Splenectomy

Splenectomy is widely used in spleen rupture, spleen (ectopic spleen), local infection of spleen or tumor, cyst, intrahepatic portal hypertension combined with hypersplenism and other diseases causing congestive splenomegaly. The spleen is the largest peripheral lymphoid organ in the human body. It can produce a variety of immune active cytokines. It is the main organ for blood storage, hematopoiesis, blood filtration and blood destruction. It has important immune regulation, anti-infection, anti-tumor, endocrine and production. The role of properdin and phagocytic peptides. Based on the current understanding of the function of the spleen and the consequences of increased susceptibility to infection after spleen spleen, it is the consensus of global surgeons to perform spleen preservation surgery as far as conditions and diseases permit. That is, "rescue the first life, keep the spleen second, the younger the more the priority is to protect the spleen." Treating diseases: rupture Indication 1. Spleen trauma: spleen rupture or subcapsular rupture caused by penetrating injury to the left upper abdomen or left hand rib and closed injury, spontaneous spleen rupture, and intraoperative injury, etc., can cause fatal bleeding, must be immediately Splenectomy stops bleeding and saves lives. 2. Traveling the spleen (ectopic spleen): Because the spleen is too long, the spleen can be overactive to swim away from the spleen. Even the spleen pedicle reversed, causing spleen necrosis. Splenectomy should be performed regardless of whether the spleen is reversed or not. 3. Local infection of the spleen: spleen abscess often occurs after sepsis, such as abscess confined in the spleen, feasible splenectomy, such as inflammation around the abscess has spread around the spleen, then can only be used for drainage. Localized splenic tuberculosis is also feasible for splenectomy. 4. Tumor: Primary tumors are relatively rare, but splenectomy should be performed whether benign (such as hemangiomas) or malignant (such as lymphosarcoma). Metastatic tumors are more common, and most have been widely transferred and are not suitable for surgery. 5. Cysts: epithelial, endothelial and true cysts, non-parasitic pseudocysts, parasitic cysts (such as spleen cysticercosis), are susceptible to secondary infection, bleeding, rupture, should be removed. 6. In the case of radical resection of gastric cancer, gastric fundus cardia cancer, pancreatic body, tail cancer, and colonic splenic cancer, whether or not there is spleen metastasis, the lymph nodes around the splenic artery or the spleen should be removed. Splenectomy. Especially when the tumor and the spleen have adhesions, the spleen should be removed together. 7. Intrahepatic portal hypertension combined with hypersplenism, extrahepatic portal hypertension, such as splenic aneurysm, spleen, venous fistula and splenic vein thrombosis caused by congestive splenomegaly, should be splenectomy . 8. Other hypersplenism diseases: 1 primary thrombocytopenic purpura, suitable for young patients, the first episode, untreated after half a year of drug treatment; chronic repeated author; acute type, can not control bleeding after drug treatment (children should be operated within 1 to 2 weeks) and Patients with early pregnancy (surgery within 4 to 5 months). 2 congenital hemolytic anemia, suitable for drug (hormone) treatment within 1 month after the treatment is not effective; long-term medication has serious side effects, can not continue to use the drug. Before the operation, radioactive 51 chromium liver spleen area should be measured, indicating that the spleen is the main destruction site of red blood cells, and surgery; if the liver is the main destruction site of red blood cells, it is not suitable for surgery. 3 primary spleen neutropenia. 4 primary whole blood cell reduction. 5 aplastic anemia, suitable for drug treatment is invalid, bone marrow examination in patients with compensatory hyperplasia (peripheral blood reticulocyte examination multiple times is not suitable for surgery). 6 acquired hemolytic anemia (selective case). Contraindications 1, with systemic diseases, can not tolerate surgery. 2, local infection, not suitable for surgery. Preoperative preparation 1. Emergency surgery: When emergency surgery is required when the spleen ruptures, hemorrhagic shock should be prevented at the same time as preoperative preparation, so that the operation can be performed in the shortest time. Patients with severe spleen rupture, due to a large number of internal hemorrhage, often accompanied by hemorrhagic shock, need a large number of rapid blood transfusion, if necessary, arterial pressure transfusion, and adequate blood preparation. At the same time, attention should be paid to the multiple injuries of other organs and given treatment. Gastrointestinal decompression should be performed before surgery to prevent the stomach from expanding and hindering the exposure. Sufficient antibiotics should also be given to prevent infection. When the preoperative preparation is basically completed and the surgical instruments are ready, the operation should be stopped as soon as possible under anti-shock treatment, and should not wait for shock to correct. 