels
Grade II
Describe a Grade III Splenic Laceration
- Subcapsular hematoma greater than 50% of surface area or expanding
- Intraparenchymal hematoma greater than 5 cm or expanding
- Laceration more than 3 cm in depth or involving trabecular vessels
- Ruptured subcapsular or parenchymal hematoma
What grade Splenic laceration?
- Subcapsular hematoma greater than 50% of surface area or expanding
- Intraparenchymal hematoma greater than 5 cm or expanding
- Laceration more than 3 cm in depth or involving trabecular vessels
- Ruptured subcapsular or parenchymal hematoma
Garde III Splenic Laceration
Describe a Grade IV Splenic Laceration
Laceration involving segmental or hilar vessels with major devascularization (> 25% of spleen)
What grade Splenic laceration?
Laceration involving segmental or hilar vessels with major devascularization (> 25% of spleen)
Grade IV
Describe a Grade V Splenic Laceration:
- Shattered spleen
- Hilar vascular injury with splenic devascularization
What grade Splenic laceration?
- Shattered spleen
- Hilar vascular injury with splenic devascularization
Grade V
Key Steps of an open splenectomy:
Understand that a left costal margin incision is preferred in most elective procedures. Midline more optimal in ruptured cases.
- Mobilize the spleen by dividing ligamentous attachments, beginning with the splenocolic ligament
- Enter the lesser sac
- Realize that in patients with significant splenomegaly, early ligation of the splenic artery along the superior border of the pancreas is an option and may be preferred
- Incise the lateral peritoneal attachments, most importantly the splenophrenic ligament, and gently develop a plane deep to the spleen and tail of the pancreas.
- Next perform individual ligation and sequential division of the short gastric vessels
- Identify the tail of the pancreas and protect it from harm. The tail of the pancreas often lies within 1 cm of the splenic hilum.
- Ligate the splenic artery and vein before dividing them.
- Remove the spleen.
- Look for accessory spleens. Common locations are the splenic hilum, splenic pedicle, greater omentum, the tail of the pancreas, and splenocolic ligaments.
- Close the abdomen without drainage.
Incidence of post-splenectomy sepsis in children
1 in 175
Incidence of post-splenectomy sepsis in adults
1 in 400 to 500
Most common organisms in post splenectomy sepsis:
Encapsulated bacteria: Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis
Recent post splenectomy patients who present with vague abdominal pain should be worked up for?
Portal vein thrombosis
Who does Portal vein thrombosis affect the most?
Up to 40% for patients presenting with both splenomegaly and myeloproliferative disorders
Work up for portal vein thrombosis in recent splenectomy patients:
CT with contrast
Typical presentation in post-splenectomy patients?
Typical presenting symptoms and signs include anorexia, abdominal pain, leukocytosis, and thrombocytosis
When should a drain be placed in splenectomy case?
When there is a pancreatic injury
The majority of nonoperative failures occur in the first __ hours postinjury. Additional significant failure can occur up to ________ postinjury.
72; 1 month
Nonoperative treatment of splenic injuries
periods of serial examinations, laboratory monitoring, bed rest, and bowel rest. This varies between institutions and grade of injury
OPSI has a high mortality rate (_______), with survivors often having associate comorbidities
50% - 70%
What benign conditions are indications for a splenectomy?
Immune thrombocytopenic purpura (ITP), hereditary spherocytosis, hypersplenism and acute splenic sequestration in sickle cell disease, and splenic abscesses
What malignant conditions are indications for a splenectomy?
lymphoma and leukemia (diagnostic procedure) resulting in thrombocytopenia (therapeutic procedure)
Accessory spleens are present in approximately ____% of cases
15
Steps for Laparoscopic splenectomy
- For normal size spleens approached laparoscopically, the right lateral (or semi-lateral) position is often used with the camera port in the periumbilical position, a 5-mm trocar subxiphoid, and two trocars along the left costal margin (with one usually a 12-mm port to allow for stapler placement
2.
Gastric Varices is likely caused by ?
Splenic thrombosis
Treatment: Splenectomy
Repeated episodes of pancreatitis and the associated inflammation result in…
Splenic vein thrombosis.
Isolated thrombosis of the splenic vein causes localized splenic venous HTN and gives rise to large collaterals from the spleen to the gastric fundus
What is the most common benign neoplasm of the spleen?
Hemangioma
MRI highly specific/sensitive
Not recommend to biopsy due to risk of rupture or bleeding
Treatment for Ectopic Spleen?
Splenopexy
What is the most common lymphoma among patients with AIDS?
Aggressive, high-grade lymphoma of B-cell origin
