In 1916, Schloffer performed the first splenectomy for idiopathic thrombocytopenic purpura (ITP) after his student Paul Kaznelson hypothesized that platelet destruction in ITP occurred in the spleen. Their first patient treated with splenectomy showed dramatic improvement. Splenectomy is now an established treatment for chronic ITP when patients have relapsed or have severe refractory thrombocytopenia. It results in complete or partial response rates of 66-72% in adults and 72% in children, with relapse rates of 15%. Predictors of response to splenectomy are not well established.

1. DR.SAJID ALI
PG Trainee
SEW KTH

2. ROLE OF SPLENECTOMY IN ITP

3. PAUL KAZNELSON
(STUDENT)
 In 1916, Schloffer became the first to remove
a spleen for idiopathic thrombocytopenic
purpura (ITP). His student Paul
Kaznelson (1898-1959) hypothesized - in
analogy with hemolytic anemia - that the
excessive destruction of platelets in ITP would
occur in the spleen and suggested to his tutor
Schloffer to perform a splenectomy on a patient
with chronic ITP. Schloffer followed Kaznelson's
suggestion. Their first patient so treated showed
a dramatic improvement
HERMANN
SCHLOFFER
(Teacher)

4. OVERVIEW
ITP is thrombocytopenia with normal bone marrow in
the absence of other causes of thrombocytopenia
Presents as acute condition(resolves within 2months)
in children and chronic condition (>12months) in
adults

6. TREATMENT OF ITP
 1.Prednisone: 1mg/kg/day
 -> 2/3 patients with Platelets>50,000 in 1 week
 -> 26% complete response
 2. IVIG: acute bleeding, pre op, pregnancy
 1g/kg x2 days ->increases Platelet count in 3 days
 -> increases efficacy of transfused Platelets

7. INDICATIONS FOR SPLENECTOMY
Chronic ITP having
 Two relapses
 Emergency splenectomy for acute hemorrhage(rare)
 Severe refractory thrombocytopenia: 6 wks of continued Plts
<10,000
 Toxic steroid dosing -> remission

8. INDICATIONS CONT……
 Relapse after initial treatment: Plts <30,000 after
transient or incomplete response over 3 months
 Pregnancy:
 2nd trimester, failed IVIG and steroid course
 -> Plts<10,000 or <30,000 with bleeding

9. PRE OP PREPARATION
Consent
FBC, U&E, G&H (consider X match)
Platelets may be required
Peri-operative antibiotics – usually IV cefazolin at induction, to
continue for 24hours
Patients with preoperative counts >20 x 10^9/L (>20 x 10^3/micro
litre) can safely undergo splenectomy….otherwise IVIG 1 to 2 days
in advance of intervention, or oral corticosteroids for a few days,
may increase platelet count to a safer level

10. IMMUNIZATION
For elective splenectomy extra immunizations should be commenced
as soon as possible and at least 2 weeks pre-operatively
For emergency splenectomy commence immunisations 2 weeks post-
operatively.
Meningococci (meningovax,Menactra)
Pnemococci (pnemovax)
H influenza ((Influvac or Fluarix)

11. POST OP CARE AND DISCHARGE
PLANNING
Bloods FBC, U&E evening or next morning
Watch platelet count – may need anticoagulants if increases
Antibiotics as per operation note (Usually IV cephazolin 24hours)
Chest physiotherapy to prevent chest infection may be required
Discuss medical alert bracelet
Ensure vaccination plan is clearly documented on discharge letter –
and clarify who will follow this through (GP)

12. CONTINUED……
 Discuss importance of seeking medical attention early for febrile
illnesses, malaria precautions if travelling overseas,
 antibiotics for dog / animal bites
 oral phenoxymethylpenicillin or erythromycin should be given to
young, splenectomized children (at least to age 5 years or for 5
years) and to adults for 2 years following splenectomy
 Provide patient education leaflet

14. ANATOMY
Normal size: 12x7 cm, 3-4 cm thick, ~150 gm
Parietal peritoneum adherent except at hilum
Peritoneal extensions- 4 ligaments:
splenocolic, splenophrenic- relatively avascular
Splenorenal: splenic vessels, tail of pancreas
Gastrosplenic ligaments: short gastric vessels

16. GASTROSPLENIC LIGAMENT
Splenocolic ligament

17. SPLENIC LIGAMENTS

18. BLOOD SUPPLY
The splenic artery is the largest branch of the
celiac artery. It carries blood to three organs:
 the spleen
 pancreas
 & the cardiac end of the stomach.

