Splenic Cysts

Parasitic Cysts
Non-parasitic Cysts : True/
Pseudocyst

Non- parasitic cyst

True cyst:
- Either congenital or acquired
- Rare, usually harmless and asymptomatic.
- If symptomatic, enlarging , gets infected, or
bleeds over time available options include:
1. Percutaneous procedures (eg, biopsy,
aspiration, drainage),
2. Direct surgical interventions such as
encapsulation/cyst wall unroofing,
3. Partial or total splenectomy - provides
diagnostic certainty, which is rarely clinically
justified.

 Pseudocyst: the spleen is a

common site for pseudocyst
formation following an attack of
pancreatitis.

Tumors of the Spleen

Primary is rare, include:
- Lymphoma, sarcoma, hemangioma,
hamartoma.
- Treatment is Splenectomy.

Secondary metastasis from solid tumors

is uncommon.

Splenic hemanigoma

Splenic Abscess
Incidence : is uncommon, (0.05-0.7 %)
Etiology: seeding from some other site of infection, e.g.:

Infected embolus,
endocarditis
typhoid/ paratyphoid fever,
Osteomyelitis
Otitis media
Puerperal sepsis
Pancreatic necrosis
Intra-abdominal infection

 Presentation:
Fever
Abdominal pain
Pleuritic chest pain
Left shoulder pain
Physical examination: abdominal
tenderness(>50%)
splenomegaly(<50%)

Splenic Abscess - Workup

CBC : leukocytosis.
Imaging :
CXR :
Elevated left hemi-diaphragm
(30%)
Pleural effusion (20%)
Ultrasound
CT

Splenic abscess Treatment

Medical:
Antibiotics
Surgical:
Splenectomy
Percutaneous drainage of the splenic
abscess under radiological guidance
(CT/US) occasionally successful.

Contraindications for
drainage :
Multiloculated or debris
filled abscess
multiple small abscess
Diffuse ascites
No safe route for drainage

Medical diseases of Surgical

importance

Splenomegaly vs.
Hypersplenism
Splenomegaly
An enlargement of the spleen.

Hypersplenism
An indefinite clinical syndrome characterized by
splenomegaly and pancytopenia, in the absence
of bone marrow or auto- immune disease.
Pancytopenia thrombocytopenia, leucopenia &
anemia.

Hypersplenism
Primary: rare, idiopathic - dx of exclusion
Secondary: to a pathologic condition:
a. disorders of splenic blood flow
b. Hemolytic diseases
c. Immunologic disorders
d. Infiltrative diseases
e. Infectious diseases
f . Neoplastic diseases

Presentation
1. Anemia, leukopenia, or
thrombocytopenia.
2. Splenomegaly, incidentally during PE
or imaging studies.
3. Pain secondary to enlargement

Evaluation
1. Peripheral blood smears.
RBCs, WBCs, plts, reticulocytosis,
abnormal morphology.
2. Bone marrow aspirate.
3. Imaging: US or CT scan.
4. Immunologic tests.

Treatment
Depends on the underlying cause.
The management of most cases of hypersplenism is
medical.
Splenectomy usually has only a secondary role, when
symptoms are significant or medical therapy fails to
control the disease.
Careful clinical judgments is required to balance the
long term and short term risks of splenectomy against
continued conservative management.

a. Disorders of splenic
blood flow
1. Portal Hypertension
2. Splenic Vein Thrombosis
3. Splenic Artery Aneurysm

b. Hemolytic diseases
1. Hereditary Spherocytosis (absolute
indication)
2. Congenital HA: Enzyme deficiencies (G6PD,
Pyruvate kinase D), Hereditary elliptocytosis,
Thalassemia major.
3. Sickle cell Anemia
4. Porphyria

c. Immunologic
disorders
1. Idiopathic thrombocytopenic
purpura (ITP)
2. Feltys Syndrome
3. Idiopathic autoimmune HA
4. Thromobtic thrombocytopenic
purpura (TTP)
5. SLE

Immune thrombocytopenic
purpura (ITP)
- Ab directed against platelets are produced by the
spleen, resulting in their destruction.
- The most frequent hematological indication for
splenectomy.
In primary ITP, we start with steroid tx for 69months.
- Splenectomy is indicated:
i - 2 relapses on steroid therapy
ii - platelet count remains low.

Feltys Syndrome
Triad = RA + leukopenia +
splenomegaly
Splenectomy = transient
improvement in the blood picture +
RA responds better to steroids.

d. Infiltrative diseases
1. Gauchers disease
2. Myeloid metaplasia
3. Sarcoidosis

e. Infectious Diseases
1. Bacterial infections
Staph.aureus, Streptococcus
2. Viral infections
Infectious mononucleosis, HIV, hepatitis
3. Parasitic infections
malaria, leishmaniasis, echinococcus
4. Fungal infections
Histoplasmosis

f . Neoplastic diseases
1.
2.
3.
4.
5.

Primary tumors
Secondary
Hodgkins disease
Non-hodgkins lymphoma
Leukemias

g. Miscellaneous
1. Rupture
2. Ectopic wandering spleen
3. Accessory spleens

Splenectomy

Splenectomy
Indications:
Trauma: - massive splenic trauma whether accidental or operative.
- spontaneous rupture
Oncological:
Primary splenic tumors
Removal en bloc with the stomach as a part of radical gasterectomy,
or with the pancreas as part of distal or total pancreatectomy.
Diagnostic
Therapeutic.
Splenic cysts .
Hematological : hereditary spherocytosis, hypersplenism.
Portal hypertension: in association with shunt or variceal surgery.

