Principles of Splenic Surgery

Contentbull Anatomybull Splenic functionbull Hypersplenismbull Splenectomybull Lap vs open splenectomybull Outcomesbull Complicationsbull Splenic traumabull Splenic repairsbull Conservative treatment

Anatomybull The spleen is situated principally in the left

hypochondriac region but its superior extremity extends into the epigastric region it lies between the fundus of the stomach and the diaphragm

bull It is the largest of the ductless glands and is of an oblong flattened form soft of very friable consistency highly vascular and of a dark purplish color

bull The normal size and weight vary somewhat The approx size is 12cm(length) x 7cm(width) x 3-4cm(thickness) with an average weight of 150g (range 80-300g)

Anatomy

Tail of Pancreas-Direct contact withspleen in 30-Otherwise within 1 cm

Relations

bull The diaphragmatic surface (facies diaphragmatica external or phrenic surface) is convex smooth and is directed upward backward and to the left except at its upper end where it is directed slightly medialward It is in relation with the under surface of the diaphragm which separates it from the ninth tenth and eleventh ribs of the left side and the intervening lower border of the left lung and pleura

Contentbull Anatomybull Splenic functionbull Hypersplenismbull Splenectomybull Lap vs open splenectomybull Outcomesbull Complicationsbull Splenic traumabull Splenic repairsbull Conservative treatment

Anatomybull The spleen is situated principally in the left

hypochondriac region but its superior extremity extends into the epigastric region it lies between the fundus of the stomach and the diaphragm

bull It is the largest of the ductless glands and is of an oblong flattened form soft of very friable consistency highly vascular and of a dark purplish color

bull The normal size and weight vary somewhat The approx size is 12cm(length) x 7cm(width) x 3-4cm(thickness) with an average weight of 150g (range 80-300g)

Anatomy

Tail of Pancreas-Direct contact withspleen in 30-Otherwise within 1 cm

Relations

bull The diaphragmatic surface (facies diaphragmatica external or phrenic surface) is convex smooth and is directed upward backward and to the left except at its upper end where it is directed slightly medialward It is in relation with the under surface of the diaphragm which separates it from the ninth tenth and eleventh ribs of the left side and the intervening lower border of the left lung and pleura

Anatomybull The spleen is situated principally in the left

hypochondriac region but its superior extremity extends into the epigastric region it lies between the fundus of the stomach and the diaphragm

bull It is the largest of the ductless glands and is of an oblong flattened form soft of very friable consistency highly vascular and of a dark purplish color

bull The normal size and weight vary somewhat The approx size is 12cm(length) x 7cm(width) x 3-4cm(thickness) with an average weight of 150g (range 80-300g)

Anatomy

Tail of Pancreas-Direct contact withspleen in 30-Otherwise within 1 cm

Relations

bull The diaphragmatic surface (facies diaphragmatica external or phrenic surface) is convex smooth and is directed upward backward and to the left except at its upper end where it is directed slightly medialward It is in relation with the under surface of the diaphragm which separates it from the ninth tenth and eleventh ribs of the left side and the intervening lower border of the left lung and pleura

Anatomy

Tail of Pancreas-Direct contact withspleen in 30-Otherwise within 1 cm

Relations

bull The diaphragmatic surface (facies diaphragmatica external or phrenic surface) is convex smooth and is directed upward backward and to the left except at its upper end where it is directed slightly medialward It is in relation with the under surface of the diaphragm which separates it from the ninth tenth and eleventh ribs of the left side and the intervening lower border of the left lung and pleura

Relations

bull The diaphragmatic surface (facies diaphragmatica external or phrenic surface) is convex smooth and is directed upward backward and to the left except at its upper end where it is directed slightly medialward It is in relation with the under surface of the diaphragm which separates it from the ninth tenth and eleventh ribs of the left side and the intervening lower border of the left lung and pleura

Drawing - Visceral surface of the spleen illustrating the splenorenal ligament and the vessels contained within

bull The visceral surface is divided by a ridge into an anterior or gastric and a posterior or renal portion

bull The gastric surface (facies gastrica) which is directed forward upward and medialward is broad and concave and is in contact with the posterior wall of the stomach and below this with the tail of the pancreas It presents near its medial border a long fissure termed the hilum This is pierced by several irregular apertures for the entrance and exit of vessels and nerves

bull The renal surface (facies renalis) is directed medialward and downward It is somewhat flattened is considerably narrower than the gastric surface and is in relation with the upper part of the anterior surface of the left kidney and occasionally with the left suprarenal gland

bull The superior extremity (extremitas superior) is directed toward the vertebral column where it lies on a level with the eleventh thoracic vertebra

bull The lower extremity or colic surface (extremitas inferior) is flat triangular in shape and rests upon the left flexure of the colon and the phrenicocolic ligament and is generally in contact with the tail of the pancreas

bull The anterior border (margo anterior) is free sharp and thin and is often notched especially below it separates the diaphragmatic from the gastric surface

bull The posterior border (margo posterior) more rounded and blunter than the anterior separates the renal from the diaphragmatic surface it corresponds to the lower border of the eleventh rib and lies between the diaphragm and left kidney The intermediate margin is the ridge which separates the renal and gastric surfaces

bull The inferior border (internal border) separates the diaphragmatic from the colic surface

bull The spleen is almost entirely surrounded by peritoneum which is firmly adherent to its capsule It is held in position by two folds of this membrane

bull The parietal peritoneum adheres firmly to the splenic capsule except at the splenic hilum The peritoneum extends superiorly laterally and inferiorly creating folds which form the suspensory ligaments of the spleen

bull The splenocolic and the splenophrenic ligaments are relatively avascular

Ligaments

bull The splenorenal ligament runs from the anterior left kidney to the hilum of the spleen as a two layered fold in which the splenic vessels and the tail of the pancreas are invested

bull The other fold the gastrosplenic ligament is also formed of two layers derived from the general cavity and the omental respectively where they meet between the spleen and stomach the short gastric and left gastroepiploic branches of the splenic artery run between its two layers The lower end of the spleen is supported by the phrenicocolic ligament

Ligaments

Suspensory Ligaments

Gastrosplenic Ligament1048707 Short Gastric Vessels1048707 Gastroepiploic Vessels

Splenorenal Ligament1048707 Splenic Vessels1048707 Tail of Pancreas

Splenocolic Ligament

Phrenicocolic Ligament1048707 Phrenicosplenic ligament

Blood supplybull The celiac axis ndash largest but shortest branch

of the abdominal aorta 15-20mm longbull Arises above the body of the pancreas and

in 82 of specimens divides into three primary branches

1048707 The left gastric artery

1048707 The hepatic artery

1048707 The splenic artery

Splenic Artery

bull In rare instances the splenic artery originates directly from the aorta and even less often a second splenic artery arises from the celiac axis

bull Other variations include the splenic artery originating from the Superior mesenteric artery the middle colic artery the left gastric artery the hepatic artery or the accessory right hepatic artery

bull As a rule the splenic artery arises from the celiac axis to the right or the midline which means that the aorta must be crossed to reach the spleen and that selective angiography is likely to be difficult at times

bull Acounts for approximately 5 of cardiac output

bull It courses along the superior border of the pancreas and the branches include numerous pancreatic branches the short gastric branches the left gastroepiploic artery and the terminal splenic branches

bull Splenic arterial geography can be divided into 2 types ndash Distributed or Magistral (Michels NA The variational anatomy of the spleen and splenic artery Am J Anat 70 21 1942)

30 - Magistral

-Branches originate 3-13cm from hilum

-Transverse Anastomoses ndash whyembolization clipping may fail

-Pancreatica Magna ndash embolic debris from angio may cause pancreatitis

70 - Distributed

-Branches originate within 35 cmof hilum

-L Gastroepiploic arteryndash Mostvaried of splenic branches (72arise several cm from splenic arteryproximal to terminal branching

