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Splenic salvage procedure

Splenic salvage procedure. Roto Robo 2002 batch. SPLENIC SALVAGE PROCEDURE. HISTORY : 1980-PEDIATRIC SURGEON. WHY? 1. IMMUNOLOGICAL FUNCTION 2 . OPSI. THREE DIFFERENT AREAS. OPERATIVE ATTEMPT NONOPERATIVE MANAGEMENT EMBOLISATION OF SPLENIC ARTERY

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Splenic salvage procedure

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  1. Splenic salvage procedure Roto Robo 2002 batch

  2. SPLENIC SALVAGE PROCEDURE • HISTORY: 1980-PEDIATRIC SURGEON. • WHY? 1. IMMUNOLOGICAL FUNCTION 2. OPSI

  3. THREE DIFFERENT AREAS • OPERATIVE ATTEMPT • NONOPERATIVE MANAGEMENT • EMBOLISATION OF SPLENIC ARTERY 1. OPERATIVE ATTEMPT-SPLENIC FUNCTION 1. SURPERFIAL HEMOSTATIC AGENTS 2.SUTURE REPAIR 3. ABSORBABLE MESH WRAP 4. RESECTIONAL DEBRIDEMENT

  4. EXPOSURE & POSITIONING • ADEQUATE EXPOSURE-LEFT UPPER QUADRANT • DIFFICULTY EXPOSURE – INCISION FOR 1.LEFT COLON PATHOLOGY 2. RENAL, ADRENAL OR RETROPERITONEAL PATHOLOGY • SKILL & EXPERIENCED SURGEON • ATLEAST 2 ASSISTANT

  5. 2ND ASSISTANT-CRITICAL • MEDIAL ROTATION OF STOMACH • UPWARD & OUTWARD RETRACTION OF LEFT LOBE OF LIVER. • ELECTROCAUTERY OF LIENORENAL LIG.-LIFTING OF SPLEEN, LAPAROTOMY PADDING. • DIVISION OF POST. SPLENIC PERITONEAL ATTACHMENT WITH ANGLED OR BENT ELECTROCAUTERY TIP. • MOBILISATION OF SPLLEN & TAIL OF PANCREAS- 2 LAPAROTOMY PAD.

  6. UPWARD & MEDIAL ROTATION OF SPLEEN AND PACKING WITH PAD

  7. ELECTROCAUTERY DIVISION OF POST: PERITONIUM

  8. MANUAL MOBILISATION OF SPLEEN & TAIL OF PANCREAS

  9. SUPERFICIAL HEMOSTATIC AGENTS 1.SURGICEL-OXIDESED REGENATED CELLULOSE 2.GELFOAM- ABSORBABLE GELATIN SPONGE, USP,PLAIN OR IMPREGNATED WID THROMBIN 3. AVITENE- MICROFIBRILLAR COLLAGEN HEMOSTATIC.

  10. avitene cont… • BETTER-PERFORMED / FLOUR COMPERSSED WITHIN SPONGE APPLIED TO SPLEEN FOLLOWED BY LARGER LAPAROTMY PADS FOR MANUAL COMPRESSION. • BLOW ON TECHNIQUE- FORCIBLY APPLIED TO INJURED CREVICES THRU. 60 ML CATHETER TIPPED SYRINGE.

  11. A- SURGICEL, B-GELFOAM, C-AVITENE,

  12. 4. ELECTROCAUTERY • 40-50 W • BEST BY ARCHING THE CURRENT ONTO SPLEEN. • FOR DEEPER HILAR & CLEFT INJURIES- USE INNER CANNULA OF A METAL POOLE SUCTION & DIRECTLY APPLY CANNULA TIP INTO THE DEPTH OF WOUND. • APPLY ELECTROCAUTERY TO CANNULA FOR THERMAL HEMOSTASIS.(POORMAN’S ARGON BEAM COAGULATOR)

  13. 5. ARGON BEAM COAGULATOR(ABC) • HEMOSTASIS BY INERT VISIBLE BEAM OF GREEN ARGON GAS SPURT FORTH LIKE A LEAF BLOWER TO KEEPS THE SPLENIC TISSUE DRY. • ELECTROCAUTERY DISCHARGED(12O-150) - UNIFORMLY 1-2MM DEPTH OF CAUTERISATION. 6. FIBRIN GLUE • COAGULUM- EQUAL PART OF CRYOPREPITATE & THROMBIN SOLN WITH OR WITHOUT CACL2 AS CATALYST. • TISSEL VK KIT. • EXPENSIVE & 2-3 APPLN REQD.

  14. ARGON BEAM COAGULATOR ARGON BEAM

  15. A-ELECTROCAUTERY, B-ARGON BEAM COAG:, C- FIBRIN GLUE B C A

  16. MODERN HIGH TECHNOLOGY TOPICAL HEMOSTATIC • DRY FIBRIN SEALANT DRESSINGS (DFSD) • RAPID & SUCCESSFUL ARREST OF MAJOR HRG EVEN IN HYPOTHERMIA & COAGULOPATY. • 2. HIGH INTESITY ULTRASOUND (HIU) • HEMOSTASIS AT ADJUSTABLE DEPTH

  17. HEMOSTATIC SUTURE TECHNIQUES • SPLENORRAPHY- SUTURE OF A WOUND OF SPLEEN. • WOUND BREAKING STRENGTH OF SUTURED SPLENIC TISSUE. • COMBINED WITH SURGICEL PATCHES OR PLEDGET TO AVOID SPLENIC CAPSULAR TEARING. • FIG. OF 8 - SIMPLE, RAPID, LESS TRAUMATIC. • BUTTRESSING OF SPLENIC REPAIR WITH TEFLON STRIP OR OMENTUM.

