BY SUNNDEEP CHOPRA:
STRUCTURE: The spleen is normally a reticuloendothelial organ (part of the immune system that consists of the phagocytic cells) that has its embryologic origin (originates in ) the dorsal mesogastrium ( apron like specialisation of the peritoneum attaching along the greater curvature of the stomach) after bout 5 weeks of germination or gestation. The same has been known to usually announce or then manifest itself as a series of hillocks that migrate or then move towards its normal adult position within the left upper quadrant (LUQ) and is attached or then linked to the stomach via the gastrolineal ligament and the kidney via the lienorenal ligament.
The ideal or desired weight of the normal adult spleen varies between 75-250 grams and the same lies within the left hypochondrium in between the gastric fundus (gastric wall) and the left hemidiaphragm, with its long axis lying parallel to the 10th rib.
FUNCTIONS: Though the spleen was always thought to be an extraneous organ and therefore dispensable, increasing or then advancing knowledge of its function (s) has given rise to a healthy degree of skepticism about the usefulness of the spleen and therefore conservative approaches or theories about it’s management and functions (conditions) have evolved in due course of time.
Most doubting thomases now grudgingly admit and recognize the indisputable fact that a resultant or incidental splenectomy during the course of some other operation or operative procedure consequentaly increases or enhances the chances of complications and death manifold. The surgeon should therefore ensure/endeavour to preserve the spleen so that it can continue to discharge the below mentioned functions:
· Immune Functions: The spleen is thought to process or then normally processes foreign antigens ( is any substance that causes your body to produce anti bodies against it) and is also the major site of specific immunoglobin M (IgM) production. The non specific opsonins (anti bodies) properdin and tuftsin are synthesised or produced in the spleen too.
· Filter Function: Macrophages (type of white blood cell that ingests or takes in foreign bodies) in the reticulum either capture or ingest both cellular as well as non-cellular material from the blood and plasma. This process includes/precludes the removal of effete platelets and red blood cells and normally takes place or occurs within the sinuses and splenic cords by the action of the endothelial macrophages. Iron is isolated and removed from the degraded haemoglobin during red cell breakdown and subsequently translocated to the plasma.
· Pitting: Particulate inclusions or matter from the red blood cells is eradicated or removed and the rejuvenated or repaired red blood cells wander or then find their way back into the circulatory process. These are inclusive of or then include the Howell-Jolly and Heinz bodies which are representative of nuclear remnants and precipitated haemoglobin respectively.
· Reservoir Function: This function is less conspicuous or marked amongst humans in comparison to other species, but the irrefutable fact is that the spleen comprises of approximately 8% of the body’s red cell mass. An enlarged or elongated spleen has been known to contain a significantly greater or larger proportion of the blood volume.
Functions of the Spleen:
Ø Immune
Ø Filter function
Ø Pitting
Ø Reservoir
Ø Cytopoiesis
Ø Splenectomy could either harm or then prove fatal for the patient.
ENLARGED SPLEEN: Massive or clearly evident splenic enlargement most frequently occurs or manifests itself in the tropical countries on account of malaria, kala-azar and schistosomiasis. Though, splengomaly often cannot be fully attributed or then completely blamed on them. The same can also manifest itself on account of or then be caused by occult infection and a direct by-product of malnutrition. The massive or chronic spelngomaly observed in malnutrition affected patients could entail the complete extrication or removal of the spleen especially in the case of patients or people severely disabled by either anaemia or a plethora of local/intrinsic symptoms.
Schistosomiasis: This spleen related condition is most commonly observed or then prevalent amongst the citizens/denizens of Africa, Asia and South America. The same is primarily caused by and infection caused by the schistoma mansoni in almost three quarters or then 75% of all recorded cases and by schistoma haematobium in the remainder. The splenic enlargement may be directly attributed to an almost rare combination of portal hypertension and hepatic fibrosis, but can equally result from or then be attributed to hyperplasia induced by the phagocytosis (engulfing,ingestion of foreign or disease causing bodies) of disintegrated worms, ova and toxins.
The splengomaly can occur irrespective of age and the diagnosis is more often than not based on a minute examination of the urine and faeces for signs or manifestations of ova, abnormal liver function tests and the presence or visibility of hypochromic anaemia.
Splengomaly is a commonly manifested or observed feature in most if not all disease processes. The irrefutable fact that many allied conditions such as idiopathic thrombocynetic purpura may be intimately associated or linked with enlargement of the spleen should always be kept in mind while examining cases of splengomaly. The gland however is seldom palpable and very few or then a miniscule minority of all recorded or observed cases will require or include splenectomy as part of their treatment methods.
