Известное выражение пиратов «Лопни моя селезенка», как мы знаем, является не таким уж крылатым. Некоторые люди действительно сталкиваются с этим неприятным обстоятельством, при этом, даже не понимая, чем грозит удаление селезенки. И тогда врачам не остается ничего другого, как удалить травмированный орган, а человеку – продолжить жизнь без селезенки.
Удаление селезенки – причины
Однако лопнувшая селезенка – это, к сожалению, не единственная причина для удаления органа. Вот несколько причин, по которым проводится данная операция:
- травма органа (отрыв от ножки, размозжение и прочее);
- гемолитическая анемия;
- онкологическое заболевание крови;
- вторичный гиперспленизм;
- образование кисты;
- поражение органа паразитами или инфекцией;
- инфаркт селезенки;
- возникновение абсцесса в органе.
Операция по удалению селезенки
Данная операция называется спленэктомия. Сегодня она не является опасной для жизни пациента. После стандартной операции на теле прооперированного человека остается длинный и хорошо заметный шрам. Потому в последнее время все большую популярность приобретает лапароскопический метод удаления селезенки.
Последствия после удаления селезенки
Селезенка является очень важным органом, принимающим активное участие к кроветворном процессе. Она разрушает старые эритроциты и тромбоциты, тем самым регулируя их количество в крови. Данный орган накапливает железо для дальнейшего образования гемоглобина, а также благодаря способности резко сокращаться выбрасывает в сосуды кровь при резком снижении ее уровня (например, из-за травмы).
Потому удаление селезенки, несмотря на распространенное мнение о ее ненужности для организма, конечно, является стрессом для него и требует колоссальной перестройки. При этом сильно снижается иммунитет больного, а значит и способность сопротивляться вирусам и инфекциям. Многие функции селезенки при ее удалении берет на себя печень и лимфатические узлы, что увеличивает нагрузку на эти органы и требует от человека придерживаться определенных правил. Вот как меняется жизнь после удаления селезенки:
-
Щадящая диета во избежание перенагрузки печени.
- воспаление, инфицирование тканей;
- образование опухолей;
- отрицательная реакция на прием некоторых медикаментов;
- повреждение сетки кровеносных сосудов в органе.
- слабый иммунитет из-за ВИЧ-инфицирования, при тромбоцитопении;
- миелофиброз костного мозга;
- лимфома, лейкемия;
- абсцесс органа;
- спленомегалия с увеличением селезенки;
- гемолитическая анемичная болезнь;
- вторичный гиперспленизм;
- кистообразование;
- паразитарное поражение органа — Гранулема Молларе или болезнь «царапин от кошки»;
- инфаркт селезенки с учащенным сердцебиением.
- злокачественный опухолевый процесс из-за метастазирования при раке в ЖКТ;
- травмирование капсулы или сосудистой ножки селезенки, когда невозможно наложить шов;
- гиперспленический синдром (спленомегалия, тромбоцитопения);
- неэффективность терапии гемолитической анемии;
- первичные или вторичные неоплазии селезенки.
- Сбор данных о пациенте и составление анамнеза.
- Клинические исследования, включающие: пальпирование области проекции; анализ крови с определением свертываемости, степени тромбоцитопении.
- Инструментальные исследования, включающие: УЗИ с целью определения формы и размера органа; сцинтиграфию, назначаемую при аутоиммунных гемолитических нарушениях крови; с маркированными эритроцитами — при спленомегалии; индукцию эритроцитами — при болезни Верльхофа.
- Дополнительное обследование: рентген грудины; ЭКГ; МРТ или КТ.
- употребление жидкой пищи;
- прием слабительного для очистки кишечника;
- необходимость пить медицинские средства противовоспалительного свойства;
- вакцинирование с целью предотвращения развития инфекции в организме.
- Лапароскопическим, т. е. с помощью специального инструмента, который оснащен камерой и осветительным устройством. Делают 4 минимальных надреза в животе. В одно отверстие вставляется лапароскоп, в остальные — необходимые для иссечения инструменты. Одновременно в полость вводится газ для расширения пространства между внутренними органами и улучшения обзора. Проводится осмотр на предмет обнаружения второй селезенки. Производится изоляция селезенки от ближайших тканей и кровотока. Орган вынимается через широкий разрез, который вместе с остальными зашивается.