2. Selective surgery: Chronic spleen diseases other than rupture should be elective surgery. Pay attention to improve the general condition, a small amount of blood transfusion, protect liver function, correct coagulation insufficiency, and perform necessary laboratory tests (including hemoglobin measurement, red blood cell count, total white blood cell count and classification, platelet count, vascular fragility test, bleeding time, clotting time, Prothrombin time, etc.). Gastrointestinal decompression should be performed before operation. For patients with esophageal varices, soft stomach tube should be selected. A small amount of liquid paraffin should be taken before the lower tube. Pay special attention to prevent major bleeding. Blood should be prepared before surgery to prepare for blood transfusion. Sufficient antibiotics should also be given. Surgical procedure 1. Position: supine position, high left pad. 2. Incision: When the spleen enlargement is not significant, the right upper abdomen lateral incision or transabdominal rectus incision is often used, which is convenient to operate and can be extended upward to fully reveal the spleen upper pole which often has adhesion. When the spleen is large or the adhesion is estimated to be heavier, a left upper abdominal l-shaped incision may be used or a transverse incision may be added on the basis of the above incision to better reveal the spleen. There are also left rib oblique incision or upper abdominal transverse incision. 3. Examination: After the elective surgery enters the abdominal cavity, the items to be inspected are: 1 liver: Most splenectomy is used to treat portal hypertension, so the liver should be routinely examined. If the liver has shrunk and is a late stage disease, surgery should be minimized to reduce the burden on the patient. Live liver biopsy was taken as necessary for pathological biopsy. 2 spleen: mainly understand the size of the spleen and adhesion around the skin (especially with the diaphragm), help to prevent bleeding when separating adhesions. In addition, the location and number of the secondary spleen need to be known. 3 other aspects of the abdomen: such as the amount of ascites, biliary tract and pancreas with or without lesions. 4 Determination of portal pressure. 4. Ligation of splenic artery: For patients with larger spleen, the splenic artery should be ligated to make the spleen shrink, easy to operate, reduce blood loss, and allow a large amount of blood in the spleen to flow into the circulating blood, becoming the best autologous blood transfusion. During operation, the gastric ligament and the gastric spleen ligament are first opened, the blood vessels in the ligament are ligated, and the small omentum cavity is exposed to reveal the pancreas and the tail. The spleen artery was struck on the upper edge of the pancreas, and a splendid artery bulge was selected at the junction of the pancreas and the tail. The peritoneum was cut open, and the splenic artery was carefully separated by a right angle forceps and ligated around the thick wire. When ligating the splenic artery, two lines must be tied (the two are 0.5cm apart). The ligation should not be too tight, so that the lumen can be closed to avoid tearing the artery wall; but it should not be too loose, so as not to block the blood flow. The role. In addition, care should be taken to avoid damage to the parallel spleen veins below it. 5. Separation of the spleen: When the spleen artery blood flow is blocked, the spleen can be quickly reduced by more than 50% by a little massage, and it is generally unnecessary to inject adrenaline and other drugs. The spleen is pushed up first, and the spleen colon ligament attached to the lower part of the spleen is ligated and cut. Then pull the spleen to the inside, cut and ligation of the spleen and kidney ligaments. At this time, the spleen has been largely separated, and you can use your right hand to reach into the back of the spleen. Grab the spleen and gently pull it downwards to gently pull it out. The other hand can help the upper pole. The membranous adhesion at the spleen ligament can be bluntly separated. If the adhesion band is thick, the spleen can be lifted out by using a hemostat clamp, cutting and ligation. In the treatment of the upper part of the gastric spleen ligament and the spleen and sac ligament, it is best to carry out under direct vision, otherwise it is often easy to damage the large curved tissue of the stomach or tear the short blood vessels of the stomach, causing bleeding. 