Spleen

Dr.Mahmoud Al-Awaysheh
General & Colorectal Surgery
MRCS
Mu’ta University
2020
 Contents:
• Anatomy
• Physiology (Functions)
• Splenic trauma
• Splenomegaly

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 Spleen Origin
• The Splenic tissue develops from
condensations of mesoderm in the dorsal
mesogastrium.

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 Anatomy
• It is the largest single mass of lymphoid tissue
in the body
• Has a size of a closed fist
• Weight of normal adult spleen: 75–250 g
• It lies in the left hypochondrium between the
gastric fundus and the left hemidiaphragm
• Its long axis lying along the tenth rib
• The hilum sits in the angle between the
stomach and the kidney and is in contact with
the tail of the pancreas
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 Surface anatomy
• Lower pole extends no further than the mid-
axillary line.
• There is a notch on the inferolateral border,
and this may be palpated when the spleen is
enlarged.

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 Splenic ligaments
• The gastrosplenic ligament
• The lienorenal ligament attaches the spleen to
the tail of the pancreas and the kidney
• The Spleno colic ligament

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 Gastrosplenic ligament

• It passes from the greater curvature of the

stomach to the spleen
• It contains the vascular supply principally the
main splenic artery and vein and the short
gastric vessels.

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 Blood Supply
• The tortuous splenic artery arises from the coeliac
axis and runs along the upper border of the body
and tail of the pancreas, to which it gives small
branches.

• The short gastric and left gastroepiploic

branches pass between the layers of the
gastrosplenic ligament.

• The main splenic artery generally divides into

superior and inferior branches, which, in turn,
subdivide into several segmental branches.
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 Splenic venous drainage
• The splenic vein is formed from several
tributaries that drain the hilum.
• The vein runs behind the pancreas, receiving
several small tributaries from the pancreas
before joining the superior mesenteric vein at
the neck of the pancreas to form the portal
vein.

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 Lymphatic drainage
• The lymphatic drainage comprises efferent
vessels in the white pulp that run with the
arterioles and emerge from nodes at the
hilum.
• These nodes and lymphatics drain via
retropancreatic nodes to the coeliac nodes.

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 Nervous supply
• Sympathetic nerve fibres run from the coeliac
plexus and innervate splenic arterial
branches.

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 Histology
• The cut surface of the spleen consists of areas
of ‘red pulp’
• within which can be seen pale, ovoid nodules
(about 1 mm diameter) of ‘white pulp’
(Malpighian bodies).
• The splenic pulp is invested by an external
serous and internal fibroelastic coat which is
reflected inwards at the hilum onto the
vessels to form vascular sheaths.

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 Functions of the Spleen
• Although the spleen was previously thought to be
dispensable, increasing knowledge of its function
has led to a conservative approach in the
management of conditions involving the spleen.

• It is now recognized that an incidental

splenectomy during the course of another
operative procedure increases the risk of
complication and death.
• The surgeon should therefore normally endeavor
to preserve the spleen to maintain the following
functions:

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 Immune function
• The spleen processes foreign antigens and is
the major site of specific immunoglobulin
M (IgM) production.
• These antibodies are of B- and T-cell origin
and bind to the specific receptors on the
surface of macrophages and leukocytes,
stimulating their phagocytic, bactericidal and
tumoricidal activity.
• The non-specific opsonins, properdin and
tuftsin, are synthesized.
 Filter function
• Macrophages in the reticulum capture cellular
and noncellular material from the blood and plasma.
• This will include the removal of effete platelets and red
blood cells.
• This process takes place in the sinuses and the splenic
cords by the action of the endothelial macrophages.
• Iron is removed from the degraded hemoglobin during
red cell breakdown and is returned to the plasma.
• Removed non-cellular material may include bacteria
and, in particular, pneumococci.

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 Pitting

• Particulate inclusions from red cells are

removed, and the repaired red cells are
returned to the circulation.
• These include Howell–Jolly and Heinz bodies,
which represent nuclear remnants and
precipitated hemoglobin or globin subunits,
respectively.

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 Reservoir function
• This function in humans is less marked than in
other species, but the spleen does contain
approximately 8 per cent of the red cell mass.
• An enlarged spleen may contain a much larger
proportion of the blood volume.

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 Cytopoiesis

• From the fourth month of intrauterine life, some

degree of hemopoiesis occurs in the fetal spleen.
• Stimulation of the white pulp may occur following
antigenic challenge, resulting in the proliferation
of T and B cells and macrophages.
• This may also occur in myeloproliferative
disorders, thalassaemias and chronic haemolytic
anaemias.

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 Splenic Trauma

• Spleen is the most common organ to be injured

in abdominal trauma.

• Etiology of trauma:
• Closed trauma: Direct, Indirect, &
Spontaneous
• Open trauma: Gun-shots, Puncture, &
Iatrogenic (e.g. Gastrectomy)

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 Classic Presentation of Rupture Spleen
• Initial shock - Lucid interval - Internal hemorrhage
• STAGE OF SHOCK

• GENERAL: Tachycardia, Hypotension, Hypothermia,

Decreased urine output
• LOCAL:
• Inspection: Ecchymosis, Bruises, Fracture of ribs,
Abdominal distention
• Palpation: Rigidity, Tenderness, Rebound tenderness
• Percussion: Shifting dullness
• Auscultation: Diminished intestinal sounds
• DRE: Fullness in retro-vesical pouch, Douglass pouch

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Very IMPORTANT- MINIOSCE

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• Special signs:
• Kehr’ Sign: Referred pain in Lt shoulder ,
hyperesthesia form diaphragmatic irritation

• Balance sign: Shifting dullness on Right side

(free blood) + Fixed Dullness on Left side
(clots, hematoma)
• Cullen’s sign: (late) Bluish discoloration
around the umbilicus

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 Risk of splenic injury
• Child
• Pathological spleen

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Management of traumatic injury
to the spleen
• ABC principles of the Advanced Trauma and
Life Support™

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 Unstable patients

• Abdominal distension
• peritonitis
• hypotension despite fluid resuscitation
• require transfer to the Operating Suite for an
emergency laparotomy

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 Haemodynamically stable
• CT is very sensitive and specific for splenic
injuries
• 65–95% of adults and 87–98% of children can
be treated conservatively.

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Grades

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 Vaccinations

• Pneumococcal vaccination before surgery and

repeated at intervals of five years
• Haemophilus influenzae and meningococcal
vaccination before surgery if not previously
received
• Influenza vaccinations given every year
• Giving vaccines minimum of two weeks before
surgery or as soon as possible after emergency
surgery
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 Antibiotics

• Lifelong penicillin should be offered (250–500

mg b.d.)

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Complications of splenectomy
• Haemorrhage
• Gastric dilation
• Pancreatic fistula
• Subphrenic abscess
• Overwhelming post-splenectomy infection

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THANK YOU