The Surgical Anatomy of the Spleen

In man the spleen shows only a faint trace of the three-lobed organ of varying size and form that is found throughout the mammalian series; while the

.posterior lobe, so large in the kangaroo and other marsupials, is reduced to. a mere projection.

The spleen swings from the diaphragm by its suspensory or phrenosplenic ligament, which forms part of the wall of the lesser omentum; it is at-

tached to the stomach by • the gastro-splenic omen- turn, which extends forward to the greater curva- ture

^•

of the - stomach, -and below 'finites with flee gastro-colic ligament.

'l'he gastro

splenic omentum is a much wider structure than formerly depicted in anatomical plates, with a tendency to curve round -the upper pole of the organ, and containing ,at least . three large blood vessels—the vasa brevia of the splenic artery which pass from the spleen to the stomach.

This may be looked upon as the superficial layer of the pedicle, for beneath it and the lieno-renal ligament which proceeds backwards to the anterior surface of the left kidney, there lies, from below upwards

--the tail of the pancreas—not in reality a tail, certainly not a tip, ,but a dead square-shaped end, and the branches of the splenic artery and vein. These number about four, and the lowest is in close juxtaposition -to the pancreatic tail.

If, as is commonly the case, the pedicle is ligated en masse with both its blades enclosed, the pan- creatic ,tail must form a portion thereof, with the result that the ligature is very liable to slip.

Moynihan states that in some cases the tail of the pancreas has accidentally or deliberately been in- cluded in the ligature surrounding the pedicle, _in order to ensure a firmer hold. Esmarch advises that this should be done if there is any doubt as to the security of the ligature. _I lost my ninth case through following this plan owing to the ligature slipping. To prevent such an accident, I now free the spleen from below dividing the lieno-renal _liga- ment; ligating also the vessels of the gastro-splenic omentum separately and as far as possible from the stomach, avoiding also the 'supra-renal _capsule which always lies exceedingly close to an _enlarged spleen. Then I divide the suspensory _ligament—

the costo-colic and the adhesions to the _diaphragm between ligatures or clamps. It is here _{also that} Haemorrhage now or subsequently—and it _{may be} uncontrollable haemorrhage may occur—owing to defective ligation of a branch from the aorta or coeliac axis, arising about the level of the cardia and running- to the left. The spleen can now be rotated out of its bed, and delivered when the splenic vessels are easily secured from behind; the lesser sac of the peritoneum being opened during the ligation.

The splenic vein is very apt to tear, hence carry- ing a ligature en masse is dangerous. When pos- sible each big vessel should be doubly ligated separately with silk, in the face of the stump.

The splenic veins lie below the artery.

G. A. .Wright in 1888 :—"Splenectomy is very

dangerous, the chief danger being from haemorrhage

and shock; and there being especial danger of bleed-

ing from a vessel that passes between the spleen

and the diaphragm.. Whether it is altogether an

an abnormal vessel -or merely a dilatation of a

small vessel existing there _I do not know, but it is

responsible for the death of my patient and of three

others, including a leukæmic patient."

1448 AUSTRALIAN MEDICAL JOURNAL. February 28, 1914.

The Operation of Splenectomy.

The surgeon should stand on the left side, as he thus obtains a better view of the pedicle, the liga- tion of which is the most important step in this operation.

Step i.—The incision should be made on the outer border of the left rectus, beginning at the costal cartilage and continuing down to or below the umbilicus.

A sterile towel soaked in saline solution is now intróduced, and pushes the intestines into the right half of the abdomen out of harm's way.

Auvray (Presse Medicale, 1905) has recom- mended that the incision be prolonged outwards and backwards over the lower part of the thorax at the level of the 8th space. In this way a flap of the soft tissue is cut, which, when dissected up and turned downwards, freely exposes the cartilaginous thoracic border, in other words, the loth, 9th, and 8th cartilages. These cartilages are then divided with knife or scissors close to their anterior ex- tremities, and freed frornt before backwards and from below upwards, the knife being kept very close to the deep surface during the separation of the underlying soft tissues. Finally the thoracic segment is excised by cutting the cartilages a little in front of the costo-chondral junction. Then, by gently retracting the soft tissues with the fingers, and raising the remains of the thoracic border with a broad retractor, the whole spleen will be ex- posed, and it will be possible to examine its anterior border, the external surface, and the two portions separated by the attachment of the gastro-splenic omentum, of the internal surface, and it will be easily possible to draw down the upper pole.

