Surgery of the Spleen, Liver and Pancreas Flashcards
Where is the Spleen suspended? & what is it attached to?
In greater omentum & attached to greater curvature of stomach (gastrosplenic lig)
Describe the blood supply of the spleen
Coeliac artery → splenic artery →dorsal and ventral branches → short gastric arteries & left gastroepiploic artery before entering the spleen. Also pancreatic branch supplies left lobe pancreas, splenic vein drain to portal vein
Describe functions of spleen
blood filtration, phagocytosis, haematopoiesis (foetus), storage of platelets, production of B and lymphocytes, iron metabolism and storage and activation of factor VIII
List some indications for Splenic Surgery
- Splenic Neoplasia
- Splenic Torsion
- Gastric dilatation/volvulus with splenic
necrosis - Infiltrative Disease and Infarction
- Traumatic Splenic Rupture
- Non neoplastic Splenic Mass
- (Haematoma, Abscess, Nodular hyperplasia)
- Immune mediated disease
- Iatrogenic trauma
what is a typical clinical presentation for haemoabdomen?
- If no history of trauma, most common presentation splenic mass
- Generally older large breed dog
- Presents with pale membranes
- Sometimes collapsed
- Signs of severe haemorrhage-tachycardia, weak pulse, abdominal swelling
Is it possible to see more chronic presentations for haemoabdomen?
YES! -> Intermittent weakness, collapse, can resemble orthopaedic condition
Causes of Haemoabdomen?
- Rupture of abdominal mass (splenic, hepatic, adrenal)
- Coagulopathy
- Splenic torsion
- Splenic infarction
- Rupture of splenic haematoma
- Liver lobe torsion
- Trauma to spleen/liver/kidney
List different splenic masses we may find?
- Haemangioma
- Haemangiosarcoma
- Leiomyoma
- Leiomyosarcoma
- Fibroma
- Plasma Cell Tumour
- Mast cell tumours
- Lymphoproliferative disorder
What diagnostics might we do for splenic sx?
- abdo palp
- US 4 quadrants for fluid
- Abdo aspiration of bloody fluid that does NOT clot
- Radiography - splenic enlargement, loss of serosal detail
- Haematology/ Biochemistry -> regen anaemia
- PCV/TS dec
- Cardiac US for PG
- Assess coag if sx
Also Splenic biopsy is rarely done what two ways can it be done?
- Percutaneous FNA, needle biopsy (US guided)
- Via celiotomy
Describe percutaneous FNA
- Difficult to interpret due to blood
- Care with cavitary lesions
Describe biopsy via coeliotomy?
- Punch of boiopsy needle -> topical haemostatic agents
- In centre -> oval incision (close with SI or mattress sutures)
- On margin -> overlapping sutures
Splenecotmy?
- Spleen is not essential and can be removed
- Be aware of extramedullary haematopoiesis
- Splenic infarcts
Splenectomy patients may be …
- Anaemic, hypovolaemic, dehydrated
- Coagulation disorder
- Perform APTT/PT
- DIC
What two routes of haemostasis for splenectomy?
- Ligate splenic artery & vein distal to the pancreatic branch and then ligate short gastric arteries
OR - Ligate individual hilar vessels 1-2 cm from spleen starting at most mobile end
What considerations with option 1?
- Mass/adhesions / fat may make this difficult
- Risk of damage to pancreas
Describe the second technique further
- Double/triple ligate larger vessels
- Smaller vessels can eb ligated in groups
- Ligate and transect omentum
- Stapling devices may also be used
What is step 1 of splenectomy?
Open the omental bursa & ligate ->
- The splenic A & V distal to pancreatic branch
- The short gastric arteries
What is step 1b?
If you choose other way of doing it can ligate the hilar vessels instead as seen above
describe neoplasia occurence in the spleen
- 2/3 of splenic masses are tumours
- 2/3 of tumours are haemangiosarcoma
- 1/2 to 2/3 metastasised at diagnosis
- 75% of haemoabdomens are due to HAS
Clinical signs of Splenic Haemangiosarc?
acute collapse, pale mucous membranes, abdominal distension,
* hypovolaemic shock
On PE with splenic haemagioS …
palpable abdo mass & haemoperitoneum
Dx of splenic Haemagios
US & abdocentesis
also:
anaemia, thrombocytopaenia, lack of clotting factors, cardiac arrythmia
Haemagionsarc may have to be euthanased - esp in what breedS?
GSD, GR, Boxers, Labs, GD, Poodles
What might objective of sx be ?
arrest haemorrhage rather than prevent metastases
What steps to splenic haemagioS management when it comes in?
- Stabilise -> fluids ++ ; +./- blood transfusion
- Splenectomy -> check liver, mesentery & omentum for masses & biopsy abn tissue
- Some non neoplastic liver nodules may be seen beware
TX/ PG?
- Survival with surgery alone 19-65d
- Doxorubicin (mean survival 140-202d)
- Metronomic chemotherapy (mean survival 178 days)
- Metronomic is low dose frequent therapy
- Cats most commonly mast cell tumour (mean survival 360
-570 days)
what complications of splenic SX?
