Surgery of the spleen

The spleen is an organ with many functions which have become better appreciated in recent times. This improved understanding, particularly with respect to its part in the immune responses, has lead to a greater emphasis on splenic salvage and preservation. The spleen is a vascular organ found under the ribcage in the left upper quadrant of the abdomen, is frequently damaged during blunt trauma and as such is commonly excised as an emergency. This article aims to give the reader greater understanding of the splenic function, splenic surgery, the complications and immune considerations following its excision.     

Surgery of the spleen

A normally functioning spleen is critical in providing adequate immune protection and in regulating blood homeostasis. Whereas primary disorders of the spleen can attenuate these important functions, absence of the spleen, most commonly as a result of surgical excision, carries the grave and lifetime risk of devastating systemic sepsis. With some historical exceptions, splenic surgery has classically involved removal of the entire organ at open surgery, either following traumatic injury or to supplement the medical management of haematological disorders. Performed primarily for this latter indication, laparoscopy has emerged over the last two decades as the strongly favoured approach for elective splenectomy, with very large splenic size being one of the few remaining reasons for a planned open approach. Even in skilled hands, laparoscopic splenectomy can prove technically demanding, where careful patient selection and recognition of major complications including haemorrhage, portal system thrombosis and pancreatic injury, requires considerable experience. Whether performed under emergency or elective circumstances and undertaken as an open or laparoscopic procedure, an optimal surgical outcome depends on the successful collaboration between surgeon, anaesthetist, haematologist and radiologist in the preoperative and postoperative phases. Finally, it is paramount that in patients undergoing splenectomy, sufficient attention is given to providing effective lifelong prophylaxis against post-splenectomy infection.     

Surgery of the spleen

A normally functioning spleen is critical in providing adequate immune protection and in regulating blood homoeostasis. Whereas primary disorders of the spleen can attenuate these important functions, absence of the spleen, most commonly as a result of surgical excision, carries the grave and lifetime risk of devastating systemic sepsis. With some historical exceptions, splenic surgery has classically involved removal of the entire organ at open surgery, either following traumatic injury or to supplement the medical management of haematological disorders. Performed primarily for this latter indication, laparoscopy has emerged over the last two decades as the strongly favoured approach for elective splenectomy, with very large splenic size being one of the few remaining reasons for a planned open approach. Even in skilled hands, laparoscopic splenectomy can prove technically demanding, where careful patient selection and recognition of major complications including haemorrhage, portal system thrombosis and pancreatic injury, requires considerable experience. Whether performed under emergency or elective circumstances and undertaken as an open or laparoscopic procedure, an optimal surgical outcome depends on the successful collaboration between surgeon, anaesthetist, haematologist and radiologist in the preoperative and postoperative phases. Finally, it is paramount that in patients undergoing splenectomy, sufficient attention is given to providing effective lifelong prophylaxis against post-splenectomy infection.     

Surgery of the spleen

Enshrouded in history as the organ associated with short temper and of little physiological importance, a normally functioning spleen is critical in providing adequate immune protection and regulating blood homeostasis. Whereas primary disorders of the spleen can attenuate these important attributes, the absence of splenic function, most commonly as a result of surgical resection, carries the grave and lifetime risk of devastating systemic sepsis. With some historical exceptions, splenic surgery has classically involved removal of the entire organ at open surgery, either following traumatic injury or to supplement the medical management of haematological disease. Performed primarily for this latter indication, laparoscopy has emerged over the last two decades as the strongly favoured approach for elective splenectomy, with very large splenic size being one of the few remaining reasons for a planned open approach. Even in skilled hands, laparoscopic splenectomy can prove technically demanding, where careful patient selection and recognition of major complications including haemorrhage, portal system thrombosis, pancreatic injury and remnant splenic tissue requires considerable experience. Whether performed under emergency or elective circumstances and undertaken as an open or laparoscopic procedure, an optimal surgical outcome depends on the successful collaboration between surgeons, anaesthetists, haematologists and radiologists in the pre- and post-operative phases. Finally, it is paramount that in patients undergoing splenectomy, sufficient attention is given to providing effective lifelong prophylaxis against post-splenectomy infection.     

