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General Surgery
The Spleen
Built from Maingot's Abdominal Operations
What’s inside
9 sections · 188 slides
Overview
- Role of the spleen in health and surgery
- Scope of this topic
- Historical views of the spleen
Relevant anatomy
Where the spleen sits, what holds it, and how blood reaches it
- Development and position of the spleen
- 150 g
- Gross anatomy of the spleen
- Surfaces and impressions of the spleen
- Peritoneal reflections around the splenic hilum
- Suspensory ligaments of the spleen
- Splenic ligaments and their attachments
- Safe distance from the tail of the pancreas
- Accessory spleens
- Common sites of accessory spleens
- Splenules in the greater omentum
- Splenoptosis, the wandering spleen
- The splenic artery
- Two patterns of splenic arterial supply
- Distributed type of splenic artery
- Magistral type of splenic artery
- Venous drainage of the spleen
- Histology of the spleen
- Splenic compartments and circulation
- White pulp, marginal zone and red pulp
- Structure of the white pulp and marginal zone
Physiology and function
What the spleen does to blood cells, and why removing it matters
- 250-300 mL
- Two routes of blood flow through the spleen
- Functions of the spleen
- Pitting: removing rigid inclusions
- Culling: removing worn-out red cells
- Platelet pooling in the spleen
- Neutrophils and haematopoiesis
- Filtration and antibody production
Splenic trauma and rupture
Why the spleen tears, how injury is graded, and when it can be left alone
- Causes of splenic rupture
- Spontaneous rupture of the spleen
- Causes of atraumatic splenic rupture
- Iatrogenic splenic injury
- Splenic haematoma after iatrogenic injury
- Penetrating injury and neighbouring organs
- Diagnosing splenic injury
- Splenic organ injury scale, classes I to III
- Splenic organ injury scale, classes III to V
- Immediate laparotomy and criteria for salvage
- Milestones in splenic surgery for trauma
- Non-operative management of splenic injury
- Success of non-operative management by injury grade
- Predictors of failed non-operative management
Local splenic disorders
Aneurysms, cysts, abscesses and tumours of the spleen
- Splenic artery aneurysm: how common
- Splenic artery aneurysm: findings in 217 cases
- Calcified splenic artery aneurysm on CT
- How a splenic artery aneurysm presents
- When to repair a splenic artery aneurysm
- Repair options by site
- Thrombosed splenic artery aneurysm on 3D CT
- Classification of splenic cysts
- Large splenic cyst on CT
- Septated splenic cyst that proved to be a lymphangioma
- Hydatid cyst of the spleen
- Diagnosing and treating splenic hydatid disease
- Non-parasitic primary cysts
- Secondary pseudocysts
- Managing splenic cysts
- Splenic abscess
- Treating a splenic abscess
- Splenic masses found on imaging
- Multiple splenic masses on CT
- Haemangioma of the spleen
- Managing splenic haemangioma
- Littoral cell angioma and lymphangioma
- Other benign splenic lesions
- Primary malignant splenic tumours
- Metastases to the spleen
- PET-active splenic lesion
Haematologic disorders
The blood diseases in which removing the spleen helps, and the ones where it does not
- First splenectomies for blood disease
- Anaemias that may improve after splenectomy
- Hereditary spherocytosis: the defect
- Role of the spleen in hereditary spherocytosis
- Hereditary spherocytosis: clinical range
- Splenectomy in hereditary spherocytosis
- Gallbladder decisions in spherocytosis
- Hereditary elliptocytosis and pyruvate kinase deficiency
- Thalassaemia: the defect
- Thalassaemia major: clinical course
- Treating thalassaemia
- Splenectomy in thalassaemia
- How sickle cell disease destroys the spleen
- Sickle cell disease: background
- Functional asplenia in sickle cell disease
- Calcified spleen in sickle cell disease
- Treating sickle cell disease
- Indications for splenectomy in sickle cell disease
