Pediatric Splenectomy

The spleen is an important immune and hematopoietic organ. During the fetal period, the spleen hematopoietic function is active, and the hematopoietic function after birth is gradually replaced by bone marrow. The spleen still bears the function of making lymphocytes and monocytes. However, when a large number of blood loss and bone marrow function disorders occur, the spleen still produces red blood cells. The spleen is an organ with extremely abundant blood supply and the largest lymphoid tissue. It is directly linked to the blood circulation and has a sponge-like structure. Usually, the blood is stored, and when the body is in urgent need, the blood is scaled to adjust the circulating blood volume. The spleen forms part of the whole body reticuloendothelial system, producing antibodies, especially IgM, which phagocytose and remove particulate matter from the blood, phagocytose white blood cells and platelets, and participate in the body's defense function. After the spleen is removed, the ability to fight infection is reduced. According to the literature, the level of IgM decreased after splenectomy, and the ability to remove particulate antigen in the blood decreased, which easily caused fulminant infection. Therefore, in recent years, it is recommended to preserve the spleen as much as possible for traumatic spleen rupture. Only about 1/3 of severe spleen trauma requires splenectomy. However, splenectomy can achieve good results in spleen diseases or blood diseases associated with the spleen. There are sometimes a number of different spleen sizes around the spleen. When splenectomy is required for splenectomy, the spleen should also be removed at the same time to avoid compensatory hypertrophy of the spleen in the future, causing recurrence of hypersplenism. However, when the spleen rupture requires splenectomy, the spleen should be kept as much as possible, and the spleen may be compensated for hypertrophy after the operation, and part of the spleen function. Treating diseases: rupture Indication Child splenectomy is available for: 1. Spleen rupture At present, non-surgical treatment is advocated for spleen rupture in children. According to a group report in Canada, 75 children with spleen rupture, 87% of non-surgical treatment success; only 7 cases of surgical treatment of 7 cases of splenectomy, 4 cases of spleen repair. The authors believe that uncomplicated spleen rupture can be cured by non-surgical treatment, and it is recommended that blood transfusion should be performed when the spleen rupture hemoglobin is below 80g/L. Simple spleen rupture generally 20ml/kg blood transfusion should be stable, if the hemodynamics is still unstable, it may be complicated by most organ damage, and should be explored early. 2. Other diseases of the spleen such as spleen and spleen stenosis, spleen cyst, spleen tumor, Hodgkin's disease, spleen tuberculosis, spleen abscess and so on. 3. Hematological diseases, certain metabolic diseases and hypersplenism, globin-forming anemia (thalassemia), hereditary spherocytosis, acquired hemolytic anemia and aplastic anemia, congenital metabolic defects and Some non-specific splenomegaly. Primary thrombocytopenic purpura recurrent, splenectomy can also be used when drug treatment is ineffective, and about 1/3 of cases have significant effects. 4. Portal hypertension, spleen function, spleen hyperfunction, splenectomy, or simple splenectomy and omentum retroperitoneal fixation. 5. When performing surgery on certain diseases, it is necessary to perform splenectomy at the same time, such as tumor resection of the tail of the pancreas. Contraindications 1. The bone marrow hematopoietic function is reduced, the spleen is compensatory and swollen, and part of the hematopoietic function is exercised. 2. Splenomegaly caused by systemic infectious diseases. Preoperative preparation 1. Selective splenectomy cases should be thoroughly examined before splenectomy, in order to do a comprehensive preoperative preparation. 2. Traumatic spleen rupture, first active non-surgical treatment, including blood transfusion, infusion, maintenance of necessary blood volume and anti-shock treatment. If necessary, perform necessary preoperative examinations, such as chest X-ray examination, abdominal CT examination, etc., try to estimate the presence of multiple injuries before surgery. 3. Prepare a certain amount of blood before surgery to prevent massive bleeding during surgery. 4. Place the nasogastric tube, the esophagus and gastric fundus varices, should be placed into a soft stomach tube to prevent damage to the dilated vein caused by massive bleeding. 5. Children with severe anemia should receive blood transfusion before surgery to correct anemia. 6. The vein should be opened before surgery to allow blood transfusion during surgery. Surgical procedure 1. The incision is mainly determined by the size of the spleen, the presence or absence of adhesion, the shape of the sick child, and the doctor's habit. Generally, an "L"-shaped incision, an arc-shaped incision, a transverse incision, or a right rectus abdominis incision under the left costal margin may be adopted. In the portal hypertension, the spleen and diaphragm and the posterior peritoneum have extensive vascular adhesions. A chest and abdomen combined incision can be used. The incision of the diaphragm is carefully separated and sutured to stop bleeding under good exposure. 