Step

2.—Separation

of adhesions.

These render the operation difficult, and it may be impossible. In my first case, at the close of a long and tedious dissection, I found the large spleen very adherent to the splenic flexure of the colon.

Dr. Embley told me that the patient had come to the limit of her endurance. In the final manipula- tion, however, I unfortunately tore widely the splenic flexure of the colon. This was rapidly su- tured. She made a good recovery.

Deal particularly carefully with the phreno.

splenic ligament, ligating, if possible, each section with double ligatures before dividing between them.

To reach this ligament Jonnesco advises that the operator should pull the spleen covered with a gauze pad, gently to the right, an assistant with his gloved hand raising the ribs and drawing the left edge of the wound to the left, thus exposing the diaphragmatic vault. It is inadvisable to trust to ligature of this ligament after removal of the spleen

—it is easier and safer to tie with the organ in situ.

The spleen should never be seized with instruments, as the haemorrhage from its torn tissue may be uncontrollable.

Step 3.—Ligation of the pedicle. See Surgical Anatomy.

At times, in very large spleens there is hardly any pedicle. In cases complicated with ascites, the operation is contraindicated as the tissues of the

pedicle become sodden and softened. In one case the ligatures cut through, and it was necessary to use and leave clamps covered with rubber at their ends. I have twice successfully used tamponage to stop haemorrhage.

Step 4.—Revision of the area from which the spleen has been removed and final haemostasis.

Bleeding from the diaphragmatic pillar may require a few sutures for its control.

Step 5.—Closure of abdomen in usual way.

The following precautions of Jacobson should be followed:—

I. To prevent any tension being exerted on the pedicle.

2. To secure every vessel.

3. To divide these in a relaxed condition at a sufficient distance from the ligatures.

4. Not to include the tail of the pancreas.

5. After all the ligatures have been applied, it may be well for sake of safety to throw one around the whole.

Indications.—The spleen may be removed for the following conditions

Splenic enlargements other than tumors can be grouped in three general classes (W. J. Mayo) :

(a) Leukemias, in which the spleen pulp be- comes converted into tissue resembling bone mar- row, and in which the spleen, in common with all the blood-forming organs, rapidly produces white blood-corpuscles of the ancestral type, much as epithelial cells run riot in cancer—a probable re- version to the fretal form of blood.

(b) Splenic anaemia, the type in which the en- largement of the spleen is accompanied by a dimi- nution of and change in character of the red blood corpuscles.

(c) Splenomegaly—an enlargement without marked blood changes, or any apparent serious in- terference with the health other than mechanical.

Injury.

3. Hydatid.

4. Wandering spleen on account of the danger of torsion of pedicle.

5. Malarial spleen under certain conditions.

6. Gunshot wound of spleen.

In a case of hydatid of the spleen of enormous size on which I operated, and sent to me by Dr.

M. U. O'Sullivan, some years ago, the patient, a robust and vigorous young man, would only con- sent to operation when pyrexia pain and other signs of commencing suppuration forced it upon him. To remove the daughter cysts it was necessary to make a section through a considerable thickness of the spleen, which presented in the depths of the wound.

The bleeding was the most terrific I have ever en-

countered, and could only be stopped by tamponage

and subsequently ligature en masse of the cut edges

of the splenic tissue. The latter is much more

friable than hepatic tissue and also more vascular,

but fortunately in this case the splenic capsule was

thickened and formed a point d'appuis for the

sutures.

