MRCS Part B (OSCE) - Online Resources

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The pancreas is an accessory digestive gland with both exocrine and endocrine functions:

• Exocrine: Secretions from the pancreatic acinar cells pass through the pancreatic ducts into the duodenum.
• Endocrine: Glucagon and insulin are produced by the islets of Langerhans in the pancreas.

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• The pancreas receives a rich blood supply from the coeliac trunk and the superior mesenteric artery.
• The splenic artery, a branch of the coeliac trunk runs along the superior margin of the pancreas and supplies the neck, body and tail through its pancreatic branches.
• The superior pancreaticoduodenal artery (a branch of the gastroduodenal artery from the common hepatic artery) and the inferior pancreaticoduodenal artery (a branch of the superior mesenteric artery) supplies the head of the pancreas at its border with the duodenum.

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The posterior relations of the head of the pancreas include the:

• IVC
• Renal veins
• Right renal artery
• Bile duct lies on its posterosuperior surface

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The posterior relations of the body of the pancreas include:

• Aorta
• Superior mesenteric artery
• Left kidney, renal vessels and suprarenal gland

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 The posterior relations of the tail of the pancreas include:

• Left kidney
• Splenic hilum
• Left colic (splenic) flexure.

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"The ampulla of Vater (hepaticopancreatic ampulla) is formed by the convergence of the bile duct and main pancreatic duct. It empties via the major duodenal papilla into the second part of the duodenum which anatomically marks the transition from the embryological foregut to the midgut. "

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The relations of the spleen are

Anterior     :       Stomach.

Medial         :       Left kidney.

Inferior       :       Left colic flexure.

Posterior    :       Left part of the diaphragm which, with the costodiaphragmatic                                recess, separates it from the pleura, lung and left 9^th to 11^th ribs.

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The spleen lies in the upper left quadrant of the peritoneal cavity, covered with peritoneum except where it reflects at the hilum.

 

The spleen has four ligaments:

• Gastrosplenic ligament :  Passes from the splenic hilum to the greater                                                  curvature of the stomach, contains short gastric                                             and left gastroepiploic vessels.
• Splenorenal ligament :  Passes from the splenic hilum to the left kidney,                                              contains the splenic vessels.
• Splenocolic ligament : Between the spleen and transverse colon is the                                              remainder of the left edge of the transverse                                                    mesocolon.
• Splenophrenic ligament : Is an extension of the splenorenal ligament to the                                            diaphragm.

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" The splenic artery takes a markedly tortuous course. It arises from the coeliac trunk, passes posterior to the omental bursa, along the superior edge of the pancreas and anterior to the left kidney before dividing into five or more branches within the splenorenal ligament and entering the hilum. "

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The American Association for the Surgery of Trauma (AAST)* has produced an anatomic injury grading of splenic injury based on findings at CT. Haematoma and lacerations are evaluated and a grading is assigned from Grade I (<10% subcapsular haematoma or capsular tear <1 cm) to Grade V (completely shattered spleen).

 

*American Association for the Surgery of Trauma. Injury Scoring Scale: A Resource for Trauma Care Professionals. 2017.

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 An isolated AAST Grade I or II splenic injury may be suitable for conservative management.
 AAST Grades III-V:
 If haemodynamically stable with signs of bleeding (dropping serial haemoglobin), consider radiological intervention +/- surgery.
 If haemodynamically unstable, early resuscitation and emergency surgery (splenectomy may be necessary).

 Following splenectomy, patients require vaccination against pneumococcus, Haemophilus influenza type B and meningococcus, with relevant subsequent boosters. Ideally, in elective splenectomy, vaccinations should be given at
least 2 weeks pre-operatively and in emergency splenectomy following trauma, the vaccinations should be given 2 weeks post-operatively.
 Children require antibiotic prophylaxis (usually with Penicillin V or Erythromycin for penicillin allergy) until the age of 15 years. Adults require antibiotic prophylaxis for at least 2 years post splenectomy, and for life if they have other risk factors, e.g., immunosuppression.
 They may also require antibiotic cover at the onset of any febrile illness and to have particular awareness of infectious diseases when travelling abroad. Patients also need to have the risks fully explained and be given an alert card to carry with them