- Полостным методом, предполагающим полный разрез брюшины по центру с открытием полости. Такой шов зарастает дольше и сильнее болит.
При обнаружении второй селезенки также нужно делать ее иссечение. - оценка принимаемых лекарств;
- прекращение приема таких медикаментов, как аспирин, противовоспалительные, «Плавикс», «Клопидогрель, «Варфарин» для разжижения крови.
- надрез по центру живота или слева, чуть ниже ребер;
- визуализация селезенки для последующего иссечения;
- если причиной вмешательства является рак, проводится осмотр лимфоузлов;
- при поражении которых также требуется иссечение;
- тщательная проверка кровотечений;
- закрытие раны.
- создание 3—4 небольших разрезов для введения лапароскопа и других инструментов;
- введение в полость углекислого газа для облегчения обзора, чтобы правильно вырезать селезенку;
- иссечение пораженного органа или его части;
- осмотр полости на предмет кровотечений;
- санация полости;
- закрытие ран.
- после полостной операции — не более 7 суток при отсутствии осложнений;
- при лапароскопии — 3—5 суток при нормальном течении реабилитации.
- избегать омовения шва водой в душе или ванне первые 3 суток после операции;
- частая смена влажных повязок на сухие;
- назначение капельниц или уколов с обезболивающим;
- проверка состояния швов;
- специальное питание не требуется. Нужно обеспечить полноценное питательное и витаминизированное меню.
- положено мыться под душем;
- пить легкие, не аспиринсодержащие обезболивающие при болях, если болит шов;
- отказ от активных физнагрузок;
- отказ от вождения машины в течение 1,5 месяцев;
- правильное питание и диета со свежими овощами, зеленью;
- железосодержащими фруктами. Отказ от вредной, канцерогенной еды;
- положено отказаться от курения, алкоголя, газировки;
- заниматься споротом;
- гулять на свежем воздухе.
- закупорка вен печени;
- травма ЖКТ;
- реактивный панкреатит;
- кровотечения;
- пневмония;
- перитонит.
- инфицирование;
- развитие грыжи;
- выпадение внутренних органов.
- хроническое изменение состава крови и формы кровяных телец;
- закупорка легочной артерии и сосудов мозга из-за увеличения свертываемости;
- иммунная дисфункция;
- подверженность гнойно-инфекционным патологиям;
- сепсис;
- уменьшение выработки иммуноглобулинов;
- фагоцитарная дисфункция.
- щадящая диета для селезенки, чтобы не перегружать печень;
- поддержка организма медицинскими препаратами, поливитаминами с целью профилактики инфекций;
- острожное посещение людных мест, особенно первые 2 года после вмешательства;
- проведение дополнительной вакцинации;
- избегание посещения стран, где распространен гепатит или малярия;
- частые медобследования;
- предохранение от переохлаждения, ОРВИ и ОРЗ.
- Сильный разрыв селезенки после несчастного случая.
- Очень сильное увеличение селезенки.
- Болезнь Ходжкина.
- Инфаркт селезенки.
- Синдром Фелти.
- Гнойный абсцесс, киста, саркоидоз.
Причины
Удаляют орган по многим причинам. Основной является ее отрыв от ножки, разрыв, размозжение или повреждение в результате сильной травмы.
В каких случаях требуется удаление селезенки у взрослых и детей?
При каких заболеваниях это рекомендовано?
Показания
Селезенка» должна быть удалена у взрослого и ребенка в следующих случаях:
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Обследование
Перед назначением операции нужно оформить обходной лист, для чего проводят:
По необходимости проводится дифференциальная диагностика.
Какие требования выставляют непосредственно перед проведением спленэктомии?
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Выполнение удаления
Иссекают селезенку под общим наркозом одним из двух способов:
Подготовка
Если имеется подозрение о разрыве органа, развилось интенсивное кровотечение из-за тромбоцитопении и резко упало давление, необходима срочная операция. При плановой операции назначается подготовка человека и оценка состояния его организма. Для этого, помимо необходимости оформить обходной лист, осуществляется:
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Анестезия
Операция по удалению селезенки осуществляется под общим наркозом, погружением человека в сон. Анестезия действует, как болеутоляющее.
Спленэктомия
Селезенка удаляется через 1 большой разрез или 4 небольших. Операция длится около 45—60 минут. После нее инвалидность не дают, но оспорить решение и оформить документы можно.