Histology

bull The spleen is invested in a fibroelastic capsule from which trabeculae pass into the parenchyma branching to form a trabecular network that subdivides the gland into small compartments

bull Parenchyma has 2 main elements - red pulp ( 75) and white pulp

bull A narrow marginal zone exists at the interface of the red and white pulps

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

bull The visceral surface is divided by a ridge into an anterior or gastric and a posterior or renal portion

bull The gastric surface (facies gastrica) which is directed forward upward and medialward is broad and concave and is in contact with the posterior wall of the stomach and below this with the tail of the pancreas It presents near its medial border a long fissure termed the hilum This is pierced by several irregular apertures for the entrance and exit of vessels and nerves

bull The renal surface (facies renalis) is directed medialward and downward It is somewhat flattened is considerably narrower than the gastric surface and is in relation with the upper part of the anterior surface of the left kidney and occasionally with the left suprarenal gland

bull The superior extremity (extremitas superior) is directed toward the vertebral column where it lies on a level with the eleventh thoracic vertebra

bull The lower extremity or colic surface (extremitas inferior) is flat triangular in shape and rests upon the left flexure of the colon and the phrenicocolic ligament and is generally in contact with the tail of the pancreas

bull The anterior border (margo anterior) is free sharp and thin and is often notched especially below it separates the diaphragmatic from the gastric surface

bull The posterior border (margo posterior) more rounded and blunter than the anterior separates the renal from the diaphragmatic surface it corresponds to the lower border of the eleventh rib and lies between the diaphragm and left kidney The intermediate margin is the ridge which separates the renal and gastric surfaces

bull The inferior border (internal border) separates the diaphragmatic from the colic surface

bull The spleen is almost entirely surrounded by peritoneum which is firmly adherent to its capsule It is held in position by two folds of this membrane

bull The parietal peritoneum adheres firmly to the splenic capsule except at the splenic hilum The peritoneum extends superiorly laterally and inferiorly creating folds which form the suspensory ligaments of the spleen

bull The splenocolic and the splenophrenic ligaments are relatively avascular

Ligaments

bull The splenorenal ligament runs from the anterior left kidney to the hilum of the spleen as a two layered fold in which the splenic vessels and the tail of the pancreas are invested

bull The other fold the gastrosplenic ligament is also formed of two layers derived from the general cavity and the omental respectively where they meet between the spleen and stomach the short gastric and left gastroepiploic branches of the splenic artery run between its two layers The lower end of the spleen is supported by the phrenicocolic ligament

Ligaments

Suspensory Ligaments

Gastrosplenic Ligament1048707 Short Gastric Vessels1048707 Gastroepiploic Vessels

Splenorenal Ligament1048707 Splenic Vessels1048707 Tail of Pancreas

Splenocolic Ligament

Phrenicocolic Ligament1048707 Phrenicosplenic ligament

Blood supplybull The celiac axis ndash largest but shortest branch

of the abdominal aorta 15-20mm longbull Arises above the body of the pancreas and

in 82 of specimens divides into three primary branches

1048707 The left gastric artery

1048707 The hepatic artery

1048707 The splenic artery

Splenic Artery

bull In rare instances the splenic artery originates directly from the aorta and even less often a second splenic artery arises from the celiac axis

bull Other variations include the splenic artery originating from the Superior mesenteric artery the middle colic artery the left gastric artery the hepatic artery or the accessory right hepatic artery

bull As a rule the splenic artery arises from the celiac axis to the right or the midline which means that the aorta must be crossed to reach the spleen and that selective angiography is likely to be difficult at times

bull Acounts for approximately 5 of cardiac output

bull It courses along the superior border of the pancreas and the branches include numerous pancreatic branches the short gastric branches the left gastroepiploic artery and the terminal splenic branches

bull Splenic arterial geography can be divided into 2 types ndash Distributed or Magistral (Michels NA The variational anatomy of the spleen and splenic artery Am J Anat 70 21 1942)

30 - Magistral

-Branches originate 3-13cm from hilum

-Transverse Anastomoses ndash whyembolization clipping may fail

-Pancreatica Magna ndash embolic debris from angio may cause pancreatitis

70 - Distributed

-Branches originate within 35 cmof hilum

-L Gastroepiploic arteryndash Mostvaried of splenic branches (72arise several cm from splenic arteryproximal to terminal branching

Histology

bull The spleen is invested in a fibroelastic capsule from which trabeculae pass into the parenchyma branching to form a trabecular network that subdivides the gland into small compartments

bull Parenchyma has 2 main elements - red pulp ( 75) and white pulp

bull A narrow marginal zone exists at the interface of the red and white pulps

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

bull The superior extremity (extremitas superior) is directed toward the vertebral column where it lies on a level with the eleventh thoracic vertebra

bull The lower extremity or colic surface (extremitas inferior) is flat triangular in shape and rests upon the left flexure of the colon and the phrenicocolic ligament and is generally in contact with the tail of the pancreas

bull The anterior border (margo anterior) is free sharp and thin and is often notched especially below it separates the diaphragmatic from the gastric surface

bull The posterior border (margo posterior) more rounded and blunter than the anterior separates the renal from the diaphragmatic surface it corresponds to the lower border of the eleventh rib and lies between the diaphragm and left kidney The intermediate margin is the ridge which separates the renal and gastric surfaces

bull The inferior border (internal border) separates the diaphragmatic from the colic surface

bull The spleen is almost entirely surrounded by peritoneum which is firmly adherent to its capsule It is held in position by two folds of this membrane

bull The parietal peritoneum adheres firmly to the splenic capsule except at the splenic hilum The peritoneum extends superiorly laterally and inferiorly creating folds which form the suspensory ligaments of the spleen

bull The splenocolic and the splenophrenic ligaments are relatively avascular

Ligaments

bull The splenorenal ligament runs from the anterior left kidney to the hilum of the spleen as a two layered fold in which the splenic vessels and the tail of the pancreas are invested

bull The other fold the gastrosplenic ligament is also formed of two layers derived from the general cavity and the omental respectively where they meet between the spleen and stomach the short gastric and left gastroepiploic branches of the splenic artery run between its two layers The lower end of the spleen is supported by the phrenicocolic ligament

Ligaments

Suspensory Ligaments

Gastrosplenic Ligament1048707 Short Gastric Vessels1048707 Gastroepiploic Vessels

Splenorenal Ligament1048707 Splenic Vessels1048707 Tail of Pancreas

Splenocolic Ligament

Phrenicocolic Ligament1048707 Phrenicosplenic ligament

Blood supplybull The celiac axis ndash largest but shortest branch

of the abdominal aorta 15-20mm longbull Arises above the body of the pancreas and

in 82 of specimens divides into three primary branches

1048707 The left gastric artery

1048707 The hepatic artery

1048707 The splenic artery

Splenic Artery

bull In rare instances the splenic artery originates directly from the aorta and even less often a second splenic artery arises from the celiac axis

bull Other variations include the splenic artery originating from the Superior mesenteric artery the middle colic artery the left gastric artery the hepatic artery or the accessory right hepatic artery

bull As a rule the splenic artery arises from the celiac axis to the right or the midline which means that the aorta must be crossed to reach the spleen and that selective angiography is likely to be difficult at times

bull Acounts for approximately 5 of cardiac output

bull It courses along the superior border of the pancreas and the branches include numerous pancreatic branches the short gastric branches the left gastroepiploic artery and the terminal splenic branches

bull Splenic arterial geography can be divided into 2 types ndash Distributed or Magistral (Michels NA The variational anatomy of the spleen and splenic artery Am J Anat 70 21 1942)

30 - Magistral

-Branches originate 3-13cm from hilum

-Transverse Anastomoses ndash whyembolization clipping may fail

-Pancreatica Magna ndash embolic debris from angio may cause pancreatitis

70 - Distributed

-Branches originate within 35 cmof hilum

-L Gastroepiploic arteryndash Mostvaried of splenic branches (72arise several cm from splenic arteryproximal to terminal branching

Histology

bull The spleen is invested in a fibroelastic capsule from which trabeculae pass into the parenchyma branching to form a trabecular network that subdivides the gland into small compartments

bull Parenchyma has 2 main elements - red pulp ( 75) and white pulp

bull A narrow marginal zone exists at the interface of the red and white pulps

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

bull The spleen is almost entirely surrounded by peritoneum which is firmly adherent to its capsule It is held in position by two folds of this membrane

bull The parietal peritoneum adheres firmly to the splenic capsule except at the splenic hilum The peritoneum extends superiorly laterally and inferiorly creating folds which form the suspensory ligaments of the spleen

bull The splenocolic and the splenophrenic ligaments are relatively avascular

Ligaments

bull The splenorenal ligament runs from the anterior left kidney to the hilum of the spleen as a two layered fold in which the splenic vessels and the tail of the pancreas are invested

bull The other fold the gastrosplenic ligament is also formed of two layers derived from the general cavity and the omental respectively where they meet between the spleen and stomach the short gastric and left gastroepiploic branches of the splenic artery run between its two layers The lower end of the spleen is supported by the phrenicocolic ligament

Ligaments

Suspensory Ligaments

Gastrosplenic Ligament1048707 Short Gastric Vessels1048707 Gastroepiploic Vessels

Splenorenal Ligament1048707 Splenic Vessels1048707 Tail of Pancreas

Splenocolic Ligament

Phrenicocolic Ligament1048707 Phrenicosplenic ligament

Blood supplybull The celiac axis ndash largest but shortest branch

of the abdominal aorta 15-20mm longbull Arises above the body of the pancreas and

in 82 of specimens divides into three primary branches

1048707 The left gastric artery

1048707 The hepatic artery

1048707 The splenic artery

Splenic Artery

bull In rare instances the splenic artery originates directly from the aorta and even less often a second splenic artery arises from the celiac axis

bull Other variations include the splenic artery originating from the Superior mesenteric artery the middle colic artery the left gastric artery the hepatic artery or the accessory right hepatic artery

bull As a rule the splenic artery arises from the celiac axis to the right or the midline which means that the aorta must be crossed to reach the spleen and that selective angiography is likely to be difficult at times

bull Acounts for approximately 5 of cardiac output

bull It courses along the superior border of the pancreas and the branches include numerous pancreatic branches the short gastric branches the left gastroepiploic artery and the terminal splenic branches

bull Splenic arterial geography can be divided into 2 types ndash Distributed or Magistral (Michels NA The variational anatomy of the spleen and splenic artery Am J Anat 70 21 1942)