  18. FIG: OF 8 SUTURE TECH:

  19. A-TEFLON STRIP, B-OMENTAL PLUG, C-OMENTAL BUTTERESSING A B

  20. MESH REPAIRS • MODERATE - SEVERELY SPLENIC INJURY. • SPLENIC CAPPING WITH DEXON OR VICRLY • TECHNIQUE • APPLYING A HAIR NET TO HOLD TOGETHER PULVERISED FRAGMENTS OF THE SPLEEN.

  21. HAIR NET WRAPPING OF SPLEEN (VICRYL MESH)

  22. PARTIAL SPLENECTOMY • SPLEEN - UNIQUE VASCULAR SYSTEM. • HILAR VESSELS - T & Y CONFUGURATION WITH PLATE LIKE SEGMENTATION.(PANCAKES) • SURGICAL EXCISION OF DAMAGED PART POSSIBLE LEAVING HEALTHY TISSUE BEHIND.

  23. VASCULAR SEGMENTATION Y

  24. Stapled resection margin of lower half Parenchymal transection of the upper pole

  25. A-SUP: POLE RESECT:,B-MIDDLE SEGMENT RESECT:, C-INF: POLE RESECT: A B

  26. SPLENIC AUTOTRANSPLANTATION • CHOPPING UP REMNANTS OF SPLEEN & IMPLANT THE PIECES INTO AN OMENTAL POUCH(SPLENIC TECO)

  27. NONOPERATIVE MANAGEMENT • NOM INITIALLY PRACTISED FOR CHILDREN. • WITH CAREFUL PATIENTS SELECTION - SUCCESS RATE APPROACHES 85-95%. • SELECTION CRITERIA: 1. HEMODYNAMICALLY STABLE. 2. CTSCAN DOCUMENTN OF SPLENIC INJURY. 3. NO CONTRAST POOLING ON CT SCAN. 4. NO OTHER INTRAABDOMINAL INJURIES REQUIRING LAPAROTOMY. 5. LIMITAN OF SPLENIC RELATED BLOOD TRANSFUSION < 2 UNITS.

  28. cont… • CONTRAINDICATION: 1. AGE > 55 YRS 2. GRADE 4 OR 5 3. SPLENIC BLUSH ON CTSCAN.

  29. CT scan of the abdomen following a motor vehicle collision, revealing a splenic injury. Patient was managed nonoperatively

  30. A, An arterial blush. Patient was observed without embolization. B, Five days later with no active extravasation and no increase in size of the subcapsular hematoma.

  31. FOLLOW UP WITH CT SCAN • RARELY NECESSARY • INDICATED FOR FALLING BP OR H/H DURING OBSERVATION. • GRADE 1 &2: 1. RARELY SHOW PROGRESSION OF LESION. 2. NO REPEAT CT IF - STABLE • GRADE 3: CT ON CASE BY CASE BASIS. • COMPLETE RESOLUTION ON CT REQD BEFORE RETURN TO ACTIVITY.

  32. EMBOLISATION OF SPLENIC ARTERY • SCLAFANI – 1981 • INDICATION – 1) POST TRAUMATIC SPLENIC INJURY 2) HYPERSPLENISM 3) SPLENIC ARTERIAL ANEURISMS 4) PORTAL HYPERTENSION 5) SPLENIC NEOPLASM 6) BEFORE LAPAROSCOPIC SPLENECTOMY

  33. AGENTS • 1) HEMOSTATIC COIL • 2) GEL FOAM • 3) MICROSPHERE TYPES OF SAE - • 1) PROXIMALSAE- HEMOSTATIC COIL IN THE MAIN TRUNK. - HIGH RISK FOR 20 RUPTURE OF SPLEEN - DECREASE VOL: OF SPLENIC BLOOD FLOW & RELATIVE HYPOTENSION IN SPLENIC BED

  34. 2) DISTAL SAE • EMBOLISATION >1 OF TERMINAL BRANCHES OF SPLENIC ARTERY • AS DISTALLY AS POSSIBLE- TO PRESERVE THE REMAINING NORMAL SPLENIC PARENCHYMA. • PLACEMENT OF COILS IN MIDDLE SEGMENT OF SPLENIC ARTERY- ALL0WS RECONSTITUTN OF BLOOD SUPPLY.

  35. METHODS • COILS INSERTED INTO SPLENIC ARTERY THROUGH ANGIOGRAFIC CATHETER. • COMPLICATIONS- • MAJOR- 1) SPLENIC INFARTIONS 2) SPLENIC ABSCESS 3) CONTRAST INDUCED RENAL INSUFFICIENCY 4) BLEEDING

  36. MINOR- 1) FEVER 2) PLEURAL EFFUSION 3) DISTAL COIL MIGRATION

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