- Haemorrhage
- Ventricular arrythmias
- Pancreatitis
- Increased risk of GDV
- Perioperative death
- If haemangiosarcoma is present, surgery often palliative
- Tumour metastases
Describe splenic torsion
- Torsion aroudn vascular pedicle alone or with GDV
- Large and giant breeds, Bulldog predisp too
CLS of splenic torsion?
vomiting, listlessness, weakness, abdominal pain, diarrhoea, jaundice,
haematuria and collapse.
PE on splenic torsion ?
- Pyrexia, dehydration, pale mm,
hypovolaemic shock - Enlarged spleen may be palpable
Diagnosing splenic torsion?
: hypoechoic and distended spleen
+/- doppler
tx for splenic torsion?
- Treatment; stabilise with fluids, give
antibiotics - splenectomy without untwisting
- avoid damage to the vessels to the left
lobe of the pancreas
What post op risk with splenic torsion?
Pancreatitis
PG for splenic torison sx?
good if done early
Describe splenic trauma?
- Not uncommon
- aggressive fluids +/- bloods
- Abdo pressure bandage
What surgical options for splenic trauma?
- suture capsule
- partial splenectomy
- splenectomy
Why would we do a pre-emptive gastropexy following splenectomy?
- Some evidence of increased risk GDV
following splenectomy - Different studies have shown conflicting
evidence - Maybe worthwhile performing gastropexy
after splenic torsion
How many lobes of liver?
6
Blood supply of liver?
Portal vein (80%) + hepatic artery (20%)
Describe billiary system ?
- Gall bladder -s tores bile
- CBD -> duodenum (papilla) -> adjacent to pancreatic duct in dogs; joint prior to duodenum in cats
Functions of the liver?
- Metabolism of carbohydrates, proteins & lipids
- Detoxification & excretion of toxins including anaesthetic agents
- Major role in haemostasis
What Diagnostics helpful in liver dx?
- Radiography non-specific hepatomegaly
- US very useful
- FNA or Trucut biopsy (US guided) useful for diagnosis
- Laparoscopic liver biopsy very useful
Treatment principles with liver?
- Localized disease can be treated surgically
- Diffuse disease treated medically
What are some peri-op considerations for liver sx?
- Haemorrhage -> Clotting times should be measured
- Hepatic encephalopathy -> Ab & lactulose pre-sx
- Hypoproteinaemia or electrolyte imbalances -> correct
- hypoglycaemia -> glucose infusion
- Care with hepatotox drugs
- Give ABs
Difficulty with haemorrhage in liver?
Extremely friable -> placement of ligatures difficult
What can we do about haemorrhage given it is the main complication of liver op?
- direct pressure
- Topical haemostatic agents
- Inflow occlusion
- Vessel sealing devices
- Electrocautery
- Hepatic artery ligation
give examples of topical haemostatic agents?
- gelatin sponge (Gelfoam)
- oxidised regenerated cellulose (Surgicell)
Describe inflow occlusion?
- Pringle manoeuvre - occlusion of hepatic artery and portal vein – place thumb across
the epiploic foramen; Dogs can tolerate < 20 minutes
Describe liver biopsy
- For bact culture, histopath, copper & ion
- Dx & monitoring
Minimally invasive options:
- US guided FNA
- US guided Trucut
- Laparoscopic
How do we do a liver biopsy/ tumour removal?
- Wedge biopsy edge of liver lobe using haemostat
- Guillotine biopsy with suture material at end of lobe
- Large biopsy require several overlapping ligatures
- Punch biopsy for central areas/lesions
- Omentum is a useful dressing
We can do a ….. or …… lobectomy
partial or total
How much liver can we remove?
up to 80%
What difficulty about quadrate or medial lobe lobectomy?
Care gallbladder, cystic duct & CBD
What difficulty with right lateral & caudate lobectomies?
Care caudal vena cava, hepatic artery & portal vein and CBD
Liver trauma?
- Common
- Stabilise with fluid, pressure bandage,
monitor PCV
Liver lobe torsion?
- Rare
- Large breed dogs
- Collapse and death if not treated
Hepatic abscesses?
- Migrating skewers
Hepatic neoplasia - how metastatic?
MEts 2.5X more common than primary neoplasia?
What liver neoplasia do digs get?
- Hepatocellular carcinoma most common
- Nodular/ diffuse -> no surgery super metastatic
- Solitary & large - >low metastases, slow, resection does okay
What liver neoplasia do cats get?
- Cholangiocellular adenoma most common -> lobectomy if amenable, good pg
What surgical pathologies of gall bladder and billiary tract?
- Gall bladder mucoceles
- Biliary Tract Rupture
- Extrahepatic Biliary Tract
Obstruction - Portosystemic Shunts
What is the msot common reason for sx of billiary tract?
Gall bladder mucocoele
CS of Mucocoele?
non sp
inc bilirubin, ALt , ALP
Dx of Mucocoele?
looks like kiwi fruit
Tx for mucocoele?
cholecystectomy
Detail cholecystectomy?
- Must check patency of CBD by catheterising duodenal
papilla - Ligate cystic duct and artery
- Care damage to liver parenchyma
Describe types of PSS?
