Splenic injuries

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Splenic injuries

  1. 1. SPLENIC INJURIES DR.M.GUNASEKARAN M.S., S2 UNIT
  2. 2. SPLEEN 2nd most commonly injured solid organ in blunt injury abdomen after liver Situated against 9-11 ribs
  3. 3. SURGICAL ANATOMY Developed from dorsal mesogastrium In children,necessary for both reticuloendothelial and RBC production Pediatric spleen has thicker capsule and tough parenchymal consistency which implies reduced need of operative intervention Adult spleen weight about 100-250g
  4. 4.  Situated posteriorly left upper abdomen Covered by peritoneum except at the hilum Posterior and lateral surface related to left hemidiaphragm and posterolateral lower ribs Lateral surface attached through splenophrenic ligament
  5. 5.  Posteriorly related to left iliopsoas muscle & left adrenal glands Posteriormedial surface related to body & tail of pancreas Antromedially related to great curvature of stomach
  6. 6.  Inferiorly related to distal transverse colon & splenic flexure Lower pole attached to colon through splenicocolic ligament These attachments require devision during mobilisation
  7. 7. BLOOD SUPPLY  Receives blood supply from celiac axis 1.spleenic artery 2.short gastric vessels that connect left gatroepiploic A. & splenic circulation along greater curvature of stomach
  8. 8. BLOOD SUPPLY
  9. 9.  Drains through splenic vein & confluence with inferior mesentric vein Through short gastric veins into left gastro epiploic vein
  10. 10. INITIAL ASSESMENT Importance of history- 1.victims located on the left side of car 2.type & nature of weapon is important in penetrating injuries 3.caliber of the gun
  11. 11. ON EXAMINATION Vitals are most important r/o left lower rib tenderness  14% patients with left lower rib tenderness have splenic injury  In children plasticity of chest will have splenic injury without rib #  Ecchymoses or abration over LUQ
  12. 12. SIGNS Kehr sign-is symptom of pain near tip of left shoulder,bcz of reffered pain from the diaphragmatic irritation P/A-generalised tenderness or LUQ tenderness May present with tachycardia ,Tachypnea, anxiety , Hypotension (shock)
  13. 13. INVESTIGATIONS In unstable patients necesesary investigation is hemoglobin,blood grouping and reservation of blood No specific labaratory studies specific to splenic injuries
  14. 14. PLAIN RADIOGRAPH 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)
  15. 15. DIAGNOSTIC PERITONEAL LAVAGE In the past Mainstay of diagnostic technique for abdominal trauma Peritoneal lavage useful when USG not available 10ml of blood or enteric contents (stool, food, etc.) constitutes a positive DPL,
  16. 16.  Other positive findings include more than 100,000 RBCs/mm3, 500 WBCs/mm3, amylase 175 IU, and detection of bile, bacteria or food fibers. Levels of 10,000 RBCs/mm3 are typically used in cases of penetrating trauma Sensitivity-97-98% for blood Complication rate 1%
  17. 17. FAST (FOCUSED ABDOMINALSONOGRAPHY IN TRAUMA) 1.non invasive procedure 2.quickly asseses viceral injuries,intra/retro peritoneal fluid collections 3.sensitivity varies from 42-93% due to operator dependency 4.specificity 90-98%
  18. 18.  DISADVANTAGES 1.not reliably detect less than 100ml of blood 2.not identify injured hollow viscus 3.cannot reliably exclude in penetrating trauma
  19. 19. CT SCAN IOC ,even for clinically unstable patients Sensitivity-100% Specificity-98% “blush” which is due to ongoing blood loss and extravasation of contrast Pseudo aneurysms
  20. 20.  MRI has also been used,in unstable patients which is less important Radio isotope scintigraphy & angiography are also used Diagnostic laparoscopy
  21. 21. AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA SPLENIC INJURY GRADING SCALE
  22. 22. MANAGEMENT SPLENIC INJURY STABLE UNSTABLE GR 5- GR 1-4- SPLENECTOMY/ STABILISE THE CONSERVATIVE ART PATIENT EMBOLISATION LAPAROTOMY SPLENORRAPH ART Y/SPLENECTOM EMBOLISATION Y
  23. 23. Indications for initialnonoperative management hemodynamic stability absence of peritonitis CT scan  No contrast extravasation  absence of other injuries Transfusions - >2 PRBC’s
  24. 24. CONSERVATIVE Gr 1-4(stable)-hospitalisation -strict bed rest -vitals monitoring -serial USG &CT monitoring -tranfuse blood if necessary Measures taken to find out delayed splenic rupture, (48-72 hrs) in 4% of patients
  25. 25. SPLENORRHAPHY Parenchyma saving surgery of spleen The technique is dictated by the magnitude of the splenic injury Nonbleeding grade I splenic injury may require no further treatment. 1.superficial hemostatic strategies like fibrin glue,gel foam,argon beem coagulation,diathermy,topical thrombin 2.non absorbable suture repair 3.absorbable mesh wrap(poly galactin) 4.resectional debridement
  26. 26. SPLENORRHAPHY
  27. 27. SPLENECTOMY indications -Gr 5 injury -delayed rupture -increasing hematoma -clinically unstable of any grade -actively bleeding Open splenectomy with midline incision prefered
  28. 28. AUTOTRANSPLANTATION implanting multiple 1-mm slices of the spleen in the omentum after splenectomy. This technique remains experimental role controversial
  29. 29. EMBOLISATION Tc99/sulphur colloid labeled contrast angiogram to detect vascular damage Presence of extravasation of contrast in arterial phase (blush sign) Pseudo aneurysm pattern needs transarterial embolisation using polyvinyl alcohol/silicone/acrylic embolic spheres Can be given to reduce blood loss preoperatively
  30. 30. SPLENIC ARTERY EMBOLISATION
  31. 31. POST OPERATIVE COMPLICATIONS INTRAOPERATIVE EARLY POST OP LATE POST OP• haemorrhage • Hematoma/seroma • OPSI• Pancreatic injury • Wound infection • splenosis• Bowel • Subphrenic abscess injury(stomach & • Lung complication colon) • Atelectasis• Diaphragmatic • Pneumonia injury • Pl effusion • Portal vein thrombosis • DVT • Paralytic ileus
  32. 32. OPSI(OVERWHELMING POST SPLENECTOMYINFECTION) A rapidly fatal infection following removal of spleen Incidence-0.23-0.42% per year Occurs 1st few years after splenectomy Common organisms 1.s.pneumonia 2.h.influenza 3.n.meningitis Mortality rate -50-80%
  33. 33.  Mechanism-organism with polysaccharide capsules need OPSONIZATION with IGg3 or C3B which attaches to special macrophages found in the spleen Post splenectomy patients lack of macrophages
  34. 34. SYMPTOMS Starts with flu like symptoms Meningitis or sepsis Rapidly progressive 12-48 hrs
  35. 35. OPSI
  36. 36. MANAGEMENT PREVENTION- pneumococcal vaccine(>2 yrs) administered within 24 – 48 hrs after splenectomy Meningococcal & H.influenza vaccine only in endemic areas Antibiotics- PENICILIN V 125mg bd(<3 yrs),250mg bd(3-14 yrs),500 mg bd (adults)

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