Spleen

Question 1

What are Howell-Jolly bodies and what is their clinical significance?

Answer 1

• nuclear remnants found in RBCs on peripheral blood smear
• suggestive of asplenism

Question 2

What does an absence of Howell-Jolly bodies after splenectomy suggest?

Answer 2

means there is probably remnant splenic tissue still functioning

Question 3

Which patients with blunt splenic injury should be considered for angiogram?

Answer 3

those with grade IV or V injuries

Question 4

Which patients with blunt splenic injury should be considered for follow up CTA at 48hrs?

Answer 4

those with grade III or higher injuries who have not already been embolized

Question 5

Describe the criteria for grade III splenic injuries. Grade IV?

Answer 5

• III: sub capsular hematoma > 50% surface area, intraparenchymal hematoma > 5cm, laceration > 3cm depth, ruptured sub capsular or intra-parenchymal hematoma
• IV: any vascular injury, active bleeding confirmed within the splenic capsule, laceration producing > 25% devascularization

Question 6

Describe the pathophysiology and management of ITP.

Answer 6

• thought to be due to auto-antibodies to GP IIB/IIIA
• initial management is with steroids and IVIG
• refractory and recurrent cases are managed with splenectomy
• would generally give medical management 4-6 weeks to work

Question 7

During a splenectomy for ITP, when would you transfuse platelets?

Answer 7

after ligation of the splenic artery

Question 8

Describe the presentation, pathophysiology, and treatment of hereditary spherocytosis.

Answer 8

• presents with anemia and splenomegaly
• due to an autosomal dominant defect in the cell membrane protein spectrin, causing RBCs to be less pliable and more readily removed in the spleen
• treated with splenectomy and cholecystectomy (hemolysis) after age 6

Question 9

How are splenic abscesses managed?

Answer 9

• a unilocular, thick-walled abscess can be percutaneously drained
• a multi-locular, thin-walled abscess is treated with splenectomy (usually echinoccocal)

Question 10

Which benign splenic cysts should be managed operatively? What are the surgical options?

Answer 10

• those that are > 5cm or symptomatic
• can treat with excision or fenestration

Question 11

What is the management of a splenic hemangioma?

Answer 11

• this is the most common splenic tumor and are benign
• managed with splenectomy if symptomatic

Question 12

Describe the management of a splenic angiosarcoma.

Answer 12

• the most common primary splenic malignancy
• associated with vinyl chloride and thorium dioxide exposure
• these are aggressive
• treat with splenectomy

Question 13

What is the role for splenectomy in those with non-hodgkin’s lymphoma?

Answer 13

for those with anemia or thrombocytopenia

Question 14

What is the most common visceral artery aneurysm?

Answer 14

splenic artery

Question 15

Which splenic artery aneurysms should be intervened upon?

Answer 15

• if > 3cm
• in all pregnant woman of childbearing age (70% risk of rupture during pregnancy)

Question 16

Splenectomy increases the risk for what infections?

Answer 16

• N. gonorrhea
• H. influenza
• S. pneumoniae

Question 17

Which patients that are s/p splenectomy are most at risk for OPSI?

Answer 17

pediatric patients with beta thalassemia

Question 18

When should patients get post-splenectomy vaccines?

Answer 18

• ideally 2 weeks prior to elective splenectomy
• otherwise at time of discharge or 2 weeks post-op

Question 19

Which patients that have undergone splenectomy should be considered for OPSI prophylaxis?

Answer 19

consider in children under 10

Question 20

How can you localize an accessory spleen?

Answer 20

• CT is often good enough
• can also perform a radionuclide spleen scan (tagged RBC scan)
• usually located at the splenic hilum

Question 21

What is an absolute contraindication to splenectomy?

Answer 21

cirrhosis with portal hypertension

Question 22

What is the preferred treatment of a wandering spleen?

Answer 22

• splenectomy if infarcted at presentation
• otherwise splenopexy

Question 23

Describe the presentation, pathophysiology, and treatment of TTP.

Answer 23

• fever, anemia, thrombocytopenia, renal disease, neurological dysfunction
• due to ADAMTS13 metalloproteinase deficiency leading to very long WF and thrombosis
• treated with plasmapharesis

Question 24

What are the indications and regimens for peri-operative stress dose steroids?

Answer 24

• indicated for anyone taking more than 5mg/day of steroids for at least three weeks within the last 3 months
• for minor/moderate surgery: 50mg hydrocortisone before induction, 25mg q8 for 24hrs, then usual dose
• for major surgery: 100mg hydrocortisone before induction, 50mg q8 for 24hrs, taper by half each day until on home dose

Question 25

Describe a laparoscopic splenectomy.

Answer 25

- supine or lazy lateral decubitus positioning - consider pre-operative steroids if on them for medical management of ITP - a subxiphoid 5mm port, a mid-clavicular 12mm port below the costal margin, another 5mm port between the two, and a 12mm port in the anterior axillary line - inspect for accessory spleens in the splenic hilum, greater momentum, and splenocolic region - divide the splenocolic ligament to mobilize the splenic flexure away - divide the gastrosplenic ligament - mobilize the lower pole of the spleen and retract it anteriorly to expose the splenic hilum and pancreatic tail - staple the splenic hilum and then mobilize the superior pole - put the spleen in a bag and then morcellate it for removal

Question 26

What are the contraindications to non-operative management of traumatic splenic injury?

Answer 26

- peritonitis - other injury requiring open repair - hypotension - concomitant TBI since these patients would not tolerate even a single episode of hypotension as well