Wandering spleen with chronic torsion

Wandering spleen, a rare clinical entity with a high incidence of splenic torsion and infarction, was preoperatively diagnosed in a 28-year-old woman. Axial computed tomography showed the absence of the spleen in the left subphrenic space and a spleen-like mass in the pelvis, suggestive of a wandering spleen. A coronal contrast-enhanced computed tomography image exhibited the enlarged spleen suspended by elongated, dilated, and somewhat tortuous splenic vessels. Owing to the symptomatic splenomegaly with hypersplenism and chronic torsion, laparoscopic splenectomy was performed.     

Wandering hemi-spleen: Laparoscopic management of wandering spleen in a case of polysplenia

INTRODUCTIONSeveral congenital anomalies of the spleen have been reported. The polysplenia is a rare anomaly in which the normal spleen is replaced with two or more smaller spleens. The wandering spleen is another anomaly resulting from the laxity of the splenic ligaments. The concomitance of both anomalies is very rare.PRESENTATION OF A CASEA 22-year old female patient presented with intermittent left hypochondrial pain for more than a year. After a thorough examination of the patient, she only had bilateral accessory nipples. Routine laboratory investigations were all normal. An abdominal ultrasound U/S scan was unremarkable except for a ptotic spleen. with a large splenule 5 cm × 3 cm located near the fundus of the stomach. These findings were confirmed by a CT scan. A decision for a surgical intervention was then made, and the laparoscopic approach was chosen which revealed the condition. Laparoscopic removal of the wandering part was executed. The patient discharged on the first post-operative day.DISCUSSIONThe decision making in cases of wandering spleen is not always the same. The association of a wandering spleen with polysplenia is an asset to the surgical decision, along with the age of the patient.CONCLUSIONThe laparoscopic approach is an important tool in the diagnosis and management of wandering spleen. The diagnosis of polysplenic anomaly could provide a guidance for the surgical strategy in patients with wandering spleen.     

Wandering spleen presenting as recurrent pancreatitis

INTRODUCTION: A wandering spleen occurs when there is a laxity of the ligaments that fix the spleen in its normal anatomical position. CASE REPORT: We present the case of a wandering spleen in a 20-year-old female who presented with recurrent pancreatitis and underwent a laparoscopic splenectomy. DISCUSSION: The presentation of a wandering spleen varies from an asymptomatic mass to splenic infarct with an acute abdomen. Its correct diagnosis relies mostly on imaging studies. Treatment consists of performing either splenectomy or splenopexy. CONCLUSION: The diagnosis of wandering spleen can often be difficult due to the intermittent nature of the torsion. Computed tomography studies for diagnosis and laparoscopic surgery have changed the management of this interesting disease.     

Identification of Accessory Spleens During Laparoscopic Splenectomy Is Superior to Preoperative Computed Tomography for Detection of Accessory Spleens

Background:

Missed accessory spleen (AcS) can cause recurrence of hematologic disease after splenectomy. The objective of the study was to determine whether detection of AcS is more accurate with preoperative computed tomography (CT) scan or with exploration during laparoscopic splenectomy.

Methods:

A retrospective chart review was performed for 75 adult patients who underwent laparoscopic splenectomy for various hematologic disorders from 1999 to 2009. Preoperative CT scans were performed in all patients. Patients were followed for recurrence of disease, and a scintigraphy scan was performed in those with suspected missed AcS.

Results:

The most common diagnosis was idiopathic thrombocytopenic purpura in 29 patients (39%), followed by non-Hodgkin''s lymphoma in 22 patients (29%). Sixteen AcSs were found during surgery in 15 patients (20%), and preoperative CT scan identified 2 of these. Twelve AcSs were located at the splenic hilum (75%). Nine patients experienced recurrence of their disease, and none had a missed AcS on subsequent scintigraphy. Sensitivity of exploratory laparoscopy for detection of AcS was 100%, and for preoperative CT scan was 12.5% (P = .005).

Conclusion:

Exploratory laparoscopy during splenectomy is more accurate than preoperative imaging with CT scan for detection of AcS. Preoperative CT scan misses AcS frequently and should not be obtained for the purpose of its identification.     

