Splenic TraumaBy Dr Saleem

Overview

• Anatomy

• Presentation

• Management

• Complications

• Follow up

Anatomy

• Spleen lies in posterior portion of lt upper quadrant, deep to ninth ,tenth and eleven ribs

• Convex surface lies under lt hemidiaphargm

• Concavities on medial side due to impression by neighbouring structures

Contd;

• Average length 7-11cm

• Weight 150 grams (70-250)

• Tail of pancreas lies incontact with spleen in 30% and within 1cm in 70%

Suspensory ligaments

• Provide attachement of spleen with adjacent structures

• These ligaments are avascular except gastrosplenic ligament (containing short gastric and gastroepiploic artery)

Arterial Supply

• Splenic artery provides major blood supply

• Arises from coeliac artery (ocassionaly aorta or SMA)

• Tortrous course (average 13 cm)

• Small blood supply from short gastric vessels.

Geographic distribution

• Distributed type

70%,

short trunk , 6-12 long branches

• Magestral

30%

Branches near the hilum

Venous drainage

• Through splenic vein

• Joins superior mesenteric vein to form portal vein

Accessory Spleens

• 20 -30% incidence

• More incidence in haematological diseases

• Found near hilum and vascular pedicle

Mechanism of injury

• Blunt abdominal trauma

from compression or deceleration

(motor vehicle accidents, falls ,direct blow to abdomen,with haematological abnormalities)

• Penetrating trauma rare

Presentation

• Clinical symptoms vary

• Pt may present with lt upper abdominal or flank pain

• Reffered pain to lt shoulder (kehr sign)

• Some may be asymptomatic

Signs

• Physical examination is insensitive and non specific.

• Pt may have signs of lt upper quadrant tenderness or signs of generalized peritoneal irritation.

• May present with tachycardia ,Tachypnea, anxiety , Hypotension (shock)

Management• Operative Vs Non Operative

• Nonoperative management of splenic injury is successful in >90% of children, irrespective of the grade of splenic injury.

• Non operative management successful in adults 65%

Factors for dicision

• Haemodynamic stability on presentation

• Age of patient

• Other associated injuries

• Grade of splenic injury

Basic principles• unstable patients suspected of splenic

injury and intra-abdominal hemorrhage should undergo exploratory laparotomy and splenic repair or removal.

• blunt trauma patient with evidence of hemodynamic instability unresponsive to fluid challenge with no other signs of external hemorrhage should be considered to have a life-threatening solid organ (splenic) injury until proven otherwise.

Imaging

• FAST• Execellent for documenting the

presence or absence of intraabdominal fluid in haemodynamically unstable patients.

• limitations in identifying solid organ injury, especially at lower grades of injury.

FAST

Plain Radiography• The most common finding associated with

splenic injury is left lower rib fracture. Rib fractures signify that adequate force has been transmitted to the LUQ to cause splenic pathology.

• classic triad indicative of acute splenic rupture (ie, left hemidiaphragm elevation, left lower lobe atelectasis, and pleural effusion)

CT Scan Abdomen

• In Haemodynamically stable patients

It is investigation of choice

• sensitivity and specificity are high for detection of splenic trauma. Intravenous contrast material is necessary for complete evaluation

• Table 1. American Association for the Surgery of Trauma—spleen Organ Injury Scale

• Class Description• I Nonexpanding subcapsular hematoma <10% of surface area• Nonbleeding capsular laceration with parenchymal involvement <1 cm deep• II Nonexpanding subcapsular hematoma 10%–50% of surface area• Nonexpanding intraparenchymal hematoma <2 cm in diameter• Bleeding capsular tear or parenchymal laceration 1–3 cm deep without

trabecular vessel• III Expanding subcapsular or intraparenchymal hematoma• Bleeding subcapsular hematoma or subcapsular hematoma >50% of surface

area• Intraparenchymal hematoma >2 cm in diameter• Parenchymal laceration >3 cm deep or involving trabecular vessels• IV Ruptured intraparechymal hematoma with active bleeding• Laceration involving segmental or hilar vessels producing major

devasularization (>25%• splenic volume)• V Completely shattered or avulsed spleen• Hilar laceration that devascularizes entire spleen

Grade 1

Grade 2

Grade 3

Grade 3

Grade 4

Grade 4

Grade 5

Region CT scoring system• Splenic parenchyma

– Intact - 0– Laceration (thin, linear defect) - 1– Fracture (thick, irregular defect) - 2– Shattered - 3

• Splenic capsule– Intact - 0– Perisplenic fluid present - 1

• Abdominal fluid– No fluid - 0– Any fluid except perisplenic - 1

• Pelvic fluid– No fluid - 0– Any pelvic fluid - 1

Interpretation

In adult patients with a total CT score of less than 2.5, nonsurgical treatment was successful in all patients.

angiography

• used more frequently for primary therapeutic management of splenic injuries.