February 28, 1914. AUSTRALIAN MEDICAL JOURNAL. 1449 I look.upon ascites as a distinct contra-indication

to operation—also grave lesions of the liver as shown by urinobiluria and jaundice, with their consequent liability to haemorrhage, haematemesis and melena. Marked painful paroxysms denoting perisplenitis and subsequent adhesions are disquiet- ing symptoms, and, of course, the larger the spleen the more difficult frequently its removal. Of all the adhesions, those with the diaphragm are the most dangerous, and in one reported case in removing them the stomach wall was injured and perforated later with fatal peritonitis.

Spleniculi were found in only one of the eleven patients, and were not removed. I'or some reason this patient eighteen months subsequently was not doing well, and Dr. Springthorpe asked me to re- open her abdomen and remove the subsidiary spleens of which two were noticed at the first operation. There was no trace of them, however, and it is probable that the removal of their blood supply by the ligation of the splenic artery caused their disappearance.

Splenectomy seems to have recently been suc- cessful in that medical reproach pernicious anaemia.

hlemperer and Hirschfeld report two cases in which they removed the spleen with marked im- provement. Eppinger has also operated in the same way in two cases. I-Ie removed the spleen on the ground that in haemolytic anaemia there seems to be a pathological excessive destruction of the reds in the spleen. The hope that the splenectomy would stimulate the new production of red blood corpuscles was fully realised, although numerous megolocytes remain.

The spleen was not enlarged in any of the six cases of pernicious anaemia reported to date. In Eppinger's cases, after six months the men were gaining in weight and feeling perfectly well.

(Therapic de Gegenwart, Berlin.)

If there be marked cachexia with haemoglobin below 4o per cent. the operation is contraindicated.

Kopylow, who has removed 13 malarial spleens, has found records of 187 others, with a total mor- tality of 25 per cent.

Blood Changes after Splenectomy.

With regard to the red cells, it was noted that there was a surprising variability from day to day, the fluctuation apparently having no connection with the degree of leucocytosis or the temperature.

The results of the final examinations show a less- ened number of red corpuscles. Microscopically the red cells showed at no time any evidence of even a moderate anaerni'a, which is a characteristic result of splenectomy in dogs. An occasional poikilocyte was seen, but no nucleated forms were seen at any time.

The h e nvoglobin estimations made showed a variability in readings slightly above or slightly below the normal, with an occasional high reading.

Roughly, we can say that there was little deviation from normal.

With regard to the leucocytes, it will be noted that at first there was a tremendous increase, so that on the morning after the operation in one case

the number was 110,000. This seems enormously high, but li uhsam has reported a "leucocytosis of 8o,000 after splenectomy for ruptured spleen."

In one case, four days later, the count had fallen to

^12,000,

Which was the lowest estimate made at any time. The sudden rise to 27,000 the following day was coincident with the onset of pneumonia.

From this on the counts remained persistently high, partly on account of the pneumonia and partly as a result of splenectomy, as evidenced by the fact that on the day of discharge from the hos- pital, apparently quite well, the patient had a leu- cocyte count of 20,400.

It was in the results of the differential leucocyte counts, however, that the most interesting features were seen. All the previous cases showed a lymphocytosis some time after splenectomy; here we were able to note the development of the lymphocytosis in the face_ of inflammation, which should normally call forth a polynuclear neutro- philic hyperleucocytosis.

At first practically all the leucocytes were poly- morphonuclear neutrophiles, but as the case de- velops the lymphocytes (adding the large and small varieties together) are steadily gaining, so that 2/ 7/'o9, in the presence of active inflammatory pro- cesses, we find the following count:—

Total leucocytes

34,000.

Polymorphoneuclear neutrophili .. 75.6 Small lymphocytes

.. .. .. .. .. 15.6

Large lymphocytes

.. .. ..

..

4.8 Large morphonuclears ..

.. .. ..

1.6 Eosinophiles .. 2.4

It is not possible in a paper such as this to furnish tables of all the differential counts made. The one above-is sufficient to show the trend of the develop- ing lymphocytosis, although the figures here given are practically normal. When it is considered, however, that the first counts made showed prac- tically all polymorphonuclear neutrophils, these re- sults, in the Light of the fact that in lymphocytosis developed in previous cases, are practically sug- gestive. One of the previöus cases showing lymphocytosis was found to have "accessory spleens"—they were not found in this case, though looked for.