SPLEEN SYMPTOMS: The most common or visible symptoms produced by or characteristic of diseases associated or involving the spleen are an all pervading pain and a heavy or overwhelming sensation in the left upper quadrant (LUQ) . Massive or rampant splengomaly may result in early satiety or fulfillment.
Pain may arise or then be a result of the acute swelling of the spleen coupled with a significant stretching of the capsule, infarction or then inflammation of the capsule. The commonly held belief for many a year was that splenic infarction or infection appeared or manifested itself without a whimper or sound and the same still holds true in many a case.
A palpable spleen is the most commonly observed or then felt physical symptom or manifestation of a diseased spleen and highly suggestive of the enlargement of the organ. The normal human spleen most often weighs less than 250 grams, decreases or then shrinks in size with advancing age, almost always entirely lies within the confines of the rib cage, has a maximum diameter of 13 cms when measured with the aid of ultrasound tools and maximum length of 12 cms and width of 7 cms when measured with the aid of a radionuclide scan and is almost always not palpable.
Physical or then clinical assessment of the spleen always comprises of or contains the conservative techniques palpation and percussion. Inspection may reveal or highlight fullness or filling up of the left upper quadrant that subsequently shows signs of descending on inspiration (a finding or result closely associated with a massive enlarged spleen).
Palpation can be most commonly initiated by resorting to bimanual palpation, ballotment and palpation from above (Middleton maneuver). The patient often has to lie down in a supine position along with flexed or bended knees, the examiner’s left hand is normally placed on the lower rib cage and gently pulls the underlying skin towards the costal margin, thereby enabling the free right hand to the tip of the spleen as it descends while the patient inspires or inhales gradually and slowly and deeply.
Percussion for splenic dullness is accomplished with any of the three below mentioned techniques mentioned below by Nixon, castell and/or barkun:
1. Nixon’s method: The patient is asked to lie down or recline on his right side so that the spleen lies directly above the colon and stomach.Percussion usually begins at the lower level of pulmonary resonance in the posterior axillary and makes a diagonal onwards progression towards or then in the direction of the lower midanterior costal margin. The upper limit or border of the dullness or pain is usually measured 6-8 cms above the costal margin. Dullness exceeding 8 cms in an adult is taken to be a precursor of splenic enlargement.
2. Castell’s Method: Percussion in the lowest or rock bottom intercostals space in the anterior axillary line (8th or 9th) normally produces a resonant sound or note if the spleen has maintained it’s optimum size. The patient is always lying down in a supine position while being subjected to this technique. The same holds true during both expiration and full and complete inspiration. The production or recording of a dull or subdued note while the patient is in full inspiration mode is taken to be the precursor of splengomaly.
3. Percussion of Traube’s semilunar space: The borders or outer limits of traubes’ space are generally the sixth rib superiorly, the left midaxillary line laterally and the left costal margin inferiorly. The patient is lying down in a supine position with the left arm slightly inwardly withdrawn or then abducted towards the patient. This space is percussed between the medial and lateral margins during normal breathing, thereby resulting in or yielding a normal or customary resonant sound. A dull or in resonant note or sound is taken to be a precursor of splengomaly.
RUPTURED SPLEEN: A ruptured spleen should always be the primary concern in any case of blunt abdominal trauma, especially when the injury occurs to the left upper quadrant of the abdomen. Iatrogenic (induced inadvertently or unintentionally by a physician or surgeon) injury or Injuries to the spleen continue to remain a frequent complication or by-product of any surgical procedure, particularly those of the left upper quadrant.
Rupture of a Malarial Spleen: This is a common place and rather frequent occurrence in tropical countries and the delayed type of manifestation consequent to a ‘trivial’ or negligible injury though not as common is also fairly prevalent. Splenectomy should always be carefully considered before the rupturing of a perisplenic haematoma (splenic clot) as the same could result in the formation of an abscess that could prove fatal for the patient.
Surgery is most often a highly complicated and challenging procedure in the case of such patients and early ligation or binding of the splenic vessels lining the superior body should be duly contemplated before disturbing or touching the haematoma.
SPLENECTOMY OR SURGICAL REMOVAL OF THE SPLEEN:
The most common pointers or indications towards splenectomy are as under:
Ø Trauma resulting from or consequent to an accident or then during an ongoing surgical procedure, as for example during mobilization of the oesophagus, stomach, distal pancreas or splenic fixture of the colon.