• Angiography is usually performed after CT scanning images are obtained showing an arterial contrast blush or active extravasation

• therapeutic angioembolization of active bleeding sites.

Agents for embolization• Gelfoam

– Soaked in an antibiotic solution– Can be cut in variable size– May result in too distal embolization– Risks for tissue infarction or late abscess formation

• Coils– Have variable size, length, diameter– Precise targeted delivery– Need normal coagulation

• Metal stents– Large-caliber patent artery

Criteria for nonoperative management

• Haemodynamic stability• Negative abdominal scan• Absence of contrast extravasation on CT• Absence of other clear indications for

exploratory laprotomy• Absence of conditions associated with

increased risk of bleeding (Coagalpathy, use of anticoagulants, cardiac failure, )

Surgical treatment

Adult patients with grade I or II injury can often be treated nonoperatively Patients with grade IV or V splenic injuries are often unstable. Grade III splenic injuries (certainly in children, and in selected adults) can be treated nonoperatively based on stability and reliable physical examination.

Failure rate for non operative(Adults)

• grade I, 5%;

• grade 2, 10%;

• grade III, 20%;

• grade IV, 33%;

• and grade V, 75%

Surgery

• operative therapy of choice is splenic conservation where possible to avoid the risk of death from overwhelming postsplenectomy sepsis that can occur after splenectomy for trauma. However, in the presence of multiple injuries or critical instability, splenectomy is more rapid and judicious.

Contd• Exploration is through a long midline

incision. The abdomen is packed and explored. Exsanguinating hemorrhage and gastrointestinal soilage are controlled first

• splenic ligamentous attachments are taken down sharply or bluntly to allow for rotation of the spleen and the vasculature to the center of the abdominal wound and to identify the splenic artery and vein for ligation.

Splenectomy contd;• Once the splenic artery and vein are

identified and controlled by ligation, • The gastrosplenic ligament with the short

gastric vessels is divided and ligated near the spleen to avoid injury or late necrosis of the gastric wall.

• Drains are typically unnecessary unless concern exists over injury to the tail of the pancreas during operation.

splenorrahphy

• Parenchyma saving operation of spleen

• The technique is dictated by the magnitude of the splenic injury

• Nonbleeding grade I splenic injury may require no further treatment. Topical hemostatic agents, an argon beam coagulator, or electrocautery

Contd;

• In grade 2 and 3 suture repair (horizontal mattress) , or mesh wrap of capsular defects. Suture repair in adults often requires Teflon pledgets to avoid tearing of the splenic capsule

Partial Splenectomy

• Grade IV to V splenic injury may require anatomic resection, including ligation of the lobar artery.

autotransplantation

• implanting multiple 1-mm slices of the spleen in the omentum after splenectomy.

• This technique remains experimental

role controversial

Post op care• Recurrent bleeding in the case of

splenorrhaphy or new bleeding from missed or inadequately ligated vascular structures should be considered in the first 24-48 hours.

• Immunizations against Pneumococcus species as a routine of postoperative management.(24 hours -2 weeks)

• Some centers also routinely vaccinate for Haemophilus and Meningococcus species

Complications• Early

Bleeding Acute gastric distention Gastric necrosis Recurrent splenic bed

bleeding Pancreatits

Subpherinic abscess

Late complications

Thrombocytosis OPSI (1 – 6 Week) DVT

DVT after splenectomy• Splenectomy thrombocytosis ( platelets)• increases risk of DVT • Portal vein thrombosis

– Abd pain, anorexia, thrombocytosis– CT with IV contrast

• Prevention of DVT– Sequential compression devises on legs– Subcutaneous heparin

Over whelming post splenectomy infection (OPSI)

• 3% of splenectomy patients Higher mortality in children (especially

thalassemia and SS) Decreased since use of pneumococcal

vaccine• Pneumonia or meningitis in half the cases• Very rapid onset of symptoms and signs

– More than half die within 2 days of admission

Contd;

• Within 2 years of splenectomy, especially children

– Single daily dose of penicllin or amoxicillin for 2 yrs

Follow up

• revaccination with pneumococcal vaccine after 4-5 years one time only.

• Patients should be warned about the increased risk of postsplenectomy sepsis and should consider lifelong antibiotic prophylaxis for invasive medical procedures and dental work.

• Wear MedicAlert bracelet or necklace

• Notify their doctor immediately of any acute febrile illness

• Seek prompt treatment even after minor dog bite or other animal bite.

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