- Types of immune haemolytic anaemia
- Alloimmune and drug-induced haemolysis
- Autoimmune haemolytic anaemia
- Warm antibody disease: clinical picture
- Treating warm autoimmune haemolytic anaemia
- Cold agglutinin syndrome and cold haemoglobinuria
- Immune thrombocytopenic purpura: mechanism
- ITP: presentation and bleeding risk
- Workup of ITP
- First-line treatment of ITP
- Second-line treatment of ITP
- Splenectomy for ITP: results and timing
- Thrombotic thrombocytopenic purpura and haemolytic uraemic syndrome
- Treating TTP and HUS
- Grouping of haematopoietic neoplasms
- Terminology of leukaemia and lymphoma
- Myeloid neoplasms and the spleen
- Blood picture and surgery in myeloproliferative disease
- Hodgkin's lymphoma: from staging laparotomy to imaging
- Non-Hodgkin's lymphoma and the spleen
- Indications for splenectomy in lymphoproliferative disease
- Splenectomy in specific lymphoid cancers
- Hairy cell leukaemia and other indications
- Splenic mass caused by sarcoidosis
Preparing for splenectomy
The immune cost of losing a spleen, and how it is reduced
- Splenectomy through the centuries
- Open versus laparoscopic splenectomy
- Evidence behind the laparoscopic approach
- Immune consequences of losing the spleen
- Overwhelming postsplenectomy sepsis
- Strategies to reduce postsplenectomy sepsis
- Vaccination before splenectomy
- Immunisation recommendations after splenectomy
- Vaccination after an emergency splenectomy
- Antibiotics and patient education
Laparoscopic splenectomy
Patient selection, the lateral approach step by step, and its complications
- Laparoscopic splenectomy: origins
- Measuring the degree of splenomegaly
- Degrees of splenomegaly by length and weight
- Patient selection for the laparoscopic approach
- Laparoscopy with massive splenomegaly versus a normal spleen
- Implications for laparoscopy in massive splenomegaly
- Preoperative splenic artery embolization
- Risks of splenic artery embolisation
- Operative approach and instruments
- Operating room setup for laparoscopic splenectomy
- Patient positioning
- Modified right lateral decubitus position
- Trocar placement
- Recommended and alternative port sites
- Search for accessory spleens at laparoscopy
- Freeing the splenic flexure and lateral attachments
- Freeing the lower pole
- Short gastric vessels and medial rotation of the stomach
- Ligating the short gastric vessels
- Endoscopic stapler across the splenic hilum
- Dividing the splenic hilum
- Removing the spleen from the abdomen
- Morcellating and bagging safely
- Closure and drains
- Hand-assisted laparoscopic splenectomy
- Single-incision splenectomy
- Postoperative care and early advice
- Complications of laparoscopic splenectomy
- Bleeding, chest and platelet problems
- Splenic-portal vein thrombosis
- Risk factors for splenic-portal vein thrombosis
- Portal vein thrombus on CT after splenectomy
- Screening for and treating vein thrombosis
- Pancreatic injury and late infection
Open splenectomy and spleen preservation
The open operation step by step, and the techniques that save splenic tissue
- Indications and incisions for open splenectomy
- Massive spleen on coronal CT
- Massive spleen at open surgery
- Steps of open splenectomy
- Dividing the splenic ligaments at open splenectomy
- Short gastric vessels and gastrosplenic omentum
- Hilar control in open splenectomy
- Three-clamp method of hilar division
- Massive spleen: control the artery first
- Controlling the splenic artery through the lesser sac
- Splenorrhaphy: repairing the torn spleen
- Hemostatic packing and surface closure of a torn spleen
- Suture closure and partial resection of a torn spleen
- Partial resection and the current role of splenorrhaphy
- Technique of partial splenectomy
- Key points: anatomy and function
- Key points: disease and its management
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- Maingot's Abdominal Operations, 12th Edition