Ø En bloc or total removal with the stomach as an integral part of a radical gastrectomy or then with the pancreas as an important part of a distal and total pancreatectomy.
Ø To reduce or control anaemia or thromobocytopenia in spherocytosis, idiopathic thrombocytopenic purpura or hypersplenism.
Ø In association or conjunction with shunt or variceal surgery for portal hypertension.
Indications or signs for the initiation of splenectomy:
Trauma:
· Accidental
· Operative
Oncological:
· Part of en bloc restoration
· Diagnostic
· Therapeutic
Haematological:
· Spherocytosis
· Purpura (ITP)
· Hypersplenism
Portal Hypertension:
· Variceal surgery.
Preoperative Preparations: Required or necessary Blood transfusions , fresh frozen plasma and cryoprecipitate of platelets should be close at hand whenever a surgical procedure is being performed on a patient with an inherent tendency to bleed profusely. Coagulation or clot related profiles should be at the near normal level during the operation and platelets should be readily available for patients afflicted by thrombocytopenia during and the period subsequent to the operation or surgical procedure.
Antibiotic ministrations or prophylaxis appropriate to the operative procedure should be given or initiated as the case may be and careful and due consideration should be given to the risk of contracting post-splenectomy sepsis or then post operative infections.
Technique of Open Splenectomy: A significant majority of all surgeons use either a midline or then transverse left subcostal incision (or long running cut) in every case of open splenectomy. A thoracoabdominal incision may rarely be warranted in the case of an inflamed or enlarged spleen conjointed or adherent to the diaphragm. The introduction of a nasogastric tube subsequent to the induction of the anaesthetic ensures the emptying of the stomach’s contents.
The gastrosplenic ligament is opened up and the short gastric vessels are consequently divided in all cases of elective splenectomy. The splenic vessels located at the superior end of the pancreas are bound with the aid of sutures or then suture ligated. The rear or posterior surface of the spleen is exposed and the pancreas is separated or eviscerated from the hilar vessels which are consequently ligated and divided.
Technique of Laparoscopic Splenectomy: The patient is asked to lie down in a supine position on his right or then placed on his right with the available space between the left ilium and costal margin conspicuously exposed. The placement or then spacing between the access ports is co-determinant upon the size of the patient and spleen.
Insufflation (the act of blowing a powder, vapour or gas into a body cavity) of the abdomen can be performed or initiated once access is gained or obtained through an incision 1 cm from the costal margin at the left mid-clavicular line. This specific operation is almost always initiated as a hand assisted procedure.
Postoperative Complications: Consequent or immediate complications specific or intrinsic to splenectomy include haemorrhage resultant from a slipped or misplaced ligature. Haematemesis (vomitting or then spewing of blood) as a result of gastric mucosal damage and gastric dilatation though uncommon is not entirely unknown. Left basal atelectasis (collapse of part of or then all of a lung) is common and widely prevalent and a pleural effusion might just end up making it’s presence felt. Adjacent or adjoining structures that are at risk during the operation or surgical procedure include both the stomach and pancreas.
A fistula may be the consequent result of post operative damage to the greater curvature of the stomach during ligation of the short gastric vessels. Minor or major damage to the tail of the pancreas may end up resulting in pancreatitis , a localized abscess or then a pancreatic fistula.
Splenectomy Related Facts:
· Remember preoperative immunization
· Prophylactic antibiotics administration in the long term.
· OPSI (post operative complications) are a real and present danger.
LOCATION: The spleen is most commonly ensconced in the left hypochondrium between the gastric fundus and left hemidiaphragm with it’s longest or then long axis lying along or then runnin parallel to the 10th rib. The hilum is placed in the created angle between the stomach and the kidney and does distantly touch or then is in contact with the tail or rear end of the pancreas.
SPLEEN CANCER OR NEOPLASMS: Haemangioma (are non cancerous abnormally dense collections or masses of dilated small blood vessels that may occur both on the skin as well as the internal organs) is the most commonplace or widely observed benign tumour of the spleen. The same may rarely if at all develop into a haemangisarcoma (cancerous growth) that calls for or requires the initiation of a splenectomy. The spleen is most rarely if at all the site of metastatic disease (is the spread of a disease from and organ or part to another non-adjacent organ or part). Lymphoma (is a cancer within the lymphatic cells of the immune system)is the most common reason or cause of neoplastic enlargement or elongation and splenectomy might just end up playing a significant role in it’s management or treatment.