In these early results, after removal of the spleen, we found no trace whatever of the eosino- philia which occurs frequently after splenectomy.

The eosinophile cells remained persistently low, and beyond the fact that an occasional myclocyte and mast cell were seen, no other cells calling for comment were noted.

Summarising the early results after splenectomy, we may say that the two .most interesting features are, firstly, the variability in number of the red cells, with 'h ae moglobin content practically normal and the microscopic appearance showing no signs of anaemia. This would seem to show a lack of balance between production and destruction of red cells consequent upon removal of the spleen, the haemoglobin remaining high to give the necessary supply of oxygen for the carrying on of metabolism.

The results seen of cases late after splenectomy

seem to show that this balance is recovered.

1450 AUSTRALIAN MEDICAL JOURNAL. February- 28, 1914.

The - second feature of the developing lympho- cytosis, .which also seems from the previous cases to he

eventually controlled:

^•

However, the eighth case has shown it developing in the face of in- flammation, which should" call forth a polymorpho- nticlear neutrophilic leïzêocytosis. This would seem to show that removal "of-the spleen gives a stimulus to the lymphatic appatatits of the body, and causes

In man the spleen shows only a faint trace of the three-lobed organ of varying size and form that is found throughout the mammalian series; while the

.posterior lobe, so large in the kangaroo and other marsupials, is reduced to. a mere projection.

The spleen swings from the diaphragm by its suspensory or phrenosplenic ligament, which forms part of the wall of the lesser omentum; it is at-

tached to the stomach by • the gastro-splenic omen- turn, which extends forward to the greater curva- ture

of the - stomach, -and below 'finites with flee gastro-colic ligament.

'l'he gastro

splenic omentum is a much wider structure than formerly depicted in anatomical plates, with a tendency to curve round -the upper pole of the organ, and containing ,at least . three large blood vessels—the vasa brevia of the splenic artery which pass from the spleen to the stomach.

This may be looked upon as the superficial layer of the pedicle, for beneath it and the lieno-renal ligament which proceeds backwards to the anterior surface of the left kidney, there lies, from below upwards

--the tail of the pancreas—not in reality a tail, certainly not a tip, ,but a dead square-shaped end, and the branches of the splenic artery and vein. These number about four, and the lowest is in close juxtaposition -to the pancreatic tail.

If, as is commonly the case, the pedicle is ligated en masse with both its blades enclosed, the pan- creatic ,tail must form a portion thereof, with the result that the ligature is very liable to slip.

The splenic vein is very apt to tear, hence carry- ing a ligature en masse is dangerous. When pos- sible each big vessel should be doubly ligated separately with silk, in the face of the stump.

The splenic veins lie below the artery.

G. A. .Wright in 1888 :—"Splenectomy is very

dangerous, the chief danger being from haemorrhage

and shock; and there being especial danger of bleed-

ing from a vessel that passes between the spleen

and the diaphragm.. Whether it is altogether an

an abnormal vessel -or merely a dilatation of a

small vessel existing there I do not know, but it is

responsible for the death of my patient and of three

others, including a leukæmic patient."

1448 AUSTRALIAN MEDICAL JOURNAL. February 28, 1914.

The Operation of Splenectomy.

The surgeon should stand on the left side, as he thus obtains a better view of the pedicle, the liga- tion of which is the most important step in this operation.

Step i.—The incision should be made on the outer border of the left rectus, beginning at the costal cartilage and continuing down to or below the umbilicus.

A sterile towel soaked in saline solution is now intróduced, and pushes the intestines into the right half of the abdomen out of harm's way.

Step

of adhesions.

These render the operation difficult, and it may be impossible. In my first case, at the close of a long and tedious dissection, I found the large spleen very adherent to the splenic flexure of the colon.