30 - Magistral

-Branches originate 3-13cm from hilum

-Transverse Anastomoses ndash whyembolization clipping may fail

-Pancreatica Magna ndash embolic debris from angio may cause pancreatitis

70 - Distributed

-Branches originate within 35 cmof hilum

-L Gastroepiploic arteryndash Mostvaried of splenic branches (72arise several cm from splenic arteryproximal to terminal branching

Histology

bull The spleen is invested in a fibroelastic capsule from which trabeculae pass into the parenchyma branching to form a trabecular network that subdivides the gland into small compartments

bull Parenchyma has 2 main elements - red pulp ( 75) and white pulp

bull A narrow marginal zone exists at the interface of the red and white pulps

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

bull The splenorenal ligament runs from the anterior left kidney to the hilum of the spleen as a two layered fold in which the splenic vessels and the tail of the pancreas are invested

bull The other fold the gastrosplenic ligament is also formed of two layers derived from the general cavity and the omental respectively where they meet between the spleen and stomach the short gastric and left gastroepiploic branches of the splenic artery run between its two layers The lower end of the spleen is supported by the phrenicocolic ligament

Ligaments

Suspensory Ligaments

Gastrosplenic Ligament1048707 Short Gastric Vessels1048707 Gastroepiploic Vessels

Splenorenal Ligament1048707 Splenic Vessels1048707 Tail of Pancreas

Splenocolic Ligament

Phrenicocolic Ligament1048707 Phrenicosplenic ligament

Blood supplybull The celiac axis ndash largest but shortest branch

of the abdominal aorta 15-20mm longbull Arises above the body of the pancreas and

in 82 of specimens divides into three primary branches

1048707 The left gastric artery

1048707 The hepatic artery

1048707 The splenic artery

Splenic Artery

bull In rare instances the splenic artery originates directly from the aorta and even less often a second splenic artery arises from the celiac axis

bull Other variations include the splenic artery originating from the Superior mesenteric artery the middle colic artery the left gastric artery the hepatic artery or the accessory right hepatic artery

bull As a rule the splenic artery arises from the celiac axis to the right or the midline which means that the aorta must be crossed to reach the spleen and that selective angiography is likely to be difficult at times

bull Acounts for approximately 5 of cardiac output

bull It courses along the superior border of the pancreas and the branches include numerous pancreatic branches the short gastric branches the left gastroepiploic artery and the terminal splenic branches

bull Splenic arterial geography can be divided into 2 types ndash Distributed or Magistral (Michels NA The variational anatomy of the spleen and splenic artery Am J Anat 70 21 1942)

30 - Magistral

-Branches originate 3-13cm from hilum

-Transverse Anastomoses ndash whyembolization clipping may fail

-Pancreatica Magna ndash embolic debris from angio may cause pancreatitis

70 - Distributed

-Branches originate within 35 cmof hilum

-L Gastroepiploic arteryndash Mostvaried of splenic branches (72arise several cm from splenic arteryproximal to terminal branching

Histology

bull The spleen is invested in a fibroelastic capsule from which trabeculae pass into the parenchyma branching to form a trabecular network that subdivides the gland into small compartments

bull Parenchyma has 2 main elements - red pulp ( 75) and white pulp

bull A narrow marginal zone exists at the interface of the red and white pulps

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

Suspensory Ligaments

Gastrosplenic Ligament1048707 Short Gastric Vessels1048707 Gastroepiploic Vessels

Splenorenal Ligament1048707 Splenic Vessels1048707 Tail of Pancreas

Splenocolic Ligament

Phrenicocolic Ligament1048707 Phrenicosplenic ligament

Blood supplybull The celiac axis ndash largest but shortest branch

of the abdominal aorta 15-20mm longbull Arises above the body of the pancreas and

in 82 of specimens divides into three primary branches

1048707 The left gastric artery

1048707 The hepatic artery

1048707 The splenic artery

Splenic Artery

bull In rare instances the splenic artery originates directly from the aorta and even less often a second splenic artery arises from the celiac axis

bull Other variations include the splenic artery originating from the Superior mesenteric artery the middle colic artery the left gastric artery the hepatic artery or the accessory right hepatic artery

bull As a rule the splenic artery arises from the celiac axis to the right or the midline which means that the aorta must be crossed to reach the spleen and that selective angiography is likely to be difficult at times

bull Acounts for approximately 5 of cardiac output

bull It courses along the superior border of the pancreas and the branches include numerous pancreatic branches the short gastric branches the left gastroepiploic artery and the terminal splenic branches

bull Splenic arterial geography can be divided into 2 types ndash Distributed or Magistral (Michels NA The variational anatomy of the spleen and splenic artery Am J Anat 70 21 1942)

30 - Magistral

-Branches originate 3-13cm from hilum

-Transverse Anastomoses ndash whyembolization clipping may fail

-Pancreatica Magna ndash embolic debris from angio may cause pancreatitis

70 - Distributed

-Branches originate within 35 cmof hilum

-L Gastroepiploic arteryndash Mostvaried of splenic branches (72arise several cm from splenic arteryproximal to terminal branching

Histology

bull The spleen is invested in a fibroelastic capsule from which trabeculae pass into the parenchyma branching to form a trabecular network that subdivides the gland into small compartments

bull Parenchyma has 2 main elements - red pulp ( 75) and white pulp

bull A narrow marginal zone exists at the interface of the red and white pulps

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

Blood supplybull The celiac axis ndash largest but shortest branch

of the abdominal aorta 15-20mm longbull Arises above the body of the pancreas and

in 82 of specimens divides into three primary branches

1048707 The left gastric artery

1048707 The hepatic artery

1048707 The splenic artery

Splenic Artery

bull In rare instances the splenic artery originates directly from the aorta and even less often a second splenic artery arises from the celiac axis

bull Other variations include the splenic artery originating from the Superior mesenteric artery the middle colic artery the left gastric artery the hepatic artery or the accessory right hepatic artery

bull As a rule the splenic artery arises from the celiac axis to the right or the midline which means that the aorta must be crossed to reach the spleen and that selective angiography is likely to be difficult at times

bull Acounts for approximately 5 of cardiac output

bull It courses along the superior border of the pancreas and the branches include numerous pancreatic branches the short gastric branches the left gastroepiploic artery and the terminal splenic branches

bull Splenic arterial geography can be divided into 2 types ndash Distributed or Magistral (Michels NA The variational anatomy of the spleen and splenic artery Am J Anat 70 21 1942)

30 - Magistral

-Branches originate 3-13cm from hilum

-Transverse Anastomoses ndash whyembolization clipping may fail

-Pancreatica Magna ndash embolic debris from angio may cause pancreatitis

70 - Distributed

-Branches originate within 35 cmof hilum

-L Gastroepiploic arteryndash Mostvaried of splenic branches (72arise several cm from splenic arteryproximal to terminal branching

Histology

bull The spleen is invested in a fibroelastic capsule from which trabeculae pass into the parenchyma branching to form a trabecular network that subdivides the gland into small compartments

bull Parenchyma has 2 main elements - red pulp ( 75) and white pulp

bull A narrow marginal zone exists at the interface of the red and white pulps

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

Splenic Artery

bull In rare instances the splenic artery originates directly from the aorta and even less often a second splenic artery arises from the celiac axis

bull Other variations include the splenic artery originating from the Superior mesenteric artery the middle colic artery the left gastric artery the hepatic artery or the accessory right hepatic artery

bull As a rule the splenic artery arises from the celiac axis to the right or the midline which means that the aorta must be crossed to reach the spleen and that selective angiography is likely to be difficult at times

bull Acounts for approximately 5 of cardiac output

bull It courses along the superior border of the pancreas and the branches include numerous pancreatic branches the short gastric branches the left gastroepiploic artery and the terminal splenic branches

bull Splenic arterial geography can be divided into 2 types ndash Distributed or Magistral (Michels NA The variational anatomy of the spleen and splenic artery Am J Anat 70 21 1942)

30 - Magistral

-Branches originate 3-13cm from hilum

-Transverse Anastomoses ndash whyembolization clipping may fail

-Pancreatica Magna ndash embolic debris from angio may cause pancreatitis

70 - Distributed

-Branches originate within 35 cmof hilum

-L Gastroepiploic arteryndash Mostvaried of splenic branches (72arise several cm from splenic arteryproximal to terminal branching