Pre-operative
Preparation
1. Blood components:
. If bleeding tendency FFP, cryoprecipitate, platelets.
. Coagulation profile normal.
. Thrombocytopenia - platelets are needed during and postoperatively.
2. Pre-immunization:
Pneumococcal, HIB and meningococcal vaccines.

Should be given at least 14 days before a scheduled

splenectomy and in the post-operative period after
emergency removal of the spleen.
3.

Antibiotic prophylaxis.

Techniques
1. Open splenectomy.
Midline or transverse sub-costal incision.
2. Laparoscopic splenectomy.
Access is obtained through an incision 1cm from
the costal margin at the left mid-clavicular line.
Note: Accessory splenic tissue occurs in 10-30% of
individuals, mostly in the hilar region. This
accessory tissue should be carefully searched for
and excised.

Post-operative Course and

Complications

Hemorrhage usually occurs intra operatively resulting

from a slipped ligature.

Injury to surrounding structures:

1. The gastric wall necrosis/ perforation.
2. Tail of the pancreas .

Fistula may result from damage to greater curvature of

the stomach during ligation of the short gastric vessels.

Damage to the tail of pancreas may result in:

pancreatitis, localized abscess, pancreatic fistula.

Post-operative Course and

Complications

Pulmonary: left lower lung atelectasis* , pneumonia

, pleural effusion.
Thrombocytosis, if plt count exceeds 1 x 10^6/ml
prophylactic aspirin. Also abnormal cell morphology.
Sub-phrenic abscess.
Splenosis - consists of transplanted splenic tissue,
which, if spontaneous, can be located anywhere
within the abdomen or pelvis. The nodules
associated with splenosis contain functioning splenic
tissue and are usually multiple.

Overwhelming postsplenectomy sepsis (OPSS)

A rapidly fatal illness caused by encapsulated bacteria
including:
- Streptococcus pneumoniae (50%).
- Neissieria Meningitidis
- H.influenzae type B

Incidence is low < 0.5%

Mortality rate is high (75%)
Begins with non-specific, mild, influenza like symptoms.
Progresses to high fever, bacteremia, thrombosis, DIC, shock,
and death.
Risk is greatest if splenectomy is performed the first 2-4
years of life.
80% of episodes occur within 2 years of splenectomy.

Post-operative
considerations
Immunizations:
Pneumococcal vaccine, recommended in patients who are > 2
years of age, every 5 years.
Meningococcal, every 5 years.
H.influenzae type B vaccine is recommended irrespective of age,
every 10 years.
Influenza vaccine annually.
Antibiotics:
Children whose spleens have been removed should receive
penicillin until the age of 18.
In adults, antibiotics are to be given for 2-3 years.
Patients should be instructed to seek medical care immediately if
fever or prodromal symptoms occurred.
Post-splenectomy identificationThe patient should have
identification item (eg, bracelet, necklace, wallet card).

 Note.
- here some questions from schwartz
just to test your knowledge :P
- as far as Im concern, past year
final question for spleen concerns
about indication splenectomy,
anatomy of spleen, investigation for
traumahek!

QUIZ
Patient undergoing elective
splenectomy should receive
vaccination against Streptococcus
pneumonia, H. influenza type b and
meningococcus
A. 2-4 weeks before surgery
B. 1 hour prior to surgery
C. 1 week after surgery
D. 1 month after surgery

 The most common complication after

open splenectomy is ?
A. atelectasis
B. hemorrhage
C. subphrenic abscess
D. wound infection

 The treatment of choice in an

otherwise healthy 22 year old patient
with a large septate splenic abscess
is
A. antibiotic therapy only
B. antibiotic + percutaneous
drainage
C. antibiotic + partial splenectomy
D. antibiotic + splenectomy

 Splenectomy is indicated in a child

with sickle cell following
A. 1 episode of sequestration
B. 2 episodes of sequestration
C. 3 episodes of sequestration
D. none

 In a normal patient, what is the

percentage of platelets sequestrated
in spleen ?
A. 2%
B. 16%
C. 33%
D. 50%

 A 48 year old patient presents with

isolated bleeding gastric varices,
splenic vein thrombosis, and normal
liver function. Which of the following
is likely treatment of choice ?
A. beta blocker and banding
B. splenorenal bypass
C. splenic vein ligation
D. splenectomy

 An 18 year old otherwise healthy

woman is incidentally found to have 2
cm splenic aneurysm of the mid
portion of splenic artery. Which of the
following is the treatment of choice ?
A. observation
B. embolization
C. ligation or resection of aneurysm
D. splenectomy

Splenic Artery Aneurysms

Splenic artery aneurysms (SAAs) are the most common of the visceral artery
aneurysms. After the aorta and iliac they are the third most common intra
abdominal aneurysms.
predominantly a disease of the female sex. There is a close association with
parity. More than 90% females with SAAs have been pregnant at least once.
Asymptomatic.
Indications for treatment are symptoms, documented enlargement,
pregnancy or anticipated pregnancy, and diameter of greater than 2.5 cm.
SAAs discovered during pregnancy should be repaired, because pregnancy
greatly increases the risk of rupture.
All potential surgical candidates should receive preoperative immunizations,
similar to splenectomy patients. However, aneurysm repair with splenic
preservation is the ideal treatment.
The main complication of SAAs is rupture.

Thank you for

listening !