SPLENECTOMY

From Big Medical Encyclopedia

SPLENECTOMY (Greek splen a spleen + ektome excision, removal) — operation of removal of a spleen.

The first attempts of S. belong to the beginning of 19 century. All of them led to a lethal outcome. In 1867 Zh. Pean made successful S. concerning a cyst spleens (see). In the next 50 — 70 years resorted to this operation incidentally, usually at the isolated damage of a spleen. In 1916 H. Schloffer removed a spleen at Verlgof's disease (see. Werlhof's disease ), what was an incitement to development of operational methods of treatment of diseases of system of blood. In the USSR along with actively P. A. Herzen, V. I. Kazansky, A. N. Bakulev, V. R. Braytsev, D. M. Grozdov dealt with S.'s development with other problems of surgical treatment.

Indications

Indications to S. happen emergency and planned. The emergency S. is made at injuries of a spleen, at patients with a Werlhof's disease at threat of intracraneal hemorrhage, at hemoblastoses in case of a rupture of a spleen, sometimes at an expanded gastrectomy concerning a carcinoma of the stomach; planned — at nek-ry diseases of system of blood, napr, at idiopathic autoimmune thrombocytopenia (see), autoimmune hemolitic anemia and a hereditary microspherocytosis (see. Hemolitic anemia ), at thalassemias (see), proceeding with splenomegaly (see) and the phenomena of a hypersplenism, and also at inefficiency of hemotransfusionic therapy, at portal hypertensia (see) and damage of the spleen (naira., heart attack, tuberculosis, abscess, cyst). In a crust, S.'s time it can be included in the comprehensive program of treatment of nek-ry forms hron. leukosis (hron. a myeloleukemia, a hairy cell leukosis), a nekhodzhkinsky lymphoma (see. Lymphosarcoma ), and also for the purpose of diagnosis and treatment lymphogranulomatosis (see).

Preoperative preparation

Preoperative preparation (see. Preoperative period ) has specific features only at gematol. patients in connection with frequent development in them of hemorrhagic diathesis (see. Hemorrhagic diathesis ). Therefore before operation it is necessary to achieve the maximum reduction of bleeding by means of haemo static and sosudoukreplyayushchy means. At the expressed anemia (hemoglobin hmeny 70 — 80 g/l) and hypoproteinemias (protein of plasma is lower than 55 g/l) the short-term course of corrective transfusion therapy is shown by donor erythrocytes or blood, and also albumine. The patient, it is long receiving high doses of hormones, for 1 — 2 day before operation in addition to enteral introduction appoint a hydrocortisone and Prednisolonum in injections that facilitates a current of the operational and postoperative periods.

It is more preferable to page to carry out under anesthesia (see) with muscular relaxants. During operation measure blood loss and fill it with components and blood preparations, colloid and crystalloid solutions. Whole donor blood is applied at hypoplastic anemia only when there is a deficit of globular and plasma components of the circulating blood. At patients with hemolitic anemia, especially immune genesis, even at very low indicators of hemoglobin it is reasonable to abstain from transfusions of any blood-substituting liquids not to strengthen hemolysis (see).

The equipment

Access to a spleen is possible both from a front abdominal wall, and through the left pleural cavity (with a diaphragmotomy). Upper median is most widespread laparotomy (see); at a splenomegaly the section is continued below a navel on 3 — 5 cm

of S. at abdominal access includes several stages. After opening of an abdominal cavity make audit of a spleen and subphrenic space. In the absence of unions the spleen is removed in a wound that works well seldom since it is usually fixed to a back surface of a peritoneum, from a cut it is otslaivat fingers then put big tampons under a spleen. It serves as means of a temporary hemostasis and brings closer a spleen to an operational wound.

For simplification of mobilization of a spleen the assistant takes a front wall of a stomach and extends it in a wound. In the field of big curvature of a stomach open a cavity of a big epiploon and consistently cut gastrosplenic, phrenic and splenic and colic and splenic sheaves between the imposed ligatures. Special attention should be paid to an alloying of short vessels in the field of an upper pole of a spleen. At capture in a ligature or damage of a wall of a stomach it is necessary to close this place gray seroznshi seams. It is necessary for mobilization of a vascular leg of a spleen. It is necessary to remember that approximately in 50% of cases the tail of a pancreas reaches a hilus lienis therefore at S. before imposing of clips or ligatures on a vascular leg it is necessary to be convinced that the pancreas will not get to them. The vascular leg is tied up two ligatures and cut, the spleen is deleted. The bed of a spleen is taken in by imposing of several seams on the tail of a parietal peritoneum.

For reduction of danger of bleeding at a splenomegaly it is possible to bare and tie up previously a splenic artery at the upper edge of a tail or a body of a pancreas.

At patients with Itsenko's syndrome — Cushing (see. Itsenko — Cushing a disease ), developed owing to prolonged treatment by hormones, and especially at the expressed bleeding access is shown that-rakodiafragmalny. He allows to mobilize a spleen under control of sight at all stages C., to avoid an injury of a tail of a pancreas, to make a careful hemostasis of vessels of a bed of a spleen, excludes an injury of a serous cover of a stomach and intestines, inevitable at their traction during S. with use of abdominal access. Advantages of torakodiaf-ragmalny access are most notable at corpulent patients at a small spleen when it is located highly under a dome of a diaphragm.

At torakodiafragmalny access the section is done on the ninth mezhreberye in position of the patient on the right side at the left. Intercostal muscles cut behind almost to necks of edges, and in front — without reaching 3 — 4 cm a costal arch. Throughout 10 — 12 cm open a diaphragm on its front slope, trying to keep large branches of a phrenic nerve. In a pleural cavity remove a spleen; cut a back leaf of a peritoneum throughout its attachment to a spleen thanks to what it gains big mobility. Further open a cavity of a big epiploon and cut a gastrosplenic sheaf in the direction of the lower upper pole of a spleen of a pla. After final mobilization of all ligaments of spleen projections of the vessels passing in it make cuts a peritoneum over a vascular leg in the direction, perpendicular. This reception allows to remove a tail of a pancreas from a spleen and it is easy to divide a vascular leg into several portions, to-rye it is possible to alloy reliably without use of clips.

At episplenitis (see) torako-phrenic access it is necessary to expand a little: to cut a costal arch and all front slope of a diaphragm. It allows to divide under control of sight unions of a spleen with a diaphragm and adjacent abdominal organs. Page at patients portal hypertensia (see) often combine with imposing of vascular splenorenalny anastomosis (see), bandaging of vessels of a stomach and gullet.

In postoperative period (see) it is necessary to korrigirovat proteinaceous volemicheskiye disturbances and anemia, and also to hold events for elimination of paresis of intestines. Gematol. patients usually need intensive hormonal and infusional care within 3 — 5 days after operation.

Possible complications are postoperative pancreatitis (see), intra belly bleeding and subphrenic abscess (see). Owing to a thrombocytosis, to-ry often arises after S., thrombosis of vessels of portal system is possible.

The lethality after S. depends on expressiveness of hemorrhagic disturbances.



Bibliography: Barkagan 3. C. Hemorrhagic diseases and syndromes, M., 1980; B and r t and I. Selezenka, the lane with it., Budapest, 1976; The Guide to hematology, under the editorship of A. I. Vorobyov and Yu. I. Lo-riye, M., 1979; F and y N sh t e y F. E. N, etc. Diseases of system of blood, Tashkent, 1980; Surgical treatment of diseases of system of blood, under the editorship of O. K. Gavrilov and D. M. Grozdov, M., 1981; StreicherH. J. Chirurgie der Milz, B. u. a., 1961.


V. A. Klimansky.

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