Histology

bull The spleen is invested in a fibroelastic capsule from which trabeculae pass into the parenchyma branching to form a trabecular network that subdivides the gland into small compartments

bull Parenchyma has 2 main elements - red pulp ( 75) and white pulp

bull A narrow marginal zone exists at the interface of the red and white pulps

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

bull It courses along the superior border of the pancreas and the branches include numerous pancreatic branches the short gastric branches the left gastroepiploic artery and the terminal splenic branches

bull Splenic arterial geography can be divided into 2 types ndash Distributed or Magistral (Michels NA The variational anatomy of the spleen and splenic artery Am J Anat 70 21 1942)

30 - Magistral

-Branches originate 3-13cm from hilum

-Transverse Anastomoses ndash whyembolization clipping may fail

-Pancreatica Magna ndash embolic debris from angio may cause pancreatitis

70 - Distributed

-Branches originate within 35 cmof hilum

-L Gastroepiploic arteryndash Mostvaried of splenic branches (72arise several cm from splenic arteryproximal to terminal branching

Histology

bull The spleen is invested in a fibroelastic capsule from which trabeculae pass into the parenchyma branching to form a trabecular network that subdivides the gland into small compartments

bull Parenchyma has 2 main elements - red pulp ( 75) and white pulp

bull A narrow marginal zone exists at the interface of the red and white pulps

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

30 - Magistral

-Branches originate 3-13cm from hilum

-Transverse Anastomoses ndash whyembolization clipping may fail

-Pancreatica Magna ndash embolic debris from angio may cause pancreatitis

70 - Distributed

-Branches originate within 35 cmof hilum

-L Gastroepiploic arteryndash Mostvaried of splenic branches (72arise several cm from splenic arteryproximal to terminal branching

Histology

bull The spleen is invested in a fibroelastic capsule from which trabeculae pass into the parenchyma branching to form a trabecular network that subdivides the gland into small compartments

bull Parenchyma has 2 main elements - red pulp ( 75) and white pulp

bull A narrow marginal zone exists at the interface of the red and white pulps

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

70 - Distributed

-Branches originate within 35 cmof hilum

-L Gastroepiploic arteryndash Mostvaried of splenic branches (72arise several cm from splenic arteryproximal to terminal branching

Histology

bull The spleen is invested in a fibroelastic capsule from which trabeculae pass into the parenchyma branching to form a trabecular network that subdivides the gland into small compartments

bull Parenchyma has 2 main elements - red pulp ( 75) and white pulp

bull A narrow marginal zone exists at the interface of the red and white pulps

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

Histology

bull The spleen is invested in a fibroelastic capsule from which trabeculae pass into the parenchyma branching to form a trabecular network that subdivides the gland into small compartments

bull Parenchyma has 2 main elements - red pulp ( 75) and white pulp

bull A narrow marginal zone exists at the interface of the red and white pulps

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

Pseudo-Segmental Blood Supply

macrophages lymphocytes plasma cells granulocytes red blood cells and platelets

lsquoWhite pulprsquo contains end arterioles surrounded by sheaths of densely packed small lymphocytes subdivided into central intermediate and peripheral marginal zones

Central zone -gt CD4+T- helper lymphocytes

Intermediate follicular zone is the B- lymphocyte zone

lsquoRed pulprsquo consists of large thin walled sinuses that are filled with blood and separated by thin plates cords of lymphoid tissue the Cords of Billroth

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

White Pulp-Opsonins ndash IgM IgG tuftsin properdin-T-Cells

Red Pulp (75 of parenchyma)-Phagocytosis-ldquoPittingrdquo damaged RBCs WBCs-Opsonized Pathogen Clearance

Splenic Function

Splenic Function

Hypersplenismbull ldquoHematologic effects of splenomegalyrdquo

bull Hypersplenism is a disorder which causes the spleen to

rapidly and prematurely destroy blood cells bull Enhanced capacity of the enlarged spleen

1048707 Pooling

1048707 Sequestering and

1048707 Destroying blood cells

bull Results in reduction of blood cell counts

1048707 Bone marrow function usually normal

1048707 Sometimes by sequestration alone

1048707 Cytopenia corrected following splenectomy

Causes and symptoms bull Primary hypersplenism ndash caused by problem with the

spleen itself

bull Secondary hypersplenism results from another disease such as chronic malaria rheumatoid arthritis tuberculosis or polycythemia vera

bull Symptoms of hypersplenism include easy bruising easy contracting of bacterial diseases fever weakness heart palpitations and ulcerations of the mouth legs and feet Individuals may also bleed unexpectedly and heavily from the nose or other mucous membranes and from the gastrointestinal or urinary tracts

HypersplenismndashMany Etiologies

Hypersplenism

Platelet Sequestration

Healthy Hypersplenism

Palpable spleen is at least twice its normal size

Hypersplenismbull Why Splenectomy in Hypersplenism 1048707 Treat Splenomegaly bull Compressive symptoms bull Risk for splenic injury if active

1048707 Improve blood counts ndash RBCrsquos Platelets

1048707 Temporize underlying condition bull Rarely curative but an adjunctive therapy bull Failed medical management bull Reduce number of required transfusions bull Pain or abscess secondary to splenic infarction (sickle cell thalassemia)

1048707 Staging Procedure

Splenectomy 1549 ndash First reported by

Zacarello in Italy

1816 ndash First in North America

OrsquoBrien 1048707 Victim stabbed in LUQ while

committing a rape

1826 - Quittenbaum

1st elective splenectomy

1048707 Portal HTN

bull 1866 ndash Bryant 1st splenectomy for leukemia

bull 1908 ndash Johnson reports mortality of 877 in 49 patients with leukemia

bull 1916 ndash Kaznelson reports good results for thrombocytopenic purpura

bull 1952 ndash OPSS reported

bull 1962 ndash Christo in Brazil Splenic salvage prevents OPSS

bull 1991 ndash Laparoscopic splenectomy reported by four different groups

Patient preparation

bull Counseledbull Vaccination - at least 7-14 days priorbull Transfusion if needed to achieve Hb gt10gdlbull Cross match - 2 ndash 4 unitsbull Platelet transfusionbull Parental corticosteroids periopratively if on steroids DVT prophylaxis Antibiotics - 1st generation cephalosporin NGT after intubation

Splenectomy techniques

bull Although laparoscopic surgery (LS) is recognized as the standard approach for normosplenic patients requiring surgery open splenectomy (OS) is still widely practiced

bull The most common indication for OS is traumatic rupture of the spleen

bull Other situations where OS may be favored include massive splenomegaly ascites portal hypertension multiple prior operations extensive splenic radiation and possibly splenic abscess

Laparoscopic Splenectomy

bull LS has steadily surpassed OS as the approach of choice for most elective splenectomies

bull Several large series have shown the benefits of LS to patients with normal sized spleens

bull Recent literature supports LS in expert hands in situations that were previously reserved for OS eg morbid obesity splenomegaly multiple prior surgeries and even pregnancy

Laparoscopic Splenectomy - Indications

bull ITP 1048707 Most Commonbull Hereditary Spherocytosisbull TTPbull Autoimmune Hemolytic Anemiabull Lymphoma 1048707 Hodgkinrsquos Dz (Staging) 1048707 Non-Hodgkinrsquos (hypersplenism)bull Leukemia (hypersplenism)bull Hemoglobinopathies 1048707 Thalassemia Sickle Cell

bull Splenic Abcessbull Splenic Cystbull Gaucherrsquos Dz (storage)bull Feltyrsquos Syndrome 1048707 RA neutropenia 1048707 Splenomegalybull Myelofibrosis 1048707 Extramedullary hematopoiesisbull Splenic Infarctbull AIDS Thrombocytopeniabull Hypersplenism 1048707 Portal HTN SLE or Sarcoid

Lap vs Open Splenectomy

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Causes and symptoms bull Primary hypersplenism ndash caused by problem with the

spleen itself

bull Secondary hypersplenism results from another disease such as chronic malaria rheumatoid arthritis tuberculosis or polycythemia vera

bull Symptoms of hypersplenism include easy bruising easy contracting of bacterial diseases fever weakness heart palpitations and ulcerations of the mouth legs and feet Individuals may also bleed unexpectedly and heavily from the nose or other mucous membranes and from the gastrointestinal or urinary tracts

HypersplenismndashMany Etiologies

Hypersplenism

Platelet Sequestration

Healthy Hypersplenism

Palpable spleen is at least twice its normal size

Hypersplenismbull Why Splenectomy in Hypersplenism 1048707 Treat Splenomegaly bull Compressive symptoms bull Risk for splenic injury if active

1048707 Improve blood counts ndash RBCrsquos Platelets

1048707 Temporize underlying condition bull Rarely curative but an adjunctive therapy bull Failed medical management bull Reduce number of required transfusions bull Pain or abscess secondary to splenic infarction (sickle cell thalassemia)

