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INTRODUCTION

Test Taking Tips

  • Be wary about idiopathic thrombocytopenic purpura (ITP) questions. Pay close attention to the preoperative details regarding platelet count, patient status, and timing of platelet transfusion.

  • Treatment of gastric varices (sinistral hypertension) with splenectomy is frequently covered.

  • Don’t forget about an accessory spleen in a refractory ITP patient.

ANATOMY

What is the arterial blood supply to the spleen?

  • Splenic artery from the celiac plexus; short gastric arteries (vasa brevia) from the gastroepiploic artery

FIGURE 17-1

Relation of splenic artery and splenic vein. (A) Vein posterior to artery (this is the usual pattern); (B) vein both anterior and posterior to artery; (C) vein anterior to artery (this is the least common configuration). (Modified with permission from Skandalakis LJ. Skandalakis’ Surgical Anatomy: The Embryologic Basis of Modern Surgery. Paschalidis Medical Publications; 2004.)

FIGURE 17-2

Sites where accessory spleens are found in order of importance. (A) Hilar region, 54%; (B) pedicle, 25%; (C) tail of pancreas, 6%; (D) splenocolic ligament, 2%; (E) greater omentum, 12%; (F) mesentery, 0.5%; (G) left ovary, 0.5%.

What is the relationship between the splenic artery and the splenic vein?

  • The splenic artery is anterior and superior to the splenic vein

What percentage of patients have an accessory spleen?

  • ∼20%

Where is an accessory spleen most commonly found?

  • The accessory spleen is found in the region of the splenic hilum and vascular pedicle in 80% of cases

What ligaments suspend the spleen?

  • Splenocolic, gastrosplenic, phrenosplenic, and splenorenal ligaments

PHYSIOLOGY

What is the function of the spleen?

  • Hematologic: removal of cytoplasmic inclusions in the erythrocytes (pitting); destruction of senescent erythrocytes (culling); hematopoiesis in the fetus or in patients with bone marrow destruction; reservoir for platelets and granulocytes

  • Immunologic: production of the opsonins tuftsin and properdin; antibody production in germinal follicles; filtration and trapping of circulatory antigens; lymphocyte stimulation and proliferation

What is the largest producer of IgM in the body?

  • The spleen

What 2 opsonins are produced by the spleen?

  • Tuftsin and properdin

NONTRAUMATIC DISEASES

What is ITP?

  • A condition in which circulating IgG antiplatelet antibodies destroy platelets

In which patient population does ITP usually resolve spontaneously?

  • Children (rarely requires surgery)

What is the first-line therapy for ITP?

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