Disusun oleh:

dr. Aji Prabowo (JIP)

   
Pembimbing:
SPLEEN dr. Bambang Suprapto. Sp.B-KBD
dr. Ahmad Tabroni Sp. B -KBD

SMF ILMU BEDAH

RSUD Abdul Wahab Sjahranie
2019
Embryogenesis of the Spleen

•
Embryogenesis of the Spleen
Development of splenic ligaments
GROSS ANATOMY OF THE SPLEEN
Location of the spleen
According to Michels, the spleen has three forms

shapes
Segmental Anatomy
 Spleen 7cm
• Length-12 cm(5 inch)
• Breadth-7cm(3 inch)
• Thickness-3cm (1inch)
• Weight-150gm(7 oz)
(80 -300 gr).
• A splenic lobule that fails to coalesce with the
developing spleen can persist as a 12 cm
supernumerary or accessory spleen . This fully
functional island of splenic tissue is found in
approximately 10% of individuals and may be
located in any part of the abdomen, or even
outside it, but is most commonly present near
the splenic hilum within the gastrosplenic
ligament or greater omentum 3 – 4 cm
 EXTERNAL FEATURES

• The spleen has :

• Two ends /
angels
• Three borders
• Two surfaces
• Hilum
 IMPRESSIONS ON VISCERAL
SURFACE
• Gastric impression
• Renal impression
• Colic impression
• Pancreatic impression (Tail)
Ligaments
• Gastro-splenic
• Lieno-renal

• Lieno-phrenic
• Phrenico-colic
 NERVE SUPPLY

• The spleen is innervated by both components of the autonomic nervous system;

the sympathetic supply is dominant. Postganglionic sympathetic nerves from
the coeliac plexus and parasympathetic nerves from the vagal trunks travel
with the splenic vessels
 The splenic artery, in most people, is a branch of the celiac trunk, arising
together with the common hepatic and left gastric arteries.
 The splenic artery varies in length from 8 to 32 cm and in diameter from 0.5
to 1.2 cm.
 The normal course of the splenic artery crosses the left side of the aorta,
passes along the upper border of the pancreas reaching the tail in front, and
then crosses the upper pole of the left kidney.
 The splenic vein travels with the splenic artery.
 One of the peculiarities of the spleen is the lack of provision for lymphatics
for the splenic pulp.
Accessory Spleens
Trauma with splenic injury
• Spleen is particularly liable to rupture in
falls and automobile accidents and
bleeding from it is difficult to control and
Splenectomy should be done.

• A splenectomy is a surgical
procedure that partially or completely
removes the spleen.
 Total splenectomy
• Total open splenectomy (the removal of the
spleen in toto) can be performed by an
anterior approach or a posterior approach
• a well-developed presplenic fold, six sheets of
peritoneum, fat, lymph nodes, and pancreas
fused into a single mass
 SURGERY OF THE SPLEEN
Twelve Principles of Splenic Surgery
1. Know surgical anatomy.
2. Know clinical and surgical pathology.
3. Know surgical procedures.
4. Perform a physical examination.
5. Assess the diseased spleen.
6. Know how to treat a ruptured spleen.
7. Perform adequate preoperative preparations.
8. Adhere to operating room rules.
9. Place the patient in a convenient position.
 Twelve Principles of Splenic Surgery

10. Choose an incision.

11. Assess congenital anomalies and variations.
12. Provide optimal postoperative care.
Preoperative Preparation

• Consent
• FBC, U&E, G&H (consider Xmatch)
• Platelets may be required
• Peri-operative antibiotics – usually IV cefazolin
at Induction, to continue for 24hours
• Pneumococcal vaccine 2weeks prior to surgery
(in emergency, it is given 2 weeks post op)
 Infection Risk in Splenectomised
patients
The risk of post-splenectomy sepsis is greatest in
the following groups:
• younger children
• early in the post-operative course (up to 2
years)
• individuals with an underlying haematologic
disorder
• immune suppressed children - eg cancer
disease
Immunisations
• No vaccines are contraindicated for
splenectomised /hyposplenic patients.
• Ensure patient is up to date with routine
immunisations according to National
Immunisation
• Schedule, especially pneumococcal,
Haemophilus influenzae type b (Hib)
 Immunisation

• Additional immunisations are recommended

for asplenia/hyposplenia; commence
immunisation programme as soon as
condition is recognised.
• For elective splenectomy extra immunisations
should be commenced as soon as possible and
at least 2 weeks pre-operatively
• For emergency splenectomy commence
immunisations 2 weeks post-operatively
 Antibiotic prophylaxis