Myelofibrosis results or then follows on from an abnormal or freak proliferation or multiplication of mesenchymal elements in the bone marrow, spleen, liver and lymph nodes. The same most commonly affects adults in the 50+ age bracket and the spleen may start paining or then become painful on account of its gross or mammoth enlargement or then from splenic infarcts or infections.
Accessory Spleen: The same may develop on account of the woeful failure of the hillocks to unify into a single tissue mass and develop in/affect around 20% of all patients.
DIAGNOSIS: Conditions or symptoms that could consequently result in splengomaly can be isolated and diagnosed on the basis of or then by taking recourse to/obtaining the complete medical history of the patient and subjecting him to a battery of both physical as well as clinical examinations. A complete blood count, reticulocyte count and required tests to either confirm or then rule out the presence of haemolysis will more often than not succeed in establishing or identifying the cause behind the anaemia.
Splengomaly associated with or then in close conjunction with portal hypertension caused by or resulting from cirrhosis is diagnosed on the basis of the history, physical signs or manifestations of liver function and clinical evidence of oesophaegal varices. Asa a vast majority of conditions that cause splengomaly are closely associated or linked with lymphadenopathy all required investigations should be expressely directed towards/at those disease processes having an intimate association with both physical signs. Lymph node biopsy can also be considered and initiated if so required.
Radiological Imaging: Plain radiology or then a plethora of x-rays are far from the favourite means of investigation in this case though the incidental or matter of chance finding or observation of the calcification of the splenic artery or spleen may raise the possible diagnosis of a splenic artery aneurysm, an old infarct, a benign cyst or then hydatid disease (parasitic infestation by a tapeworm). Multiple or then widespread areas of calcification may point towards or then suggest the presence of splenic tuberculosis. Ultrasonography can play a pre-dominant role in determining the size and consistency of the spleen and either confirm or then completely rule out the presence of a cyst.
CONGENITAL ABNORMALITIES: Splenic agenesis ( the failure of an organ to develop during embryonic growth) is uncommon but still found in almost 10% of all children afflicted by congenital heart disease. Polysplenia ( congenital disease manifested by small accessory spleens) is a rare and extremely uncommon condition resulting or then following on from the failure of splenic fusion.
Splenunculi are either single or multiple accessory or subsidiary spleens that re manifested in or found in approximately 10-30% of the world’s population. They are most commonly located near the hilum of the spleen in almost half or 50% of all cases and are inextricably related to the splenic vessels or then in the nether regions of the tail of the pancreas in almost 30%. The remainder are located in either the mesocolon or the splenic ligaments.
Hamartomas (a focal growth that resembles a neoplasm but results from faulty development within an organ) are almost extinct and rarely found in living homo sapiens; and can vary in size fro a pithy 1 cm to masses large or then effective enough to produce or cause a swelling of the abdominal area.
Non-parasitic splenic cysts are again extremely rare. True or real cysts form or then begin to manifest themselves from embryonal rests and include both dermoid and mesenchymal inclusion cysts. These cysts are commonly lined by flattened epithelium and should be differentiated or distinguished from false cysts that are a consequence of some trauma or the other and can contain serous or haemorrhagic fluid.
CAUSES OF ENLARGED SPLEEN:
· Infective-------Bacterial---------Typhoid and parathypoid, typhus, tuberculosis, septicaemiasplenic abscess
· Spirochaetal-------weils’ disease, syphilis
· Viral------infectious mononucleosis, HIV-related or linked thrombocytophenia, psittacosis.
· Protozoal and parasitic-------malaria, schistosomiasis, trypanosomiasis, kala-azar, hydatid cyst, tropical spleno megaly.
Ø Blood disease………acute leukaemia……idiopathic thrombocytopenic purpura
Ø Chronic leukaemia…….hereditary spherocytosis
Ø Pernicious anaemia……….autoimmune haemolytic anaemia
Ø Polycythaemia vera…….thalassaemia
Ø Erythroblastosis fetalis…….sickle cell disease
# Metabolic: rickets, amyloid, porphyria, gaucher’s disease
} Circulatory__________Infarct, portal hypertension, segmental portal hypertension________(pancreatic carcinoma, splenic vein thrombosis)
] Collagen Disease…….still’s disease, felty’s syndrome
+ Non-parasitic cysts____________congenital, acquired
~ Neoplastic: angioma, primary fibrosarcoma, hodgkin’s lymphoma, other lumphomas, myelofibrosis.
Short Notes:
Ø HIV, human immunodeficiency virus:
· Often benefited by splenectomy
· Splenectomy may be indicated
· Benefited by splenectomy
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