Splenic Trauma

Principles and Management

Don't forget to mention vaccinations.

Grading of Injury (AAST)

I = Haematoma; subcapsular <10% surface area
  = Laceration; capsular tear <1cm deep

II = Haematoma; subcapsular tear 10-50% area; intraparenchymal, <5cm diameter
    = Laceration; capsular tear 1-3cm, does not involve a trabecular vessel

III = Haematoma; Subcapsular >50cm area or expanding, ruptured haematoma, or intraparenchmal >5cm or expanding
      = Laceration; Parenchymal depth >3cm or involving trabecular vessels.

IV = Laceration involving segmental or hilar vessels, >25% of spleen devascularized

V  = Completely shattered spleen; or hilar vascular injury with devascularized spleen


Non-Operative Management

Prevents unnecessary laparotomies and complications of splenectomy
- including preservation of splenic funciton.
Success rates of 90% now reported with conservative management.

Patient Selection
Refer algorithm.

1. Haemodynamic status is paramount
Compromised
--> Laparotomy
Not compromised
Conservative management appropriate
--> IF: SBP<90 or HR>120 --> laparotomy
--> IF Hb drop <40% in 12h and with no haemodynamic changes --> Consider angioembolization.

2. CT scan with IV contrast
Grade of injury.
Does not preclude conservative management but does correlate with failure of conservative management
- grade IV and V have a 50-75% failure rate
- large degree of haemoperitoneum also correlates.

3. Contraindications:
- haemodynamic instability
- peritonitis
- intraperitoneal or retroperitoneal organs requiring operation.
- need for anticoagulation or a coagulopathy that cannot be corrected
- i.e. typically polytrauma with extensive intra-abdominal injuries.
- lengthy operations and inability to assess course non-operatively

4. Children
- multiple transfusions should be approached with caution.
- transfusion is an independent risk factor for infection.

5. Predictors of failure
- grade of injury (but this is not a contraindication)
- admission instability
- requirement for transfusion
- age >55y
- concomitant injuries

6. Role of angioembolization
- decreases failure rate of conservative management, for all grades of injury
- when selective, controls for bleeding and splenic salvage can be>80%
- some say grade 3+ or presence of blush should indicated angiography.
- in addition to criteria given above.
- can be done proximally or distally or both; proximal embolization decreases pressure in spleen, allowing intrinsic haemostasis

7. Monitoring
- HDU; if no change in Hb or haemodynamics for 24h then can step down.
- monitor 24-72h
- higher grade injuries should be kept for up to 7d to allow time for failures to declare; majority declare in 1w
- dvt prophylaxis contraindicated initially, but then guided by common sense; TEDs etc.

8. Follow up and mobilization
- Avoid contact sports for 2-4 months (animal models of splenic healing show capsule strength takes >8weeks)
- Interval CT for high-grade lesions (III+) can ssist; e.g. large focal haematomas.

9. Failure of conservative management
- Usually within 4d
- Occasionally an injured vessel was in spasm on original imaging.
- Haemodynamic instability warrants surgery.  Else Interventional angiography.

10. Complications of conservative management
- asplenia, impaired immunity, opsi
- contrast-induced nephropathy
- splenic abscesses

11. Vaccination
- Ideally given in the presence of functional splenic tissue, so imperfect here.
- Else administer day prior to discharge to ensure they were received.
- Aggressive arterial embolization of spleen results compromises splenic immunity; if in doubt, immunize

12. Example flow
image



Operative Management

1. Example Flow
image

2. Principles
- durable haemostasis
- salvage if possible

3. Low grade
- often there are multiple injuries; usually don't operate on just grade I and II lesions
- short period of packing, argon bean and surgicel can be effective
- fibrillar and nunit packing helpful.

4. Notes on Complex Salvage Maneuvres (Splenorraphy)
- not commonly done but is worth consideration.
- may need to carefully mobilize spleen to manipulate it.
- suture of splenic capsule requires pledgets (horizontal mattress through surgicel)

image

5. Severe stellate injuries
- some use mesh-wrap techniques to compress splenic tissue and capsule back together, aided by purse-string sutures.
- obviously not appropriate in damage control, and unlikely to be something trainees will have experience in.