Преимущества
Малоинвазивная хирургия отличается меньшей травматичностью и послеоперационной болезненностью, в отличие от открытой техники. После лапароскопии человек быстрее приходит в норму, меньше подвержен осложнениям. Удаление селезенки этим методом показано не всем. Решение зависит от возрастной категории пациента, состояния и размера пораженного органа. Лапароскопическая хирургия не применяется при ожирении, рубцевании тканей от ранее проведенных операций.
Открытая техника
Этапы проведения полостной операции по удалению поврежденной селезенки:
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Лапароскопия
Этапы применения малоинвазивной техники:
Почему метод может не применяться? Если размеры органа слишком большие.
После операции
После того, как удалили орган, больного направляют в послеоперационный покой. При больших потерях крови человеку нужно делать переливание. Вырезанная часть удаленной селезенки отдается на анализ.
Сколько положено находится в больнице?
Почему важно соблюдать рекомендации после того, как вырезали селезенку? Они позволяют избежать инвалидности и смерти от тяжелых осложнений. Перечень требований:
Больного нужно оформить на учет к гематологу.
Реабилитация
Полностью восстановить состояние после спленэктомии возможно за 1—1,5 месяца.
Рекомендации врача в период восстановления:
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Осложнения
Проникновение в брюшную полость вызывает такие последствия удаления селезенки:
Проблемы со швом:
Специфические осложнения после удаления селезенки:
Особенно опасен с точки зрения слабости иммунитета период первых двух лет после операции. Если не беречь себя, дадут оформить инвалидность из-за развития осложнений. Рекомендуется ежегодная прививка от гриппа.
Нужно срочно идти к врачу, если появились следующие признаки:
Прогноз
Летальность при плановой и избирательной спленэктомии — 1—3%. Во время срочных операций, требуемых при травме или сепсисе, летальный исход грозит в 15% случаев. Опасность для жизни представляют осложнения.
Люди не оформят инвалидность после иссечения, так как без селезенки пациент живет полноценную жизнь без нарушений функций организма.
Профилактика
Полноценно прожить после удаления селезенки удастся, если соблюдать все рекомендации врача:
Ребенку после операции положена антибактериальная терапия и ежегодная постановка прививок от гриппа.
Удаление селезенки (спленэктомия) – хирургическая процедура по удалению поврежденного или больного органа. Спленэктомия может вызывать серьезные долгосрочные осложнения, которые требуют медикаментозного лечения. Хирургическую процедуру чаще всего проводят пациентам с тяжелой спленомегалией. После удаления селезенки рекомендуется пройти реабилитационные процедуры. Перед оперативным вмешательством необходимо в обязательном порядке сообщить врачу о принятых накануне лекарственных средствах.
Показания к удалению селезенки
При разрыве селезенки возникают боли в левой верхней части живота (селезенка располагается в левом подреберье в промежутке между 9 и 11 парой ребер)
Нормальная селезенка, помимо защитной функции, удаляет дефектные эритроциты (красные кровяные клетки) и тромбоциты. Она также хранит белые кровяные клетки и тромбоциты. При спленомегалии с гиперспленизмом (гиперфункция селезенки) разрушается больше клеток, нежели необходимо, что может привести к анемии и повышенной восприимчивости к инфекциям. В этих случаях спленэктомия может быть вариантом лечения.
Спленомегалия является вторым наиболее распространенным показанием к проведению спленэктомии, после разрыва селезенки. После выявления увеличенной селезеночной ткани врач ищет признаки гиперспленизма. Пациенты проходят тщательные исследования под наблюдением терапевта и гематолога. Часто лечение основного заболевания может привести к улучшению ситуации.
Наиболее распространенным доброкачественным гематологическим заболеванием, при котором удаляется селезенка, является иммунная тромбоцитопеническая пурпура. Лапароскопическая спленэктомия также проводится при наследственном сфероцитозе, талассемии со вторичным гиперспленизмом, серповидно-клеточной анемии и рефрактерной аутоиммунной гемолитической анемии.
Основные показания к удалению селезеночной ткани:
При разрыве селезенки часто возникают боли в левой верхней части живота. Нередко пациент теряет большое количество крови, поэтому возникают типичные симптомы кардиогенного шока: бледность, головокружение, спазмы в матке (у женщин), профузная потливость.