6. Excision of the spleen: Put the spleen out of the incision and immediately block the large gauze pad in the spleen socket, which not only helps stop the blood, but also prevents the spleen from sliding back to the abdominal cavity. Then, the connective tissue around the spleen pedicle is cleaned, and the spleen gate and vein are respectively ligated and cut (the proximal blood vessel needs to be ligated and sutured). If the spleen is larger and the spleen is thicker, the spleen pedicle should be clamped in parallel with the three large hemostats at the spleen gate, and cut between the two distal jaws. The remaining two hemostats are ligated with thick wires at the proximal end. Then sew together between the two pliers. If the blood vessel is thick, the spleen and vein can be ligated separately. Care should be taken to avoid damage to the tail of the pancreas when treating the spleen. The excised spleen is placed on a sterile funnel, and the blood in the spleen naturally flows into a blood storage bottle containing an anticoagulation maintenance solution for autologous blood transfusion. 7. Hemostasis, examination: after splenectomy (especially after splenectomy of portal hypertension), retroperitoneal and spleen ligament, spleen and kidney ligament, often ruptured varicose veins oozing, resulting in postoperative axillary blood, Secondary infection and underarm abscess, so the bleeding points in the operation should be ligated one by one to stop bleeding. Especially in the posterior and posterior peritoneum of the left kidney and the left kidney, the stomach should be pushed to the right with the left hand, and the bleeding point should be sutured intermittently with the needle of the long needle holder. In addition, the tail of the pancreas should be sutured and covered with a posterior peritoneal suture. The omentum is then placed in the left kidney and spleen to establish a collateral circulation, which is also beneficial for the reduction of the spleen of the colon. In patients with portal hypertension, after splenectomy, the portal vein pressure should be measured again and compared with preoperative to estimate the effect. 8. Drainage and suturing: Due to poor liver function and poor coagulation function, even if hemostasis is completed during operation, hemorrhage may occur after operation, and even postoperative fever and underarm infection should be in the spleen and pancreas. Drains are routinely placed at the tail. Generally, a soft double-chamber silicone tube can be placed in the spleen fossa, and a cigarette is placed at the tail of the pancreas, and the wound is taken out from the incision, and the drainage port should be loose. Double lumen drainage can be placed for a long time [3 ~ 5 days] as appropriate, if necessary, a vacuum device can be placed, and continuous suction after surgery to reduce the possibility of blood or effusion under the arm. Cigarette drainage can be removed 24 to 48 hours after surgery. If the operation is severely oozing, kanamycin or gentamicin can be added to the spleen before the abdomen, and the antibiotics can be injected through the drainage tube for 2 to 5 days after surgery to prevent the infection of the underarm. The layers of the incision were sutured intermittently with silk. If there is more oozing under the skin, the rubber sheet can be drained under the skin and removed 24 to 48 hours after surgery. complication Abdominal complications 1 Bleeding: Postoperative delayed intra-abdominal hemorrhage often occurs in patients with hypersplenism and poor liver function. For these patients, measures should be taken before and after surgery to improve coagulation function to prevent bleeding. 2 underarm infection or abscess: more patients secondary to blood in the armpits. After 3 to 4 days after surgery, if the body temperature rises again, it is necessary to be highly vigilant and check in time. If an abscess has formed, the drainage should be cut in time. 3 postoperative acute pancreatitis: Although less common, but the condition is very serious, often caused by intraoperative injury. For patients with severe upper abdomen or left upper abdominal pain, trypsin should be measured in time to confirm the diagnosis and timely treatment. 2. Pulmonary complications Atelectasis and pneumonia are the most common, especially in the elderly. If there is left ventricular reactive effusion, there should be suspected subgingival infection, but it can also be caused by pulmonary complications. Thoracic puncture should be performed in time for further diagnosis and treatment. 3. Other complications 1 splenic phlebitis: after the ligation of the splenic vein, because the proximal end becomes a blind end, it is prone to thrombosis, such as high fever, abdominal pain and sepsis often occur after the infection, should pay attention to prevention and treatment. Splenic phlebitis is often the main cause of high fever after splenectomy, but it should also be noted that due to splenectomy, the patient's immunity is reduced and susceptible to infection. 2 postoperative jaundice and hepatic coma: more patients with cirrhosis, the general prognosis is poor, should be vigilant, timely prevention and treatment.