Teknik operasi Splenektomi 2

8/17/2019 Teknik operasi Splenektomi 2

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Splenectomy


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Introduction

• Surgical Anatomy of the Spleen – Topography and Relations

– Splenic Functions

• Operative Indication

• Operative Technique

• Post Operative Care

Referensi : Sandalais! "ollinger!

To#nsend


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• The spleen measures

1 x 3 x 5 inches (2.5 x

7.5 x 12.5 cm)

• The spleen weighs 7

oz (220 g)

• The spleen relates to

let ri!s " through 11


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Splenic $orders


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Spleen is de%ned as having three to %vesegments


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Three&dimensional 'ones


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(eneral arterial distri$ution


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)ight ligament


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Possi$le con%gurations of the $lood supply to thedistal pancreas


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Splenic vein


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*ymphatic drainage

T#o groups: the nodes of the splenic hilum and thenodes of the tail of the pancreas


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Assesory Spleen

• supernumerary spleen!splenule! or splenunculus+

• is a small nodule of splenictissue found apart from the

main $ody of the spleen• They may $e found

any#here along the splenicvessels! in the

gastrosplenic ligament! thesplenorenal ligament! the#alls of the stomach orintestines! the pancreatictail! the greater omentum!

or the mesentery


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Splenic Functions

Four function : $lood storage! hematopoiesis!%ltration! and immunologic responseFiltrationA/ Culling0erythrocyte 1or other $lood cell+

destruction-/ Physiologic 1as red $lood cells age+./ Pathologic

a/Associated #ith $lood cell a$normalities$/Associated #ith primary splenic changes

2/ Pitting 13facelifting3 of erythrocytes+-/ Removal of cytoplasmic inclusions./ Remodeling of cell mem$ranes

C/ )rythroclasis0destruction of a$normal red $lood

cells #ith li$eration into circulation of erythrocytefragments


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Indications for Surgery

• Trauma

• 5on Trauma : – 6ypersplenism

– Congenital anemias

– 6emolytic anemias

– *euemia or lymphoma

– Other nonspeci%c diseases

• 6odgin staging

• 7iscellaneous – A$scess

– Cyst

– Tumor


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The Technical Steps in Performing aSplenectomy

For Trauma For Hematologic

Disorders

Staging Procedure

Incision Incision Incision

7o$ili'ing thespleen

Arterial ligation 4etailed e,ploratorylaparotomy 1lymphnodes+

8ascular ligation 7o$ili'ing the spleen 9edge and needle$iopsies of $oth lo$esof liver

4ividing the hilum 4ividing the hilum Total splenectomy

6emostasis 6emostasis Retroperitoneal

e,ploration4rains Accessory spleen 2iopsy of iliac crest

marro#

Closure 4rains Search for accessoryspleens

Closure Translocation ofovaries


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Incision


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Ligation of the Splenic Pedicle: AnteriorApproach

-/ Incision

./ Clamp! incise! and ligate the left part of thegastrocolic ligament and the gastroepiploic artery andvein/ This #ill provide access to the lesser sac

/ *ocate the splenic artery at the superior $order of the$ody of the pancreas/ Carefully ligate the artery in

continuity and dou$ly! #ith ligatures $eing placed asdistally as possi$le

;/ Clamp! divide! and ligate the short gastric arteries andveins! one at a time


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Ligation of the Splenic Pedicle: AnteriorApproach

=/ )levate the spleen! tail! and part of the $ody of thepancreas! $eing particularly careful #ith the tail of the

pancreas/ The spleen is no# outside the peritonealcavity and is attached only $y one of the $ranches ofthe splenic arteries and veins/

>/ Close to the hilum! clamp! divide! and ligate all

$ranches of the splenic artery/ The splenic vein and its$ranches are easily torn and should not $e clamped/*igate and divide the splenic vein and $ranches incontinuity #ith .?@ sil/ The spleen is no# free andshould $e removed

/ Inspect the site for $leeding! $eginning #ith thediaphragm and continuing to the greater curvature ofthe stomach! pancreatic tail! gastrosplenic ligament!splenorenal ligament! splenocolic ligament! and

splenic $ed and other ligaments


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*igation of the splenic artery and theshort gastric arteries and vein


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4ivision of the ligaments and delivery of the spleento the outside of the peritoneal cavity


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Ligation of the Splenic Pedicle:Posterior Approach-/ 6old the spleen medially

./ 4ivide the splenorenal! splenophrenic! andsplenocolic ligaments

/ *ift the spleen outside the peritoneal cavity! $eingparticularly careful #ith the tail of the pancreas/

;/ 4issect rapidly and mo$ili'e the $leeding spleenimmediately/

/ Remove the s leen and secure an $leedin oints/


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7edial position of the spleen during the posteriorapproach tosplenectomy! sho#ing division of the splenocolic

ligaments/


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Compression of the splenic artery andvein


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*igation of the splenic artery


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Post Operative Care

• A nasogastric tu$e is continued in place until evidence ofeBective gastric emptying is clearly present/

• Complications : Pancreatic %stula! (astric %stula!Over#helming postsplenectomy sepsis may occur

• Incentive spirometry and pulmonary toilet are importantto limit postoperative atelectasis and pneumonia/

• Prophyla,is for deep venous throm$osis 148T+ #ithfractionated heparin may $egin on postoperative day -/

• In the patients #ho undergo splenectomy! immuni'ation

against pneumococcus! meningococcus! and Haemophilusinf uenzae should $e administered $efore discharge fromthe hospital


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Teknik operasi Splenektomi 2