Splenectomy
Introduction
Surgical Anatomy of the Spleen
Topography and Relations
Splenic Functions
Operative Indication
Operative Technique
Post Operative Care
Referensi : Skandalakis, Zollinger,
Townsend
The spleen measures
1 x 3 x 5 inches (2.5 x
7.5 x 12.5 cm)
The spleen weighs 7
oz (220 g)
The spleen relates to
left ribs 9 through 11
Splenic borders
Spleen is defined as having three to five
segments
Three-dimensional zones
General arterial distribution
Peritoneal attachments of the
spleen
Eight ligament
Possible configurations of the blood supply to the
distal pancreas
Splenic vein
Lymphatic drainage
Two groups: the nodes of the splenic hilum and the
nodes of the tail of the pancreas
Assesory Spleen
supernumerary spleen,
splenule, or splenunculus)
is a small nodule of splenic
tissue found apart from the
main body of the spleen
They may be found
anywhere along the splenic
vessels, in the
gastrosplenic ligament, the
splenorenal ligament, the
walls of the stomach or
intestines, the pancreatic
tail, the greater omentum,
or the mesentery
Splenic Functions
Four function : blood storage, hematopoiesis,
filtration, and immunologic response
Filtration
A. Cullingerythrocyte (or other blood cell)
destruction
1. Physiologic (as red blood cells age)
2. Pathologic
a.Associated with blood cell abnormalities
b.Associated with primary splenic changes
B. Pitting ("facelifting" of erythrocytes)
1. Removal of cytoplasmic inclusions
2. Remodeling of cell membranes
C. Erythroclasisdestruction of abnormal red blood
cells with liberation into circulation of erythrocyte
fragments
Indications for Surgery
Trauma
Non Trauma :
Hypersplenism
Congenital anemias
Hemolytic anemias
Leukemia or lymphoma
Other nonspecific diseases
Hodgkin staging
Miscellaneous
Abscess
Cyst
Tumor
The Technical Steps in Performing a
Splenectomy
For Trauma
Incision
Mobilizing the
spleen
Vascular ligation
For Hematologic
Disorders
Incision
Arterial ligation
Mobilizing the spleen
Dividing the hilum Dividing the hilum
Hemostasis
Hemostasis
Drains
Accessory spleen
Closure
Drains
Closure
Staging Procedure
Incision
Detailed exploratory
laparotomy (lymph
nodes)
Wedge and needle
biopsies of both lobes
of liver
Total splenectomy
Retroperitoneal
exploration
Biopsy of iliac crest
marrow
Search for accessory
spleens
Translocation of
ovaries
Incision
Ligation of the Splenic Pedicle: Anterior
Approach
1. Incision
2. Clamp, incise, and ligate the left part of the
gastrocolic ligament and the gastroepiploic artery and
vein. This will provide access to the lesser sac
3. Locate the splenic artery at the superior border of the
body of the pancreas. Carefully ligate the artery in
continuity and doubly, with ligatures being placed as
distally as possible
4. Clamp, divide, and ligate the short gastric arteries and
veins, one at a time
5. Mobilize the spleen by dividing the several ligaments
with scissors. Insert the index finger deeply to
separate the spleen from the renal covering. With the
use of sharp and blunt dissection, clamp, divide, and
ligate the splenocolic and splenophrenic ligaments
Ligation of the Splenic Pedicle: Anterior
Approach
6. Elevate the spleen, tail, and part of the body of the
pancreas, being particularly careful with the tail of the
pancreas. The spleen is now outside the peritoneal
cavity and is attached only by one of the branches of
the splenic arteries and veins.
7. Close to the hilum, clamp, divide, and ligate all
branches of the splenic artery. The splenic vein and its
branches are easily torn and should not be clamped.
Ligate and divide the splenic vein and branches in
continuity with 20 silk. The spleen is now free and
should be removed
8. Inspect the site for bleeding, beginning with the
diaphragm and continuing to the greater curvature of
the stomach, pancreatic tail, gastrosplenic ligament,
splenorenal ligament, splenocolic ligament, and
splenic bed and other ligaments
Ligation of the splenic artery and the
short gastric arteries and vein
Division of the ligaments and delivery of the spleen
to the outside of the peritoneal cavity
Ligation of the Splenic Pedicle:
Posterior Approach
1. Hold the spleen medially
2. Divide the splenorenal, splenophrenic, and
splenocolic ligaments
3. Lift the spleen outside the peritoneal cavity, being
particularly careful with the tail of the pancreas.
4. Dissect rapidly and mobilize the bleeding spleen
immediately.
5. Bleeding
can
be
controlled
by
manually
compressing the splenic artery and vein and the
tail of the pancreas between the thumb and index
finger or with a noncrushing clamp (Fig.
6. Ligate the arterial and venous branches close to
the hilum using 20 and 30 ligatures. Doubly ligate
the splenic artery Ligate the short gastric vessels.
7. Remove the spleen and secure any bleeding points.
Medial position of the spleen during the posterior
approach
to
splenectomy, showing division of the splenocolic
ligaments.
Compression of the splenic artery and
vein
Ligation of the splenic artery
Post Operative Care
A nasogastric tube is continued in place until evidence of
effective gastric emptying is clearly present.
Complications : Pancreatic fistula, Gastric fistula,
Overwhelming postsplenectomy sepsis may occur
Incentive spirometry and pulmonary toilet are important
to limit postoperative atelectasis and pneumonia.
Prophylaxis for deep venous thrombosis (DVT) with
fractionated heparin may begin on postoperative day 1.
In the patients who undergo splenectomy, immunization
against pneumococcus, meningococcus, and Haemophilus
infl uenzae should be administered before discharge from
the hospital
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