• Some children may require long term

antibiotic prophylaxis against pneumococcal
infection (with amoxicillin, penicillin or
erythromycin if beta lactam allergy)
 TECHINIQUE
• Anaesthesia; general with cuffed ETT
• Position; supine
• Surgeon, assistant and periop. nurse scrub,
gown and gloved. With the surgeon on the right
side of the patient the assistant on the left and
the peri-op the left side of the assistant.
• The skin is prepared from the nipple line to the
mid-thigh and draped
• Incision
– Emergency - upper midline incision
– Elective- left subcostal incision
TECHINIQUE

Splenectomy Due to Hemorrhage Secondary to

Trauma
Step 1. Make an incision.
Step 2. Mobilize the spleen.
Step 3. Ligate the vessels.
Step 4. Divide the hilum.
Step 5. Obtain hemostasis.
Step 6. Provide drainage.
Step 7. Close the wound.
Procedure (trauma)
• Incision deepened to access the peritoneal cavity.
• Pack the 4 quadrant of the peritoneal cavity
• Suck out all free blood and clot
• Remove packs starting from least area of bleeding.
• Use your fingers to temporarily secure hemostasis at
the hilum(to prevent clamping of the tail of pancreas)
• Place the left hand on the spleen and draw it down to
divide the lieno renal ligament lying posteriorly
• Deliver the spleen into the abdominal incision
• Then a non-crushing clamp is applied at the hilum
safeguarding the pancreas
• Examine the spleen for grade of injury
• Ligate and divide; the short gastric arteries, left gastro-
epiploic arteries. Slightly away from the stomach with
non absorbable suture
TECHINIQUE

Splenectomy Due to Hematological Disorders

(Hypersplenism)
Step 1. Make an incision.
Step 2. Ligate the arteries.
Step 3. Mobilize the spleen.
Step 4. Divide the hilum.
Step 5. Obtain hemostasis.
Step 6. Search for accessory spleens.
Step 7. Provide drainage.
Step 8. Close the wound.
Compression of splenic vessels
 Partial splenectomy
• Decision is based upon the age of the patient,
the condition of the patient, and the condition
of the spleen.
• Procedure of choice:
• Splenorrhaphy
• Splenorrhaphy with omental fixation
• Debridement, perhaps with
partial splenectomy and
omental fixation
• Splenic mesh wrap
• Autotransplantation
Technique of Intrasplenic Dissection

• With scalpel, make a superficial anterior

incision of the splenic capsule on the viable
side of the line of demarcation.
• Using the scalpel handle, gradually deepen the
incision until the entire spleen has been
divided.
• Ligate all vessels with hemoclips or with
figure-of-eight 4–0 silk.
• In partial splenectomy or a deeply lacerated
spleen, use absorbable mesh.
• Observe the splenic remnant for 10 min to
ascertain the completeness of
hemostasis.
• The surgeon should determine whether
drainage is required.
Thank You
 References
• Andrew T Raftery, applied basic sciences for
basic surgical training, second edition, 2008
• Skandalakis L. Skandalakis J. Surgical anatomy
and techinique, fourth edition, 2014
• Skandalakis’ surgical anatomy, skandalakis
TOC.mht
 Effects of splenectomy
Haematological effects
• capacity of the spleen to remove immature or
abnormal red cells from the circulation reduces
• The red cell count does not change, but red cells
with cytoplasmic inclusions increases
• Target cells, reticulocytes and siderocytes appear
within a few days of operation.
• Granulocytosis occurs immediately after
splenectomy
• The platelet count is usually increased
Postsplenectomy sepsis
• the younger the patient undergoing splenectomy
and the more severe the underlying condition,
the greater is the risk of developing
overwhelming postsplenectomy sepsis
• Streptococcus pneumoniae, Haemophilus infl
uenzae and meningococci are the most common
pathogens.
• The risk of fatal sepsis is less after splenectomy
for trauma.
• For planned procedures a polyvalent
pneumococcal vaccine should be given prior to
splenectomy
• The vaccine is only effective against 80% of
pneumococcal organisms.
• it is recommended that prophylactic penicillin
be given for two years after splenectomy
• Antibiotic prophylaxis is essential in children
under two years of age.
• Some authorities believe that antibiotic
prophylaxis should be continued for life.
• Vaccination against H. influenzae type b (HiB)
and meningococci A and C should also be
given
Summary of immunisation
Summary of immunisation