Dr. Embley told me that the patient had come to the limit of her endurance. In the final manipula- tion, however, I unfortunately tore widely the splenic flexure of the colon. This was rapidly su- tured. She made a good recovery.

Deal particularly carefully with the phreno.

splenic ligament, ligating, if possible, each section with double ligatures before dividing between them.

—it is easier and safer to tie with the organ in situ.

The spleen should never be seized with instruments, as the haemorrhage from its torn tissue may be uncontrollable.

Step 3.—Ligation of the pedicle. See Surgical Anatomy.

At times, in very large spleens there is hardly any pedicle. In cases complicated with ascites, the operation is contraindicated as the tissues of the

pedicle become sodden and softened. In one case the ligatures cut through, and it was necessary to use and leave clamps covered with rubber at their ends. I have twice successfully used tamponage to stop haemorrhage.

Step 4.—Revision of the area from which the spleen has been removed and final haemostasis.

Bleeding from the diaphragmatic pillar may require a few sutures for its control.

Step 5.—Closure of abdomen in usual way.

The following precautions of Jacobson should be followed:—

I. To prevent any tension being exerted on the pedicle.

2. To secure every vessel.

3. To divide these in a relaxed condition at a sufficient distance from the ligatures.

4. Not to include the tail of the pancreas.

5. After all the ligatures have been applied, it may be well for sake of safety to throw one around the whole.

Indications.—The spleen may be removed for the following conditions

Splenic enlargements other than tumors can be grouped in three general classes (W. J. Mayo) :

(b) Splenic anaemia, the type in which the en- largement of the spleen is accompanied by a dimi- nution of and change in character of the red blood corpuscles.

(c) Splenomegaly—an enlargement without marked blood changes, or any apparent serious in- terference with the health other than mechanical.

Injury.

3. Hydatid.

4. Wandering spleen on account of the danger of torsion of pedicle.

5. Malarial spleen under certain conditions.

6. Gunshot wound of spleen.

In a case of hydatid of the spleen of enormous size on which I operated, and sent to me by Dr.

The bleeding was the most terrific I have ever en-

countered, and could only be stopped by tamponage

and subsequently ligature en masse of the cut edges

of the splenic tissue. The latter is much more

friable than hepatic tissue and also more vascular,

but fortunately in this case the splenic capsule was

thickened and formed a point d'appuis for the

sutures.

February 28, 1914. AUSTRALIAN MEDICAL JOURNAL. 1449 I look.upon ascites as a distinct contra-indication

Splenectomy seems to have recently been suc- cessful in that medical reproach pernicious anaemia.

The spleen was not enlarged in any of the six cases of pernicious anaemia reported to date. In Eppinger's cases, after six months the men were gaining in weight and feeling perfectly well.

(Therapic de Gegenwart, Berlin.)

If there be marked cachexia with haemoglobin below 4o per cent. the operation is contraindicated.

Kopylow, who has removed 13 malarial spleens, has found records of 187 others, with a total mor- tality of 25 per cent.

Blood Changes after Splenectomy.

With regard to the red cells, it was noted that there was a surprising variability from day to day, the fluctuation apparently having no connection with the degree of leucocytosis or the temperature.

The h e nvoglobin estimations made showed a variability in readings slightly above or slightly below the normal, with an occasional high reading.

Roughly, we can say that there was little deviation from normal.

With regard to the leucocytes, it will be noted that at first there was a tremendous increase, so that on the morning after the operation in one case

the number was 110,000. This seems enormously high, but li uhsam has reported a "leucocytosis of 8o,000 after splenectomy for ruptured spleen."

In one case, four days later, the count had fallen to

Which was the lowest estimate made at any time. The sudden rise to 27,000 the following day was coincident with the onset of pneumonia.

From this on the counts remained persistently high, partly on account of the pneumonia and partly as a result of splenectomy, as evidenced by the fact that on the day of discharge from the hos- pital, apparently quite well, the patient had a leu- cocyte count of 20,400.

small vessel existing there _I do not know, but it is