· 20% of splenectomies are 2° iatrogenic damage
· Most common injured organ following blunt trauma
Isolated in 30%
30-60% associated intra-abdominal injury
· 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
· Signs depend on degree of blood loss
· Lower rib #
· Kehrs sign: pain referred to left shoulder
· Hb, WCC, plts
Immobile L diaphragm
Enlarged splenic shadow
Medial displacement gastric shadow / splenic flexure
In unstable patient
American association of surgical trauma
Subcapsular <10 % of surface area
Non-bleeding <1 cm depth
Subcapsular <50 %
Bleeding <3cm depth
Subcapsular >50 %. Expanding ruptured with active bleeding
>5cm or expanding
>3cm involving trabecular vessel
Ruptured intraparenchymal with active bleeding
Involves segmental vessel
>25% splenic devascularization
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.
· 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
· Cardiovascular instability
· Laparotomy for additional organ damage
· Ongoing bleeding
· Failed conservative Rx
Up to 30%
Diseased spleen & trauma
· Can be considered if laparotomy for other cause
· 30-90% splenic injuries suitable
Extensive hilar injuries
Extensive splenic fragmentation
· Critical mass »30%
· 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
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