1048707 Staging Procedure

Splenectomy 1549 ndash First reported by

Zacarello in Italy

1816 ndash First in North America

OrsquoBrien 1048707 Victim stabbed in LUQ while

committing a rape

1826 - Quittenbaum

1st elective splenectomy

1048707 Portal HTN

bull 1866 ndash Bryant 1st splenectomy for leukemia

bull 1908 ndash Johnson reports mortality of 877 in 49 patients with leukemia

bull 1916 ndash Kaznelson reports good results for thrombocytopenic purpura

bull 1952 ndash OPSS reported

bull 1962 ndash Christo in Brazil Splenic salvage prevents OPSS

bull 1991 ndash Laparoscopic splenectomy reported by four different groups

Patient preparation

bull Counseledbull Vaccination - at least 7-14 days priorbull Transfusion if needed to achieve Hb gt10gdlbull Cross match - 2 ndash 4 unitsbull Platelet transfusionbull Parental corticosteroids periopratively if on steroids DVT prophylaxis Antibiotics - 1st generation cephalosporin NGT after intubation

Splenectomy techniques

bull Although laparoscopic surgery (LS) is recognized as the standard approach for normosplenic patients requiring surgery open splenectomy (OS) is still widely practiced

bull The most common indication for OS is traumatic rupture of the spleen

bull Other situations where OS may be favored include massive splenomegaly ascites portal hypertension multiple prior operations extensive splenic radiation and possibly splenic abscess

Laparoscopic Splenectomy

bull LS has steadily surpassed OS as the approach of choice for most elective splenectomies

bull Several large series have shown the benefits of LS to patients with normal sized spleens

bull Recent literature supports LS in expert hands in situations that were previously reserved for OS eg morbid obesity splenomegaly multiple prior surgeries and even pregnancy

Laparoscopic Splenectomy - Indications

bull ITP 1048707 Most Commonbull Hereditary Spherocytosisbull TTPbull Autoimmune Hemolytic Anemiabull Lymphoma 1048707 Hodgkinrsquos Dz (Staging) 1048707 Non-Hodgkinrsquos (hypersplenism)bull Leukemia (hypersplenism)bull Hemoglobinopathies 1048707 Thalassemia Sickle Cell

bull Splenic Abcessbull Splenic Cystbull Gaucherrsquos Dz (storage)bull Feltyrsquos Syndrome 1048707 RA neutropenia 1048707 Splenomegalybull Myelofibrosis 1048707 Extramedullary hematopoiesisbull Splenic Infarctbull AIDS Thrombocytopeniabull Hypersplenism 1048707 Portal HTN SLE or Sarcoid

Lap vs Open Splenectomy

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

HypersplenismndashMany Etiologies

Hypersplenism

Platelet Sequestration

Healthy Hypersplenism

Palpable spleen is at least twice its normal size

Hypersplenismbull Why Splenectomy in Hypersplenism 1048707 Treat Splenomegaly bull Compressive symptoms bull Risk for splenic injury if active

1048707 Improve blood counts ndash RBCrsquos Platelets

1048707 Temporize underlying condition bull Rarely curative but an adjunctive therapy bull Failed medical management bull Reduce number of required transfusions bull Pain or abscess secondary to splenic infarction (sickle cell thalassemia)

1048707 Staging Procedure

Splenectomy 1549 ndash First reported by

Zacarello in Italy

1816 ndash First in North America

OrsquoBrien 1048707 Victim stabbed in LUQ while

committing a rape

1826 - Quittenbaum

1st elective splenectomy

1048707 Portal HTN

bull 1866 ndash Bryant 1st splenectomy for leukemia

bull 1908 ndash Johnson reports mortality of 877 in 49 patients with leukemia

bull 1916 ndash Kaznelson reports good results for thrombocytopenic purpura

bull 1952 ndash OPSS reported

bull 1962 ndash Christo in Brazil Splenic salvage prevents OPSS

bull 1991 ndash Laparoscopic splenectomy reported by four different groups

Patient preparation

bull Counseledbull Vaccination - at least 7-14 days priorbull Transfusion if needed to achieve Hb gt10gdlbull Cross match - 2 ndash 4 unitsbull Platelet transfusionbull Parental corticosteroids periopratively if on steroids DVT prophylaxis Antibiotics - 1st generation cephalosporin NGT after intubation

Splenectomy techniques

bull Although laparoscopic surgery (LS) is recognized as the standard approach for normosplenic patients requiring surgery open splenectomy (OS) is still widely practiced

bull The most common indication for OS is traumatic rupture of the spleen

bull Other situations where OS may be favored include massive splenomegaly ascites portal hypertension multiple prior operations extensive splenic radiation and possibly splenic abscess

Laparoscopic Splenectomy

bull LS has steadily surpassed OS as the approach of choice for most elective splenectomies

bull Several large series have shown the benefits of LS to patients with normal sized spleens

bull Recent literature supports LS in expert hands in situations that were previously reserved for OS eg morbid obesity splenomegaly multiple prior surgeries and even pregnancy

Laparoscopic Splenectomy - Indications

bull ITP 1048707 Most Commonbull Hereditary Spherocytosisbull TTPbull Autoimmune Hemolytic Anemiabull Lymphoma 1048707 Hodgkinrsquos Dz (Staging) 1048707 Non-Hodgkinrsquos (hypersplenism)bull Leukemia (hypersplenism)bull Hemoglobinopathies 1048707 Thalassemia Sickle Cell

bull Splenic Abcessbull Splenic Cystbull Gaucherrsquos Dz (storage)bull Feltyrsquos Syndrome 1048707 RA neutropenia 1048707 Splenomegalybull Myelofibrosis 1048707 Extramedullary hematopoiesisbull Splenic Infarctbull AIDS Thrombocytopeniabull Hypersplenism 1048707 Portal HTN SLE or Sarcoid

Lap vs Open Splenectomy

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Hypersplenism

Platelet Sequestration

Healthy Hypersplenism

Palpable spleen is at least twice its normal size

Hypersplenismbull Why Splenectomy in Hypersplenism 1048707 Treat Splenomegaly bull Compressive symptoms bull Risk for splenic injury if active

1048707 Improve blood counts ndash RBCrsquos Platelets

1048707 Temporize underlying condition bull Rarely curative but an adjunctive therapy bull Failed medical management bull Reduce number of required transfusions bull Pain or abscess secondary to splenic infarction (sickle cell thalassemia)

1048707 Staging Procedure

Splenectomy 1549 ndash First reported by

Zacarello in Italy

1816 ndash First in North America

OrsquoBrien 1048707 Victim stabbed in LUQ while

committing a rape

1826 - Quittenbaum

1st elective splenectomy

1048707 Portal HTN

bull 1866 ndash Bryant 1st splenectomy for leukemia

bull 1908 ndash Johnson reports mortality of 877 in 49 patients with leukemia

bull 1916 ndash Kaznelson reports good results for thrombocytopenic purpura

bull 1952 ndash OPSS reported

bull 1962 ndash Christo in Brazil Splenic salvage prevents OPSS

bull 1991 ndash Laparoscopic splenectomy reported by four different groups

Patient preparation

bull Counseledbull Vaccination - at least 7-14 days priorbull Transfusion if needed to achieve Hb gt10gdlbull Cross match - 2 ndash 4 unitsbull Platelet transfusionbull Parental corticosteroids periopratively if on steroids DVT prophylaxis Antibiotics - 1st generation cephalosporin NGT after intubation

Splenectomy techniques

bull Although laparoscopic surgery (LS) is recognized as the standard approach for normosplenic patients requiring surgery open splenectomy (OS) is still widely practiced

bull The most common indication for OS is traumatic rupture of the spleen

bull Other situations where OS may be favored include massive splenomegaly ascites portal hypertension multiple prior operations extensive splenic radiation and possibly splenic abscess

Laparoscopic Splenectomy

bull LS has steadily surpassed OS as the approach of choice for most elective splenectomies

bull Several large series have shown the benefits of LS to patients with normal sized spleens

bull Recent literature supports LS in expert hands in situations that were previously reserved for OS eg morbid obesity splenomegaly multiple prior surgeries and even pregnancy

Laparoscopic Splenectomy - Indications

bull ITP 1048707 Most Commonbull Hereditary Spherocytosisbull TTPbull Autoimmune Hemolytic Anemiabull Lymphoma 1048707 Hodgkinrsquos Dz (Staging) 1048707 Non-Hodgkinrsquos (hypersplenism)bull Leukemia (hypersplenism)bull Hemoglobinopathies 1048707 Thalassemia Sickle Cell

bull Splenic Abcessbull Splenic Cystbull Gaucherrsquos Dz (storage)bull Feltyrsquos Syndrome 1048707 RA neutropenia 1048707 Splenomegalybull Myelofibrosis 1048707 Extramedullary hematopoiesisbull Splenic Infarctbull AIDS Thrombocytopeniabull Hypersplenism 1048707 Portal HTN SLE or Sarcoid

Lap vs Open Splenectomy

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Hypersplenismbull Why Splenectomy in Hypersplenism 1048707 Treat Splenomegaly bull Compressive symptoms bull Risk for splenic injury if active

1048707 Improve blood counts ndash RBCrsquos Platelets

1048707 Temporize underlying condition bull Rarely curative but an adjunctive therapy bull Failed medical management bull Reduce number of required transfusions bull Pain or abscess secondary to splenic infarction (sickle cell thalassemia)