2. When the traumatic spleen ruptures, the blood in the abdominal cavity is quickly aspirated after laparotomy, and the location, extent, and active bleeding of the spleen are examined. If there is still bleeding, it should be quickly pressed with a gauze pad, and quickly detect liver, kidney and all gastrointestinal, retroperitoneal large blood vessels and pancreas, duodenum with or without damage. In cases of selective splenectomy, the spleen should be carefully examined for adhesion to surrounding organs, and the liver should be explored for abnormalities in the biliary system. 3. After exposure and free spleen rupture and rupture, the spleen shrinks and there is no adhesion. The surgeon can hold the spleen out of the incision, and then fill the spleen bed with a large gauze pad. When the spleen is large or the spleen is hyperactive, the spleen is more adherent to the surrounding area, and most of them are vascular adhesions. Special care should be taken when lifting the spleen to prevent massive bleeding caused by rough operation. 4. After the spleen is removed, the omentum of the large curved side of the stomach should be separated and separated, and the branch of the short gastric artery should be separated along the large curvature of the stomach. The spleen and stomach ligament should be separated and the spleen and stomach ligament should be separated. The peritoneum was cut in the tail of the pancreas, and the splenic artery was isolated and ligated with silk to reduce bleeding. The spleen colon ligament, spleen and kidney ligament and spleen ligament ligament were then treated in turn, and the spleen was completely freed 5. After treating the spleen pedicle, the ligament around the spleen has completely separated, and finally the spleen pedicle is treated. First, the tail of the pancreas was separated, and the spleen artery and the splenic vein were clamped with three vascular clamps, the proximal end was ligated and sutured through the silk thread, and the spleen pedicle blood vessels were cut. The spleen was removed, and the surface of the diaphragm was carefully examined for oozing and whether the spleen vascular ligation was secure, and then the separated posterior peritoneum was sutured. If the spleen bed is sutured without oozing, the drainage may not be allowed. However, if the spleen adheres tightly to the surrounding organs during surgery, and there may be local bleeding after surgery, the smoke can be drained and the hole is drawn from the left upper abdominal wall. Generally, after 24 to 48 hours, the drainage strip can be removed without oozing. complication Intraperitoneal hemorrhage It is the most serious complication after splenectomy, and multiple blood vessel ligation lines are loosened or spleen adhesions are separated after oozing. Clinical manifestations showed more blood in the splenic drainage tube within 24 to 48 hours after surgery, and the symptoms and signs of shock occurred in the sick children. The laparotomy should be performed in time to stop bleeding, and it is not possible to wait for observation and delay the rescue. 2. Infraorbital infection and splenic venous phlebitis After splenectomy, the underarm blood is easy to secondary infection to form an underarm abscess. The clinical manifestations of high fever are not regressed, the total number of white blood cells is increased, X-ray plain film and ultrasonography can help to confirm the diagnosis and localization. If necessary, CT examination can be performed, and the abscess can be puncture under ultrasound guidance or the drainage can be cut again. Sometimes the infection under the arm affects the ligation of the splenic vein, causing thrombophlebitis, which is one of the causes of long-term fever after splenectomy. Antibiotic treatment often does not work in the short term, and sepsis can occur if treatment is not timely. 3. Thrombosis Platelet counts after splenectomy often increased significantly, reaching a peak at 2 weeks after surgery, and then gradually decreased. Individual cases can be extended to more than 1 month, especially in cases of hypersplenism before splenectomy, in patients with hereditary spherocytosis, postoperative platelets can be as high as 100×10 Above 10/L, platelets suddenly increase, causing intravascular coagulation to form a thrombus, most commonly in the portal vein, and severe cases can be fatal. Therefore, from 1 week after surgery, platelets should be checked regularly. In case of sudden rise, in order to prevent thrombosis, dipyridamole (Pandidin) or heparin anticoagulant therapy can be used. 4. Outbreak infection Because the spleen has the function of phagocytosis and antibody production, the sensitivity of bacterial infection will increase after splenectomy. In recent years, there have been many reports in this area in China. Some authors reported that 6916% of children with spleen resection died of serious infection, while non-fatal infections accounted for 4.37%, and the sum of the two was 8.3%. We also have deaths due to severe fulminant pneumococcal septicaemia after splenectomy. Therefore, in determining the splenectomy of children, we should weigh the pros and cons, if not life-threatening, try to postpone splenectomy until 2 to 3 years old.