19. SPLENIC VEIN & ARTERY

20. BLOOD SUPPLY
Splenic artery:
off celiac trunk, multiple pancreatic branches, short
gastric, left gastro epiploic, terminal splenic branches-
> segmental branches-> 2nd, 3rd order vessels
Splenic vein:
Inferior to artery , posterior to pancreatic tail, body
Joins SMV behind pancreatic neck-> portal vein

21. OTHER INDICATIONS
1) Non hematologic
 splenic cysts
 hydatid cysts
 pseudocysts
 wandering spleen
 splenic abscess
 splenic trauma(most common indication)

22. OTHER INDICATIONS
2) Hematologic
 Hereditary spherocytosis
 Hereditary eliptocytosis,
 Hodgkin lymphoma
 Non Hodgkin lymphoma
 CLL,CML
 Hairy cell leukemia

23. LAP PROCEDURE
Patient position
 Right lateral decubitus, flexed at waist
 Cushion placed under lumber fossa

24. SURGICAL TEAM
 The surgeon faces the patient, the assistant is behind the patient.
They each have their own video screen. The camera person
stands next to the assistant.

25. TROCARS PLACEMENT
 Optical trocar, 10mm
 Anterior axillary line below the left costal margin
 Operating trocar, 5mm
 Mid-axillary line below left costal margin
 Operating trocar, 5mm
 Mid-clavicular line, a few cm below the left costal
margin
 Retractor or operating trocar, 8-12mm
 Mid-scapular line below the 12th rib

26. PROCEDURE
Exploration
Check for mobility of the spleen and
location of possible adhesions
Exposure
Dissection of the splenophrenic ligament
with the harmonic scalpel

27.  Dissection of the splenocolic
ligament
 Check for and remove any
attachments to the abdominal wall

28. Exposure and transection of the
tissue and vessels in the
gastrosplenic ligament.

29. STEPS CONTIN……
Dissection of the splenorenal ligament.
Careful dissection of the splenic hilum
Identify and staple the splenic artery.
Identify and staple the splenic vein.

30. CONTINUED….
Detachment
Fully detach the spleen by removing any remaining
attachment
Extraction
A bag is introduced in the retraction trocar.

31. PROCEDURE
Insert the spleen in the bag and close
Pull the tip of the bag up through the retraction
trocar.
The bag is cut away from the rim.
The spleen is morcellized with spleen scoops
and removed.

32. LAP VS OPEN
Primary benefit of laparoscopic is several small
incisions instead of one large incision
Shorter hospital stay
Quicker recovery
Better cosmetic result
Laparoscopic procedure is a more demanding
technique
Highly vascularized organ
Fragile parenchyma
Attached by several ligaments to other organs
Hematological disease often associated with a low
platelet count

33. RESPONSE TO SPLENECTOMY
Systematic review of 436 articles from 1966-2004:
66% complete and 88% partial response in adults-median F/U 29
months
72% complete response in children and adults
15% relapse- median F/U 33 months

34. PREDICTORS OF SUCCESSFUL SPLENECTOMY
No consistent factors
Age, response to steroids - not a predictor
Indium 111-platelet scintigraphy:
Splenic sequestration-> 87-93% response rate
Hepatic sequestration-> 7-30% response rate
-> long term cure rates unchanged

35. ITP POST SPLENECTOMY
Response within 10 days postop
Durable response: >50,000 on POD#3
>150, 000 on POD#10
Chronic ITP: ? Accessory spleen if unresponsive
to continued treatment with steroids and
azathioprine

36. ACCESSORY SPLEEN
Accessory spleens are
usually located at
 Splenic hilum 75%
 Tail of pancreas 20%
 Gastrosplenic &
splenorenal ligaments
 Omentum
 Mesentry

37. LAP VS OPEN RESPONSE
Laparoscopic splenectomy:
85% immediate response
4% relapse rate
15% accessory spleen
Open Splenectomy:
81% immediate response
12 % relapse rate
16% accessory spleen

38. LAP VS OPEN
Blood 2004;104:2623

39. THANK YOU