Противопоказания
После стандартной операции по удалению селезенки, на теле остается длинный и хорошо заметный шрам
Противопоказаний к проведению традиционной или лапароскопической спленэктомии мало. При выборочной открытой спленэктомии единственными абсолютными противопоказаниями являются некорректируемая коагулопатия и тяжелые сердечно-сосудистые заболевания, которые запрещают введение общих анестетиков.
Хотя были опубликованы сообщения о безопасности лапароскопической спленэктомии у пациентов с циррозом печени и портальной гипертензией, многие считают эти состояния абсолютным противопоказанием.
Возможные осложнения
После спленэктомии пожизненно увеличивается риск развития бактериальных и грибковых инфекций. В первую очередь пациенты страдают от пневмококков, менингококков и гемофильной палочки. У некоторых больных развивается сепсис и другие опасные для жизни последствия в течение нескольких часов после удаления селезенки. Любая лихорадка может быть признаком инфекционного заболевания. В этом случае рекомендуется внутривенное или внутримышечное введение антибиотиков. После спленэктомии пациенту дают антибиотик в таблетках, который рекомендуется принимать при возникновении лихорадки.
Всем пациентам, прошедшим спленэктомию, необходима вакцинация против стрептококковой пневмонии, палочки Пфайффера и менингококков. Также нужно ежегодно вакцинироваться от вируса гриппа. При выборочной спленэктомии вакцинация должна начинаться до запланированной операции.
Удаление селезенки может привести к значительному увеличению количества тромбоцитов в крови. Тромбоцитоз может увеличить вероятность возникновения тромбов (сгустков крови), которые способны закупорить воротную вену.
Чтобы предотвратить тромбоз, назначают антикоагулянт. Поскольку антикоагулянтная терапия может привести к усилению кровотечения, необходимо проконсультироваться с врачом. В первые недели или месяцы используется в профилактической дозе низкомолекулярный гепарин, а затем – ацетилсалициловая кислота.
Постспленэктомический синдром возникает через несколько дней или лет после операции на селезенке. Часто возникает синдром Уотерхауса-Фридериксена. Пациенты должны пожизненно принимать антибиотики, чтобы предотвратить инфекционные заболевания. Отличительными признаками синдрома являются симптомы сепсиса. Заболевание начинается с лихорадки или озноба, сопровождаемого болями в животе. Если антибиотикотерапия начинается слишком поздно, развивается состояние шока. У пациента нарушается сознание и возникают делириозные состояния. Дыхание ускоряется, кровяное давление падает, а частота сердечных сокращений увеличивается.
Без лечения пациент может погибнуть в течение нескольких часов. В организме нарушается процесс свертывания крови и возникает внутреннее кровотечение. Поскольку нарушается кровообращение, органы страдают от дефицита кислорода. В результате постепенно начинают отказывать различные органы. На коже возникают петехии – небольшие точечные кровоизлияния. Как только отказали органы, дальнейшее лечение не принесет пользы. Из-за необратимого повреждения тела пациент впадает в кому и умирает.
Виды и методика проведения
За день до операции анестезиолог объяснит пациенту, как правильно подготовиться.
Как открытая, так и лапароскопическая хирургия практически всегда выполняется под общей анестезией. При спленэктомии пациент теряет мало крови, поэтому только в особых случаях требуется переливание.
Традиционный метод
Спленэктомия длится от 45 минут до 1 часа под общей анестезией
Открытая спленэктомия выполняется под общим наркозом. Доступ к органу проводится через разрез передней брюшной стенки. Разрез зависит от размера селезенки и предпочтения хирурга.
Как правило, в чрезвычайной ситуации предпочтительнее разрез в верхней срединной линии, поскольку он обеспечивает хорошую видимость органов брюшной полости. Вначале хирург выполняет ревизию органов, а затем перерезает кровеносные сосуды, которые снабжают кровью селезенку. На конечном этапе необходимо убрать сам орган.
Лапароскопический метод
Первая спленэктомия была выполнена Адирано Закарелло в 1549 году у молодой женщины со спленомегалией. Пациентка жила 6 лет после удаления селезенки. Традиционно хирургическое удаление осуществлялось открытым путем через разрез либо в верхней срединной линии, либо левой подреберной области. С появлением малоинвазивных методов лапароскопическая спленэктомия стала стандартной процедурой для выборочного удаления селезенки при большинстве показаний.
