Topic: Splenomegaly, cholecystitis, portal hypertension, liver abscess
Question: Describe the therapeutic indications of splenectomy. detail the steps involved in splenectomy.
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Therapeutic Indications for Splenectomy:
– Idiopathic thrombocytopenic purpura (ITP) – Splenectomy is indicated in cases of ITP where platelet counts remain low (<30,000/μL) despite treatment with corticosteroids, IVIG, rituximab or thrombopoietin receptor agonists. It is a potential cure for ITP.
– Hereditary spherocytosis – Splenectomy is curative in this hemolytic anemia to prevent ongoing red blood cell destruction and hemolysis by the spleen. It is usually done after the age of 5 years.
– Splenic rupture/trauma – Emergent splenectomy is indicated following traumatic splenic injury and rupture to control hemorrhage and prevent delayed splenic rupture.
– Hypersplenism – Splenectomy reverses cytopenias involving one or more cell lines (thrombocytopenia, anemia, leukopenia) caused by an overactive spleen sequestering cells.
– Splenic abscess – Drainage along with splenectomy may be required for abscesses not resolving with antibiotics alone.
– Massive splenomegaly – Splenectomy provides symptomatic relief in hematologic malignancies like CML, lymphoma, hairy cell leukemia.
– Hereditary hemolytic anemias – Curative option for refractory hemolytic anemia in disorders including sickle cell disease, thalassemia, and enzyme deficiencies.
– Hodgkin’s lymphoma staging – Splenectomy is occasionally done to aid in disease staging and prognosis.
Surgical Steps in Splenectomy:
1. Patient is induced under general anesthesia and placed in supine/right lateral decubitus position.
2. A midline or subcostal left upper quadrant incision is made and the abdomen is entered.
3. The splenic flexure of colon and tail of pancreas are mobilized to access the splenic hilum.
4. The peritoneum overlying the spleen is incised and the splenic ligamentous attachments are taken down.
5. The splenic artery and vein are individually dissected, ligated and divided.
6. All short gastric vessels are ligated and divided to fully mobilize the spleen.
7. Any remaining attachments are taken down and spleen is delivered out of the wound.
8. Splenic bed is inspected for bleeding and irrigated. Hemostatic agents can be applied.
9. Absorbable sutures close the peritoneum. Drain may be left near splenic bed.
10. Fascia and skin are closed in layers. Specimen is sent for histopathology.
Modern techniques include laparoscopic and robotic splenectomy. But the key steps of hilar control, mobilization, resection, hemostasis and drainage remain the same.
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