1048707 Staging Procedure

Splenectomy 1549 ndash First reported by

Zacarello in Italy

1816 ndash First in North America

OrsquoBrien 1048707 Victim stabbed in LUQ while

committing a rape

1826 - Quittenbaum

1st elective splenectomy

1048707 Portal HTN

bull 1866 ndash Bryant 1st splenectomy for leukemia

bull 1908 ndash Johnson reports mortality of 877 in 49 patients with leukemia

bull 1916 ndash Kaznelson reports good results for thrombocytopenic purpura

bull 1952 ndash OPSS reported

bull 1962 ndash Christo in Brazil Splenic salvage prevents OPSS

bull 1991 ndash Laparoscopic splenectomy reported by four different groups

Patient preparation

bull Counseledbull Vaccination - at least 7-14 days priorbull Transfusion if needed to achieve Hb gt10gdlbull Cross match - 2 ndash 4 unitsbull Platelet transfusionbull Parental corticosteroids periopratively if on steroids DVT prophylaxis Antibiotics - 1st generation cephalosporin NGT after intubation

Splenectomy techniques

bull Although laparoscopic surgery (LS) is recognized as the standard approach for normosplenic patients requiring surgery open splenectomy (OS) is still widely practiced

bull The most common indication for OS is traumatic rupture of the spleen

bull Other situations where OS may be favored include massive splenomegaly ascites portal hypertension multiple prior operations extensive splenic radiation and possibly splenic abscess

Laparoscopic Splenectomy

bull LS has steadily surpassed OS as the approach of choice for most elective splenectomies

bull Several large series have shown the benefits of LS to patients with normal sized spleens

bull Recent literature supports LS in expert hands in situations that were previously reserved for OS eg morbid obesity splenomegaly multiple prior surgeries and even pregnancy

Laparoscopic Splenectomy - Indications

bull ITP 1048707 Most Commonbull Hereditary Spherocytosisbull TTPbull Autoimmune Hemolytic Anemiabull Lymphoma 1048707 Hodgkinrsquos Dz (Staging) 1048707 Non-Hodgkinrsquos (hypersplenism)bull Leukemia (hypersplenism)bull Hemoglobinopathies 1048707 Thalassemia Sickle Cell

bull Splenic Abcessbull Splenic Cystbull Gaucherrsquos Dz (storage)bull Feltyrsquos Syndrome 1048707 RA neutropenia 1048707 Splenomegalybull Myelofibrosis 1048707 Extramedullary hematopoiesisbull Splenic Infarctbull AIDS Thrombocytopeniabull Hypersplenism 1048707 Portal HTN SLE or Sarcoid

Lap vs Open Splenectomy

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Splenectomy 1549 ndash First reported by

Zacarello in Italy

1816 ndash First in North America

OrsquoBrien 1048707 Victim stabbed in LUQ while

committing a rape

1826 - Quittenbaum

1st elective splenectomy

1048707 Portal HTN

bull 1866 ndash Bryant 1st splenectomy for leukemia

bull 1908 ndash Johnson reports mortality of 877 in 49 patients with leukemia

bull 1916 ndash Kaznelson reports good results for thrombocytopenic purpura

bull 1952 ndash OPSS reported

bull 1962 ndash Christo in Brazil Splenic salvage prevents OPSS

bull 1991 ndash Laparoscopic splenectomy reported by four different groups

Patient preparation

bull Counseledbull Vaccination - at least 7-14 days priorbull Transfusion if needed to achieve Hb gt10gdlbull Cross match - 2 ndash 4 unitsbull Platelet transfusionbull Parental corticosteroids periopratively if on steroids DVT prophylaxis Antibiotics - 1st generation cephalosporin NGT after intubation

Splenectomy techniques

bull Although laparoscopic surgery (LS) is recognized as the standard approach for normosplenic patients requiring surgery open splenectomy (OS) is still widely practiced

bull The most common indication for OS is traumatic rupture of the spleen

bull Other situations where OS may be favored include massive splenomegaly ascites portal hypertension multiple prior operations extensive splenic radiation and possibly splenic abscess

Laparoscopic Splenectomy

bull LS has steadily surpassed OS as the approach of choice for most elective splenectomies

bull Several large series have shown the benefits of LS to patients with normal sized spleens

bull Recent literature supports LS in expert hands in situations that were previously reserved for OS eg morbid obesity splenomegaly multiple prior surgeries and even pregnancy

Laparoscopic Splenectomy - Indications

bull ITP 1048707 Most Commonbull Hereditary Spherocytosisbull TTPbull Autoimmune Hemolytic Anemiabull Lymphoma 1048707 Hodgkinrsquos Dz (Staging) 1048707 Non-Hodgkinrsquos (hypersplenism)bull Leukemia (hypersplenism)bull Hemoglobinopathies 1048707 Thalassemia Sickle Cell

bull Splenic Abcessbull Splenic Cystbull Gaucherrsquos Dz (storage)bull Feltyrsquos Syndrome 1048707 RA neutropenia 1048707 Splenomegalybull Myelofibrosis 1048707 Extramedullary hematopoiesisbull Splenic Infarctbull AIDS Thrombocytopeniabull Hypersplenism 1048707 Portal HTN SLE or Sarcoid

Lap vs Open Splenectomy

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

bull 1866 ndash Bryant 1st splenectomy for leukemia

bull 1908 ndash Johnson reports mortality of 877 in 49 patients with leukemia

bull 1916 ndash Kaznelson reports good results for thrombocytopenic purpura

bull 1952 ndash OPSS reported

bull 1962 ndash Christo in Brazil Splenic salvage prevents OPSS

bull 1991 ndash Laparoscopic splenectomy reported by four different groups

Patient preparation

bull Counseledbull Vaccination - at least 7-14 days priorbull Transfusion if needed to achieve Hb gt10gdlbull Cross match - 2 ndash 4 unitsbull Platelet transfusionbull Parental corticosteroids periopratively if on steroids DVT prophylaxis Antibiotics - 1st generation cephalosporin NGT after intubation

Splenectomy techniques

bull Although laparoscopic surgery (LS) is recognized as the standard approach for normosplenic patients requiring surgery open splenectomy (OS) is still widely practiced

bull The most common indication for OS is traumatic rupture of the spleen

bull Other situations where OS may be favored include massive splenomegaly ascites portal hypertension multiple prior operations extensive splenic radiation and possibly splenic abscess

Laparoscopic Splenectomy

bull LS has steadily surpassed OS as the approach of choice for most elective splenectomies

bull Several large series have shown the benefits of LS to patients with normal sized spleens

bull Recent literature supports LS in expert hands in situations that were previously reserved for OS eg morbid obesity splenomegaly multiple prior surgeries and even pregnancy

Laparoscopic Splenectomy - Indications

bull ITP 1048707 Most Commonbull Hereditary Spherocytosisbull TTPbull Autoimmune Hemolytic Anemiabull Lymphoma 1048707 Hodgkinrsquos Dz (Staging) 1048707 Non-Hodgkinrsquos (hypersplenism)bull Leukemia (hypersplenism)bull Hemoglobinopathies 1048707 Thalassemia Sickle Cell

bull Splenic Abcessbull Splenic Cystbull Gaucherrsquos Dz (storage)bull Feltyrsquos Syndrome 1048707 RA neutropenia 1048707 Splenomegalybull Myelofibrosis 1048707 Extramedullary hematopoiesisbull Splenic Infarctbull AIDS Thrombocytopeniabull Hypersplenism 1048707 Portal HTN SLE or Sarcoid

Lap vs Open Splenectomy

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Patient preparation

bull Counseledbull Vaccination - at least 7-14 days priorbull Transfusion if needed to achieve Hb gt10gdlbull Cross match - 2 ndash 4 unitsbull Platelet transfusionbull Parental corticosteroids periopratively if on steroids DVT prophylaxis Antibiotics - 1st generation cephalosporin NGT after intubation

Splenectomy techniques

bull Although laparoscopic surgery (LS) is recognized as the standard approach for normosplenic patients requiring surgery open splenectomy (OS) is still widely practiced

bull The most common indication for OS is traumatic rupture of the spleen

bull Other situations where OS may be favored include massive splenomegaly ascites portal hypertension multiple prior operations extensive splenic radiation and possibly splenic abscess

Laparoscopic Splenectomy

bull LS has steadily surpassed OS as the approach of choice for most elective splenectomies

bull Several large series have shown the benefits of LS to patients with normal sized spleens

bull Recent literature supports LS in expert hands in situations that were previously reserved for OS eg morbid obesity splenomegaly multiple prior surgeries and even pregnancy