Пациента ставят в правое боковое положение. Используемый рабочий стол сконструирован таким образом, чтобы тело можно было слегка согнуть на высоте поясничного отдела. Процедура проводится под общей анестезией. Для проведения лапароскопической хирургии используется четыре троакара диаметром от 5 до 12 мм. Из-за правильного бокового положения соседние органы, такие как желудок и толстая кишка, отпадают от селезенки, поэтому область становится хорошо видимой.
После удаления селезенки обычно остается большая полость, в которую вставляют дренажную трубку.
При некоторых опухолях (например, болезнь Ходжкина) целесообразно удалять не только этот орган, но и некоторые лимфатические узлы. Нередко берется образец ткани из печени (биопсия) прямо во время операции. Затем может быть проведено гистологическое исследование, которое поможет определить возможную причину увеличения селезенки.
Цена, где сделать операцию
Средняя стоимость лапароскопической спленэктомии в Москве и Московской области – 70 000 российских рублей. Стоимость открытого хирургического вмешательства варьируется в широких пределах – от 80 000 до 150 000 российских рублей. Перед проведением хирургической процедуры нужно в обязательном порядке проконсультироваться о возможных постоперационных осложнениях.
Восстановление и реабилитация
Если вмешательство прошло без осложнений, то на 4 день после операции пациент покидает хирургическое отделение, полное восстановление происходит в течение 1–1,5 месяцев
Пациент остается в больнице на один день и ночь. Важно контролировать кровяное давление и пульс, а также концентрацию гемоглобина в крови. Удаление селезенки может вызвать анемию вследствие сильной кровопотери во время операции. Если вакцинация не была проведена до операции по полному удалению селезенки, рекомендуется провести ее через 10 дней. Пациенты в этом случае остаются в больнице около недели.
В зависимости от послеоперационного состояния и степени кровопотери пациенты быстро восстанавливаются после спленэктомии. Рекомендуется не заниматься спортом в течение примерно 2-3 недель после операции. При большой лапаротомии следует избегать тяжелых нагрузок в течение 4 недель. Регулярные анализы крови рекомендуется сдавать для контроля успеха лечения.
После спленэктомии, как упоминалось выше, повышается восприимчивость к некоторым бактериальным инфекциям. Основными формами воспаления являются пневмония и менингит. Поэтому пациент должен был быть вакцинирован против этих агентов уже за 2-3 недели до операции. Затем прививки следует повторять через 5 лет.
Диета
После выписки из больницы рекомендуется соблюдать постельный режим не менее 1-2 недель. Пациентам разрешено кушать легкоусвояемую пищу и выполнять умеренные упражнения. С другой стороны, следует избегать напряженной физической работы. Особая диета после полного или частичного удаления селезенки не требуется.
Диета при полном удалении селезенки должна состоять в основном из бобовых, различных видов орехов и красного мяса, поскольку высокое содержание железа и витамина В12 ускоряет гемопоэз – образование клеток крови. Рацион питания после полного удаления селезенки определяется диетологом.
Прогноз
У детей спленэктомию рекомендуется отложить до достижения 12-летнего возраста
После удаления селезенки при регулярной антибиотикопрофилактике продолжительность жизни не уменьшается. Хотя постспленэктомический синдром может предрасполагать пациентов к тромбоэмболическим осложнениям, основная опасность заключается в снижении иммунитета. Врачи стараются при хирургических процедурах сохранить как можно больше селезеночной ткани, однако заболеваемость и смертность от гипоспленизма или аспленизма по-прежнему очень высокая.
У детей спленэктомию рекомендуется отложить до достижения 12 лет. Во время спленэктомии из-за риска травмы хирурги должны работать как можно осторожней с селезеночной тканью. Профилактика против заражения бактериями и вирусами – неотъемлемая часть жизни пациентов. Клинические и экспериментальные исследования показывают, что конъюгированные вакцины более благоприятны, чем традиционные 23-валентные полисахаридные (ППВ-23) у детей младшего возраста, но пока имеется слишком мало данных, чтобы рекомендовать их для общего применения.
Пациенты, их родственники и практикующие врачи должны быть в курсе возможных последствий после удаления селезенки. Немедленная антибактериальная терапия необходима не только детям, но и пациентам с ослабленным иммунитетом. Иммунодефицит может грозить летальным исходом, особенно на фоне инфекции.
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