Jerome's Notes

Splenic trauma

Epidemiology

· 20% of splenectomies are 2° iatrogenic damage

· Most common injured organ following blunt trauma

— Isolated in 30%

Aetiology

· Accidental

— Blunt

30-60% associated intra-abdominal injury

— Penetrating

· Iatrogenic

· Delayed rupture – occurs in less than 1% of patients with splenic injury

— 50% within 1/52

— 75% within 2/52

— Can occur ³ 4/52

· Spontaneous rupture

— Usually 2° to trivial injury

— Most commonly as complication of diseased spleen

            Malaria

            Infectious mononucleosis

Clinical

· Signs depend on degree of blood loss

· Lower rib #

· Kehr’s sign: pain referred to left shoulder

Ix

· Hb, WCC, plts

· AXR

— Immobile L diaphragm

— Enlarged splenic shadow

— Medial displacement gastric shadow / splenic flexure

· CT

— Gold standard

· DPL

— In unstable patient

Staging

American association of surgical trauma

Grade

Subcapuslar Haematoma

 

Intraparenchymal haematoma

Parenchymal

Laceration

Vascular Injury

I

Subcapsular <10 % of surface area

 

 

Non-bleeding <1 cm depth

 

 

II

Subcapsular <50 %

 

<5cm

Bleeding <3cm depth

 

III

Subcapsular >50 %. Expanding ruptured with active bleeding

 

>5cm or expanding

>3cm involving trabecular vessel

 

IV

 

Ruptured intraparenchymal with active bleeding

Involves segmental vessel

>25% splenic devascularization

V

 

 

 

Shattered

Hilar avulsion or complete splenic devascularization

 

v Advance 1 stage for multiple injuries up to grade III

· Patients who are unstable require laparotomy

· The garding system is based on CT findings.

· Grade I-III injuries can frequently (95%) be managed non-opertaively.

· Grade IV injuries often require operative intervention

· Grade V injuries require immediate surgery

Which patients can be managed by embolization

· Haemodynamically stable but requiring transfusion for active bleeding.

· Here embolization can be used if the bleeding vessel can be seen on angio.

Which patients should be managed by surgery?

· Haemodynamically unstable

· Persistent coagulopathy despite attempted correction

· Having laparotomy for other reason.

What are the indications for failure of non-operative Mx

Haemodynamically unstable, worsening pain, persisting bleeding (requiring Tx), Progressive injury on CT.

Mx

· ABCDE

· Resus

Conservative

· CT scan

· Close monitoring

— HDU for first 48 hours

· Daily Hb

· Restrict activity for 4-6/52

· Avoid contact sports 6/12

· Weekly scan to monitor resolution

Surgery

Indications

· Cardiovascular instability

· Laparotomy for additional organ damage

· Ongoing bleeding

· Failed conservative Rx

— Up to 30%

Splenectomy

· Indications

— Concurrent injury

— Unstable patient

— Irreparable injury

— Diseased spleen & trauma

Splenorrhaphy

· Can be considered if laparotomy for other cause

· 30-90% splenic injuries suitable

· Contraindications

— Extensive hilar injuries

— Extensive splenic fragmentation

— Avulsion

— Peritoneal contamination

— Diseased spleen

· Critical mass »30%

Operative

· Temporary haemorrhage control: packing and compression

· Completely mobilize the spleen – can do this with blunt dissection by dividing the splenorenal and splenophrenic to bring the spleen and tail of pancreas to midline. · Vascular control of the splenic hilum with fingers or a soft bowel clamp.

· Assess whether to repair or remove.

· In favor of removal: heavy trauma burden, significant blood loss, older age of the patient, lack of experience of splenic preservation.

· To remove the spleen, clamp and ligate the splenic vessels from posterior.

· Stay close to spleen to avoid tail of pancreas.

· The gastrosplenic vessels are then ligated. Stay close to splenic hilum to avoid the stomach wall.

· Divide the spleen. Inspect for bleeding

Splenic preservation – local pressure and topical haemostatic with argon beam coagulation for capsular tear.

· Capsular suture using straight PDS suture and Teflon bolster

· Passing a TA90 with 4.8mm staples across the injured area and slowly closing the stapler.

· If one attempt at splenic repair fails then remove the spleen.

Complications post spleenectomy

Immediate: Bleeding

Early: Subphrenic abscess, left basal pneumonia, post splenectomy thrombocytosis, pancreatic fistula, gastroparesis.

Late: Post spleenectomy sepsis – give pneumococcal, meningococcal, HiB and influenza vaccines 2 weeks after spleenectomy. The risk is greatest in children who should receive prophylactic penicillin. Adults should be given advice about infection signs and give Abx to take after the earliest sign of infection