Laparoscopic Splenectomy - Indications

bull ITP 1048707 Most Commonbull Hereditary Spherocytosisbull TTPbull Autoimmune Hemolytic Anemiabull Lymphoma 1048707 Hodgkinrsquos Dz (Staging) 1048707 Non-Hodgkinrsquos (hypersplenism)bull Leukemia (hypersplenism)bull Hemoglobinopathies 1048707 Thalassemia Sickle Cell

bull Splenic Abcessbull Splenic Cystbull Gaucherrsquos Dz (storage)bull Feltyrsquos Syndrome 1048707 RA neutropenia 1048707 Splenomegalybull Myelofibrosis 1048707 Extramedullary hematopoiesisbull Splenic Infarctbull AIDS Thrombocytopeniabull Hypersplenism 1048707 Portal HTN SLE or Sarcoid

Lap vs Open Splenectomy

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Splenectomy techniques

bull Although laparoscopic surgery (LS) is recognized as the standard approach for normosplenic patients requiring surgery open splenectomy (OS) is still widely practiced

bull The most common indication for OS is traumatic rupture of the spleen

bull Other situations where OS may be favored include massive splenomegaly ascites portal hypertension multiple prior operations extensive splenic radiation and possibly splenic abscess

Laparoscopic Splenectomy

bull LS has steadily surpassed OS as the approach of choice for most elective splenectomies

bull Several large series have shown the benefits of LS to patients with normal sized spleens

bull Recent literature supports LS in expert hands in situations that were previously reserved for OS eg morbid obesity splenomegaly multiple prior surgeries and even pregnancy

Laparoscopic Splenectomy - Indications

bull ITP 1048707 Most Commonbull Hereditary Spherocytosisbull TTPbull Autoimmune Hemolytic Anemiabull Lymphoma 1048707 Hodgkinrsquos Dz (Staging) 1048707 Non-Hodgkinrsquos (hypersplenism)bull Leukemia (hypersplenism)bull Hemoglobinopathies 1048707 Thalassemia Sickle Cell

bull Splenic Abcessbull Splenic Cystbull Gaucherrsquos Dz (storage)bull Feltyrsquos Syndrome 1048707 RA neutropenia 1048707 Splenomegalybull Myelofibrosis 1048707 Extramedullary hematopoiesisbull Splenic Infarctbull AIDS Thrombocytopeniabull Hypersplenism 1048707 Portal HTN SLE or Sarcoid

Lap vs Open Splenectomy

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Laparoscopic Splenectomy

bull LS has steadily surpassed OS as the approach of choice for most elective splenectomies

bull Several large series have shown the benefits of LS to patients with normal sized spleens

bull Recent literature supports LS in expert hands in situations that were previously reserved for OS eg morbid obesity splenomegaly multiple prior surgeries and even pregnancy

Laparoscopic Splenectomy - Indications

bull ITP 1048707 Most Commonbull Hereditary Spherocytosisbull TTPbull Autoimmune Hemolytic Anemiabull Lymphoma 1048707 Hodgkinrsquos Dz (Staging) 1048707 Non-Hodgkinrsquos (hypersplenism)bull Leukemia (hypersplenism)bull Hemoglobinopathies 1048707 Thalassemia Sickle Cell

bull Splenic Abcessbull Splenic Cystbull Gaucherrsquos Dz (storage)bull Feltyrsquos Syndrome 1048707 RA neutropenia 1048707 Splenomegalybull Myelofibrosis 1048707 Extramedullary hematopoiesisbull Splenic Infarctbull AIDS Thrombocytopeniabull Hypersplenism 1048707 Portal HTN SLE or Sarcoid

Lap vs Open Splenectomy

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Laparoscopic Splenectomy - Indications

bull ITP 1048707 Most Commonbull Hereditary Spherocytosisbull TTPbull Autoimmune Hemolytic Anemiabull Lymphoma 1048707 Hodgkinrsquos Dz (Staging) 1048707 Non-Hodgkinrsquos (hypersplenism)bull Leukemia (hypersplenism)bull Hemoglobinopathies 1048707 Thalassemia Sickle Cell

bull Splenic Abcessbull Splenic Cystbull Gaucherrsquos Dz (storage)bull Feltyrsquos Syndrome 1048707 RA neutropenia 1048707 Splenomegalybull Myelofibrosis 1048707 Extramedullary hematopoiesisbull Splenic Infarctbull AIDS Thrombocytopeniabull Hypersplenism 1048707 Portal HTN SLE or Sarcoid

Lap vs Open Splenectomy

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Lap vs Open Splenectomy

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Laparoscopic Splenectomy

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Laparoscopic Splenectomy

bull Patient Positioning

1048707 Usually right lateral decubitus position

1048707 Anterior approach for large spleens(gt25-30cm)

bull Trocar placement

lateral ndash 3 or 4 ports

anterior ndash 5-6 ports

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Laparoscopic Splenectomy

Procedure The stomach is retracted medially to expose the spleenbull A thorough search is made for accessory spleens Any accessory

spleens found should be removed immediately as they are considerably harder to locate once the spleen is removed and the field is stained with blood

bull Splenocolic ligament divided as are the lateral peritoneal attachments resulting in medial mobilization of the spleen Short gastrics divided by individual application of clips endovascular stapler or haemostatic energy sources

bull After retracting the lower pole of the spleen the splenic hilum is then accessible to clips or stapling device

bull Once excised the spleen is placed in a nylon or freezer bag the neck of which is pulled through one of the trocar sites

bull The spleen is then morcellated and extracted piecemeal

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Splenic Traumabull Most common indication for laparotomy following blunt

trauma

bull MVArsquos most common source

bull Other mechanisms include motorcycle crashes falls RTArsquos bicycle crashes and sports

bull Splenic injuries are produced by rapid deceleration compression energy transmission through the posterior lateral chest wall over the spleen or puncture from adjacent rib fractures

bull Rapid deceleration results in the spleen continuing to move forward while tethered at the point of attachment

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Splenic Trauma contrsquod

bull Injuries produced by decelerating forces result in capsular avulsion along the various ligamentous attachments and linear or stellate fractures of varying depths

bull Because of the solid structural characteristics and density energy transfer is relatively efficient

bull Injuries cause by assaults or falls are usually the result of direct blows over the lower chest wall with transmission of energy resulting in splenic lacerations

bull The spleen receives about 5 of the cardiac output The splenic artery divide into several segmental vessel supplying the poles and midportion and these vessels divide into 2nd and 3rd order vessels that course transversely within the spleen

bull Because of this extensive supply even small lacerations or capsular avulsions yield substantial hemorrhage

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Splenic Trauma

bull Most frequently injuredintraabdominal organ inblunt trauma

bull Fractured left ribs andpulmonary contusionmost common associatedInjuries

bull Hematuria most common nonspecific finding1048707 Renal injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Splenic Trauma - Diagnosis

bull Old Peritoneal Lavage1048707 gt100000 RBCrsquosHPF1048707 Food Particles1048707 Very Sensitive1048707 Many False +rsquosbull Intermediate CT Scanbull New FAST1048707 Looking for Blood only1048707 NOT looking for organ detail1048707 Wait for foley may get more detail if bladder full

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)

Grade Injury description Score

I Hematoma Subcapsular lt10 surface areaLaceration Capsular tear lt1cm parenchymal depth

22

II Hematoma Subcapsular 10-50 surface area intraparenchymal lt5 cm in diameter

Laceration Capsular tears 1-3cm parenchymal depth does not involve a trabecular vessel

2

III Hematoma Subcapsular gt50 surface area or expanding ruptured subcapsular or parenchymal hematoma intraparenchymal hematoma gt5cm or expanding

Laceration gt3cm parenchymal depth or involving trabecular vessels

33

IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (gt25 of spleen)

4

V Laceration Completely shattered spleen

Vascular Hilar vascular injury that devascularises spleen

55

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Splenic Trauma

bull Treatment has come full circle

1048707 1890rsquos ndash Nonoperative Management

1048707 1900rsquos ndash Operative Management

1048707 1970rsquos-1990rsquos ndash Nonoperative Management

bull OPSS ndash Not as likely following Trauma

1048707 Partial Splenectomy

1048707 Accessory Spleens

1048707 Splenosis

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

bull Spleen Removal (Splenectomy) This exhibit illustrates the splenectomy procedure in which the spleen is removed The first image shows the midline incision in the abdomen through which the damaged spleen is exposed The second image depicts the mobilization of the lacerated spleen and ligation (binding) of the splenic vessels which will be clipped An enlargement of the removed spleen is pictured off to the side to highlight the specific injuries

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Splenic repairs

bull Splenic conservation historically performed in Children

bull - More likely to develop OPSS saving splenic function protective

bull - Capsule more amenable to repair (adults tear)

bull -Lower arterial pressure in splenic arterial system ndash easier hemostasis

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Splenectomy outcomes

Results in characteristic changes to blood composition

These include

appearance of Howell Jolly bodies and siderocytes

Leukocytosis ndash WBC raises within one (1) day and may remain elevated for several months

Increased platelets occur wihin 2 days (but may not peak for several weeks)