腹腔镜脾切除治疗外伤性脾破裂

目的探讨采用腹腔镜脾切除的方法治疗外伤性脾破裂的可行性. 方法 2004年8月～2005年5月我院采用腹腔镜脾切除方法治疗外伤性脾破裂8例. 结果 7例顺利完成腹腔镜脾切除术,1例改行手辅助腹腔镜脾切除术成功.手术时间150～200 min,平均180 min.术中出血量600～5 500 ml,平均2 200 ml.Ⅱ级损伤5例,Ⅲ级3例,术后恢复佳,无并发症. 结论腹腔镜脾切除治疗外伤性脾破裂安全、可行.     

Laparoscopic splenectomy in blunt trauma.

We describe the first reported use of laparoscopic splenectomy as initial treatment in high-grade blunt splenic trauma. A 21-year-old man sustained a blow to the left flank from a large construction pipe and was transferred to our hospital with a grade V splenic laceration and a grade II left peri-renal hematoma with hematuria. He was hemodynamically stable. He underwent a laparoscopic splenectomy shortly after arrival. The patient's renal injury was managed nonoperatively, and he was discharged home with no complications and has remained well.     

腹腔镜脾切除术55例临床分析

目的 探讨腹腔镜脾切除术在各类脾脏疾病中的安全性及疗效.方法 回顾分析2007年5月至2009年12月完成的55例腹腔镜脾切除术资料.其中特发性血小板减少性紫癜(ITP)11例,自身免疫性溶血性贫血6例,球形红细胞增生症1例,脾淋巴瘤1例,脾囊肿10例,脾血管瘤5例,脾脉管瘤2例,肝硬化门脉高压脾功能亢进(脾亢)患者9例,肝硬化脾亢患者9例,不明原因脾肿大脾亢1例.结果 55例患者均顺利完成腹腔镜脾切除术,无中转手助或中转开腹,平均手术时间(119.7±33.0)min.术中出血量平均(83.8±65.2)ml.术后平均住院时间(5.7±1.1)d.术后腹水1例,腹腔引流液淀粉酶升高7例,无手术死亡.结论 腹腔镜脾切除术能安全有效地适用于多种脾脏疾病的手术治疗.     

The role of the spleen in tumor bearing host: I. Characterization of spleen cells in tumor-bearing mice

Morphologic changes of the spleen and dynamic changes of biologic activity of spleen cells from C₃H/HeJ mice bearing methylcholanthrene induced fibrosarcoma (MCA-F) were investigated in different stages of tumor growth, using local adoptive transfer assay (LATA). The spleen size, weight and the number of spleen cells increased with the tumor growth. In early and late stages of tumor growth, tumor-bearing mice possessed non-specific tumor-enhancing cells which were radioresistant (700 rads), phagocytic and adherent, suggesting that they were macrophages. On the other hand, in middle stages of tumorgenesis, tumor-bearing mice possessed specific cytotosic cells which were radiosensitive (700 rads) and anti-Thy 1.2 serum positive, suggesting that they were T-cells. Thus, the appearance of tumor-enhancing cells was earlier than cytotoxic cells in MCA-F bearing host, and the balance of tumor-enhancing and cytotoxic cells may influence the tumor outgrowth in different stages of tumorgenesis. The spleen serves as a reservoir of factors which either abrogate cell mediated resistance or stimulate neoplastic growth, or as the source of cytotoxic cells, at certain times of tumor burden.     

Wandering spleen in childhood: A report of three cases

Wandering spleen is a rare cause of abdominal pain in children, and an accurate diagnosis is seldom made preoperatively. A splenectomy is the treatment of choice in cases of splenic torsion and infarction, while in patients with chronic symptoms splenopexy may also be attempted. We herein report three patients with wandering spleen, of whom two presented with acute torsion of the splenic pedicle and one demonstrated an asymptomatic mobile abdominal mass. In the first case splenopexy was attempted, but during follow-up the spleen was found to have undergone atrophy. The presentation, diagnostic procedures, and treatment modalities in pediatric wandering spleen are reviewed.     