- Young animals (<12 months)
- Intrahepatic - large breed dogs
- Extrahepatic - small breeds
- Congenital or Acquired
CLs of PSS?
- lack of growth and poor condition
- hepatic encephalopathy- disorientation, agitation, seizures blindness, hepatic coma and ataxia
- vomiting, diarrhoea, pica
- Hyper salivation & copper coloured irises in cats
- Polyuria, polydipsia, ammonium urate urolithiasis
PSS Diagnostics?
- *+/- elevation of pre and post prandial
bile acids - mild microcytic anaemia
- hypoalbuminaemia, hypoglycaemia, low
urea, ↑ ALP and ALT - scintigraphy, ultrasonography, venous
portography = definitive diagnosis
PSS tx approach?
medical first then sx
What does medical management of PSS involve?
- DIetary protein restriction
- Oral or rectal lactulose (alters intestinal pH & favors retention of ammonia in gut lumen )
- Oral ABs -> reduce bact load = dec ammonia
- Supportive (IVFT)
- Anticonvulsant if seizures
What does medical tx do?
- Reduces clinical signs but does not stop deterioration of liver
- Long term medical management where not financially able to treat surgically (can live years)
- Acquired shunts are not usually amenable to surgery as multiple and tortuous
PSS tx ?
- Ligate abnormal vessel
- Complete attenuation →life threatening portal
hypertension - Several methods for gradual occlusion
- Peri-op mortality up to 25%
How do we deal with extrahepatic shunts?
- Ligation: silk or synthetic non absorbable suture material
- Ameroid constrictor rings= gradually expands →vascular constriction + foreign body reaction
- Cellophane banding =foreign body reaction and gradual occlusion
How do we deal with intrahepatic shunts?
- Ligation: silk or synthetic non absorbable suture material
- Ameroid constrictor rings
- Cellophane banding
- Percutaneous coil embolisation
- Extravascular anastomoses
What does an extravascular anastamoses involve?
Create artificial extrahepatic shunt, completely occlude the
intrahepatic shunt and gradually occlude the artificial shunt vessel
PSS Post op care?
- Monitor: temperature, glucose, albumin and PCV
- Continue medical treatment for 6 weeks after
surgery - Assess liver function with BAS
- May require second surgery if still some blood flow
PSS COmplications?
- Portal hypertension (first 72hrs, can get ascites)
- Seizure (pre-treat with levetiracetam; 12 hrs - 3 days)
- Hypoglycaemia
The pancreas has two sections/functions :
Exocrine (digestive enzymes and bicarbonate) and endocrine (insulin and glucagon)
Structure of pancreas?
Right lobe (in mesoduodenum), left lobe (in greater omentum), central body (adjacent to the pylorus)
Dog pancreas?
- 2 pancreatic ducts
- pancreatic duct (major duodenal papilla) and accessory duct ( minor deuodenal papilla).
Cat pancreas?
only pancreatic duct
Indications for pancreatic sx?
- Biopsy
- Neoplasia
- Cysts/pseudocysts
- Abscessation
PAncreatic patients may be …
anorexic, painful, vomiting, electrolytes abnormalities-> make sure to stabilise first
Pancreatic biopsy usually done for …
Diffuse dx -> most easily accessible region (usually the distal aspect of the right limb) is sampled
HOW do biopsy pancreas?
- Avoid excessive handling by manipulation of adjacent structures (i.e. mesodeuodenum)
- Avoid tissue desiccation
- Biopsy at edges to avoid ducts
What two ways to biopsy edges/avodi ducts
➢ Guillotine - loop of suture used to ligate a small section or lobule
➢ Dissection - use a mosquito forcep to carefully dissect between lobules*
* vessels and ducts are ligated& the biopsy is excised
Can we do a partial pancreatectomy?
yes can remove 70-90% but do not remove body or proximal right lobe (ducts)
Can we do total pancreatectomy?
NO
What three pancreatic neoplasias?
- INSULINOMA
- Gastronoma
- Glucagonoma
Describe Insulinoma
- MOst common
- From beta cells
- 51% metastases at diagnosis
CLS & Dx of insulinoma?
- Clinical signs of excess insulin -> Hypoglycaemia
= Weakness, tremors, collapse, seizures, ataxia - Diagnosis difficult – not readily detected by US
= Requires ex-lap and biopsy
Tx & complications of insulinoma?
- Treatment – excision/partial pancreatectomy dependent upon location
- Complications – pancreatitis, hypoglycaemia (not fully excised), hyperglycaemia
Medical maangement from insulinoma?
- Diet and feeding
- Glucocorticoids
PAncreatic post op monitoring?
Fluids, electrolytes, glucose
What. isa major complication of pancreatic surgery?
Pancreatitis
How to avoid pancreatitis?
- Gentle handling
- Avoid operative hypotension
- Aggressive fluid therapy perioperative
- Early feeding/enteral feeding
- Naso-oesophageal,
oesophageal
What types of biopsies can. wedo of LNs?
- FNA
- Tru-cut
- Wedge
- Excisional