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actual incidence of delayed rupture very

low 1048707 Need to inform patients of this prior to

Dischage

Failure of nonoperative management of Blunt Splenic Injury

bull Increasing or persistent fluid requirements to maintain normal hemodynamic status

bull Failed angioembolization of arteriovenous fistula pseudoaneurysm

bull Transfusion requirement to maintain hematocrit and hemodynamic stability

bull Increasing hemoperitoneum associated with hemodynamic instability

bull Peritoneal signsrebound tenderness

• Principles of Splenic Surgery
• Content
• Anatomy
• Slide 4
• Relations
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
• Slide 11
• Slide 12
• Slide 13
• Slide 14
• Blood supply
• Splenic Artery
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Histology
• Pseudo-Segmental Blood Supply
• Slide 23
• Splenic Function
• Slide 25
• Hypersplenism
• Causes and symptoms
• HypersplenismndashMany Etiologies
• Slide 29
• Slide 30
• Splenectomy
• Slide 32
• Slide 33
• Patient preparation
• Splenectomy techniques
• Laparoscopic Splenectomy
• Laparoscopic Splenectomy - Indications
• Slide 38
• Lap vs Open Splenectomy
• Laparoscopic Splenectomy
• Slide 41
• Slide 42
• Slide 43
• Slide 44
• Slide 45
• Slide 46
• Splenic Trauma
• Splenic Trauma contrsquod
• Slide 49
• Splenic Trauma - Diagnosis
• American Association for the Surgery of Trauma (AAST) splenic injury scale (1994)
• Slide 52
• Slide 53
• Slide 54
• Slide 55
• Splenic repairs
• Slide 57
• Slide 58
• Slide 59
• Splenectomy outcomes
• Hematologic outcomes
• Complications
• Slide 63
• Slide 64
• Slide 65
• Overwhelming Post- Splenectomy Sepsis aka OPSS OPSI
• Pathogens
• Clinical manifestations
• Labs
• Management
• Prevention
• Vaccinations
• Vaccination Recommendations
• Prophylactic Antibiotics
• Post-Splenectomy Sepsis
• Nonoperative management
• Nonoperative Management
• Slide 78
• Slide 79
• Failure of nonoperative management of Blunt Splenic Injury

Hematologic outcomes

bull Divided into initial and long term responses

bull For thrombocyopenia Initial response rise in platelets within several days Long term response is defined as a platelet count gt 150 000ml more that 2 months after surgery with out medication LS long term response obtained in 85 OS has success rate of 60-90

bull For chronic hemolytic anemias a rise in hemoglobin levels to above 10gdl without the need for transfusion signifies a successful response to splenectomy

successful in 60-80of cases For patients with hereditary spherocytsis the success rate is 90-100

Complications

bull Classified as Pulmonary

Hemorrhagic

Infectious

Pancreatic

Thromboembolic

Functional

Pulmonary

Left lower lobe atelectasis - Most common (16 of patients)

Pleural effusions and pneumonia (10)

Hemorrhagic

Usually occurs intra op and corrected then but may present as a

subphrenic hematoma

Transfusions have become less frequent with LS and depend on the

indication for splenectomy

Across all elective cases ndash need for transfusion occur in 3-5 of cases

Infectious

Subphrenic abscess (usually associated with drain placement)

OPSS (see below)

Pancreatic

Pancreatitis

Pseudo cyst formation

Pancreatic fistula

These may all be due to trauma to the pancreas especially to the tail during the dissection of the splenic hilum

bull Thromboembolic

eg portal vein thrombosis deep vein thrombosis Occurs in 5-10 of patients and DVT prophylaxis is recommended

The risk is even higher in patients with hemolytic anemia myeloproliferative disorders and splenomegaly

Functional

Persistence of hyperspleenism (unresected accessory spleen)

Overwhelming Post- Splenectomy Sepsis

aka OPSS OPSI

RISK bull All post splenectomy patients have an increased risk of

overwhelming bacterial infection Certain factors however do influence the degree of risk

Age Younger patients have greater risk

Underlying disease Risk with underlying immunodeficiency gt thalassemia gt sickle cell anemia gt traumatic splenectomy

Time since splenectomy Recent splenectomy has greater risk than many years post-operatively with 80 of cases occurring within 2 years of splenectomy

Pathogens

bull The most common cause of overwhelming post-splenectomy sepsis is S pneumoniae (50-60) however all of the pathogens listed below can be a source of serious infection in these patients

middot Encapsulated bacteria S pneumoniae H influenza (20- 30) N meningitidis (10-20)

middot S aureus

middot Numerous gram negatives including E coli K pneumoniae Salmonella sp and Capnotcytophagia sp (the latter usually acquired from a dog bite)

middot Malaria

middot Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod Martharsquos Vineyard Nantucket Block Island)

Clinical manifestations

bull Feverndash Any fever must be viewed as possible PSS

bull Bacteremiabull Coagulopathy

ndash Purpura petechiaebull Meningitis

ndash Headache neck stiffness seizurebull Respiratory symptoms

ndash Cough dyspnea respiratory failurebull GI symptoms

ndash Nausea vomiting diarrhea GI bleedingbull Shock

Labs

bull CBCbull Blood smearbull DIC profilebull Lumbar puncturebull CXRbull Blood culture

Management

bull Broad-spectrum antibioticsndash Based on expert opinionndash Must cover

bull penicillin-resistant pneumococcusbull beta-lactamase producing Hinfluenzae

ndash General suggestionbull Ceftriaxone + Vancomycinbull Levofloxacin + Vancomycin

bull Life-support measuresndash HD or CVVH for ARFndash Ventilatorndash Inotropic agentsndash Fluid

Preventionbull Avoid unnecessary splenectomy 1048707 Splenic salvage highly desirable when safe Selective nonoperative management (ie Trauma) Operative splenorrhaphy Intentional splenosis when appropriate

bull Immunizationndash Timing

bull 14 days before splenectomybull 14 days after splenectomy (not immediately)

ndash Pneumococcal vaccinebull PPV-23 for adultsbull PCPV-7 for children and some adults

ndash Haemophilus B vaccinendash Meningococcal vaccinendash Re-immunizationndash Other vaccines influenza vaccine

Vaccinations

bull There are currently 2 licensed pneumococcal vaccine bull 1) a 23-valent Pnemococcal Polysaccharide Vaccine PPV-23

(Pneumovaxreg) This vaccine is immunogenic only in those gt 2 years of age and provides protection against the greatest number of clinically relevant serotypes

2) a 7-valent Protein-Conjugated Vaccine PCV-7 (Prevnarreg) which is immunogenic and safe beginning at 6 weeks of age It has not been well studied in older patients and provides protection against only 7 serotypes

Vaccination Recommendations

Current recommendations for this use of these vaccines post splenectomy are as follows

bull Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age 2 4 6 and 12-15 months of age These children should be given PPV-23 at 2 years of age

bull Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart followed gt 2 months later by a dose of PPV-23

bull Older children and adults should receive the PPV23

bull A booster PPV23 should be given approximately 5 years after the initial vaccineseries

bull Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals gt 2 years of age

bull Hemophilus influenza vaccine should be given once to all individuals gt 2 years of age and at the time of routine vaccination for younger children

Prophylactic Antibiotics

The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia Resistance to penicillin (and other antibiotics) is a growing concern so itrsquos efficacy is currently presumed to be lower In addition compliance with an indefinite daily regimen is extremely difficult

bull The patients who are most likely to benefit from prophylaxis are 1048707 Children lt 5 years of age 1048707 Individuals who have had splenectomy within the past year 1048707 Those with an underlying immunodeficiency in addition to splenectomy

bull Regimens for children Penicillin G Pediatrics 250 mg po bid (less than 5 years 125 mg po bd)

Alternatives Amoxicillin Pediatrics 20mgkgday divided bid As there are currently no ideal second line oral agents allergy to the

penicillins should be assessed carefully

No data are available in adults and antibiotic prophylaxis is generally not recommended this population

Pre-op for distal pancreatectomy in case splenectomy performed

Post-Splenectomy Sepsis

Nonoperative management

bull With careful patient selection success rate now approaches 95 (85-95) 1048707 Hemodynamic stability 1048707 No contrast lsquopoolingrsquo on CT 1048707 No other intraabdominal injuries requiring laparotomy

bull Follow frequent serial vital signs and HH 1048707 Treat persistently falling RBC with pRBCrsquos 1048707 Rebleeding most likely within 1st 48 hours 1048707 Likely failure if patient requires ge 2 u pRBCs If still falling after 2u consider angio for embolization If hypotension develops consider angiography

Nonoperative Management

bull Follow-up CT scans rarely necessary 1048707 Indicated for falling BP or HH during observation 1048707 Grade I-II rarely show progression of lesion or other complications on CT No need for repeat CT scan if HH and vitals stable 1048707 Grade III CTrsquos on case-by-case basis 1048707 Consider US for monitoring if necessary 1048707 Contact Sports Complete resolution on CT required before can return to activitybull 2-5 of patients treated nonoperatively will develop

parenchymal infarction or infection

Nonoperative Management

Nonoperative Management

bull Delayed Rupture1048707 75 occur within 2 weeks in several

seriesbull Hematoma liquifying 1048707 Can occur anytime (1 month ndash years) 1048707 Actu