Handheld gamma probe used to detect accessory spleens during initial laparoscopic splenectomies

Background Preoperative determination of the accessory spleen still is a major factor in the failure of both laparoscopic and conventional techniques. This study aimed to evaluate the practicability and efficacy of a handheld gamma probe in identifying accessory spleens at the initial intervention. Methods This study evaluated 17 patients undergoing laparoscopic splenectomy attributable to benign hematologic disorders. All the patients had preoperative ultrasonography, computed tomography (CT) scan, and nuclear scintigraphic examination of the abdominal cavity to assess the size of the spleen, and to determine the existence of the accessory spleen or spleens. For all the patients, a handheld gamma probe count was used intraoperatively as an adjuvant method to define the presence and location of the accessory splenic tissue. Control nuclear scintigraphic examinations of all the patients were performed 1 month after the surgical procedure. Results In two cases, intraoperatively accessory splenic tissue was detected by gamma probe, confirming the preoperative CT findings for the patients. One of these patients had three accessory spleens, although preoperative CT scan showed only two of them. However, by the help of the gamma probe, a third spleen located retroperitoneally was defined. For two patients, laparoscopic exploration and handheld gamma probe count did not identify any accessory splenic tissue, although preoperative CT scan indicated accessory spleens. For detecting accessory splenic tissue, the sensitivities of the studied techniques were 0% for ultrasonography, 75% for CT scan, 0% for preoperative nuclear scintigraphy, 75% for laparoscopic exploration, and 100% for perioperative gamma probe examination. Conclusion Preoperative imaging methods for accessory spleen determination still have limited benefits because of their limited sensitivity. Thus, the handheld gamma probe technique may be an adjuvant method for laparoscopic exploration ensuring that no accessory splenic tissue is missed during the initial surgical treatment of benign hematologic disorders.     

Laparoscopic splenectomy for histiocytic sarcoma of the spleen

Primary histiocytic sarcoma of the spleen is a rare but potentially lethal condition. It can remain asymptomatic or only mildly symptomatic for a long time. An 81-year-old woman presented with an extremely enlarged spleen. She suffered from progressive anemia and required a red blood cell transfusion once a month. Although computed tomography, ultrasonography, and magnetic resonance imaging were performed for diagnosis, a confirmed diagnosis was not obtained. Her enlarged spleen compressed her stomach, and she suffered from gastritis and a sense of gastric fullness just after meals. She underwent laparoscopic splenectomy for therapeutic and diagnostic purposes. Her post-operative course was uneventful. After surgery, her red blood cell and platelet counts increased markedly. The tumor was diagnosed as splenic histiocytic sarcoma. Post-surgical chemotherapy was not performed, and the patient died of liver failure due to liver metastasis 5 mo after surgery. Laparoscopic splenectomy is minimally invasive and useful for the relief of symptoms related to hematological disorders. However, in cases of an enlarged spleen, optimal views and working space are limited. In such cases, splenic artery ligation can markedly reduce the size of the spleen, thus facilitating the procedure. The case reported herein suggests that laparoscopic splenectomy may be useful for the treatment of splenic malignancy.     

外伤性脾破裂脾部分切除术探讨

目的探讨外伤性脾破裂Gall3级和Gall4级的脾部分切除术的治疗效果。方法通过回顾分析1998年4月至2003年9月行8例Gall3级和1例Gall4级的脾破裂脾部分切除术的手术方法和治疗效果。结果8例Gall3级和1例Gau4级的脾破裂脾部分切除术,术后恢复顺利,保留脾存活好。结论Gall3级的脾破裂在掌握适应症下行脾部分切除术是安全可行的。     

Avulsion of wandering spleen after traumatic torsion

Wandering spleen usually causes clinical symptoms by torsion. Cases of torsion or hemorrhage after blunt trauma are reported. The authors experienced avulsion of wandering spleen after traumatic torsion in the victim of pedestrian injury. The spleen had been located in the left upper quadrant on the time of torsion, but it moved into the right paracolic gutter after avulsion. The avulsed spleen was removed, and the postoperative course was uneventful.     

Littoral cell angioma of the spleen treated by laparoscopic splenectomy.

Massive splenomegaly due to multifocal littoral cell angioma was discovered incidentally in a 55-year-old man during a workup for an unrelated condition. The tumor was removed successfully by laparoscopic splenectomy. We report the second case of littoral cell angioma of the spleen treated laparoscopically.