Splenic Trauma By Dr Saleem

Overview Anatomy Presentation Management Complications Follow up

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

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%

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)

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.

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

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

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

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

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

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)

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%

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

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.

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

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)

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

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

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

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.

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.

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

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, )

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.

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%

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.

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.

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.

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

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

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.

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

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

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

Early  Bleeding  Acute gastric distention  Gastric necrosis  Recurrent splenic bed bleeding  Pancreatits  Subpherinic abscess

Late complications  Thrombocytosis  OPSI (1 – 6 Week)  DVT

 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

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

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

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.

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.

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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