In this presentation, I discussed splenic injury- including the mechanism of injury, clinical features, grading, and how to diagnose and treat them.

1. SPLENIC
RUPTURE
DR.B.SELVARAJ MS;Mch;FICS;
‘Surgical Educator’
MALAYSIA
BLUNT ABDOMINAL
TRAUMA

2. SPLENIC RUPTURE
• Etiology
• Pathology
• Clinical features
• Workup/Investigations
• Differential diagnosis
• Splenic CT injury grading
• Treatment
• Complications- OPSI
• Treatment algorithm for Splenic injury
LEARNING OBJECTIVES

3. SPLENIC RUPTURE
• H/O Blunt abdominal or lower thoracic trauma
• Penetrating trauma to Left Hypochondrium
• Iatrogenic
• Spontaneous rupture
- Malaria
- Leukemia
- Infectious mononucleosis
ETIOLOGY
• Injury types
• Laceration
• Hilar injury
• Subcapsular hematoma
• Injury associated with other organ
injuries
• Mechanism of injury
• Crushing
• Deceleration
• Sudden increase in intra abdominal
pressure

4. SPLENIC RUPTURE
• Classically associated with left lower ribs fracture
• Delayed rupture is a characteristic feature in
Subcapsular hematoma
• A ruptured spleen can cause life-threatening
bleeding into the abdominal cavity.
PATHOLOGY

5. SPLENIC RUPTURE
• H/O Trauma
• Pain abdomen
• Occasional distension and vomiting
• In severe bleeding associated with shock, syncope or
dizziness
• Kher’s sign Pain over left shoulder joint
• Fixed dullness to percussion on the left, and shifting
dullness on the right (Ballance’s sign).
• Tenderness all over the abdomen with or without
guarding and rigidity
• Bowel sounds are absent
CLINICAL FEATURES

6. SPLENIC RUPTURE
• Other causes for hemoperitoneum
• Liver injury
• Ruptured ectopic pregnancy
• Ruptured abdominal aortic aneurysm
• Acute hemorrhagic pancreatitis
DIFFERENTIAL DIAGNOSIS

7. SPLENIC RUPTURE
INVESTIGATIONS

8. SPLENIC RUPTURE
INVESTIGATIONS- CECT
 CT is the procedure of choice for diagnosis and
estimation of the degree of splenic injury in the
hemodynamically normal patient.
 Contrast blush (intraparenchymal hyperdense
contrast collection)suggests active hemorrhage and
is associated with failure of nonoperative
management in all solid organ injuries.

9. SPLENIC RUPTURE
INVESTIGATIONS
SELECTIVE CELIAC ARTERIOGRAPHY
 Angiography may be
used in patients
demonstrating a
contrast blush on CT
scan to identify and
treat a vascular
abnormality

10. SPLENIC RUPTURE
INVESTIGATIONS DPA/DPL

11. SPLENIC RUPTURE
AAST – CT GRADING

12. SPLENIC RUPTURE
TREATMENT
Nonoperative management
 Requires ICU monitoring in a dedicated
trauma center and immediate ability to
convert to operative management should
that become necessary
Indications
 Hemodynamic stability
 Minimal evidence of blood loss, < 2 units
packed red blood cells as transfusion
requirement
 Absence of active contrast extravasation on
CT scan
 Absence of other indication for laparotomy
 Length of intensive care unit (ICU) monitoring is generally
24 to 48 hours initially, with serial hematocrit evaluation
and continuous hemodynamic monitoring
 Blood transfusion is limited to 2 units of packed red blood
cells. If the patient has an ongoing transfusion
requirement of more than 2 units, operative management
should be performed
 The majority of pediatric splenic trauma is successfully
managed nonoperatively.
 Recovery recommendations include restricted activity in
terms of contact sports, running, or similar stresses for 3
months following injury.
 Angiography is performed in patients who are
hemodynamically normal and have a blush on initial CT
scan.

13. SPLENIC RUPTURE
TREATMENT
Operative management
 Should be performed in those patients
demonstrating peritonitis or
hemodynamic instability, those failing
nonoperative therapy, and those with
gunshot wounds to the abdomen
 Splenectomy is indicated with
significant blood loss (>1000 mL),
significant associated injuries, hilar
involvement, coagulopathy, or massive
splenic disruption
 Splenic salvage includes splenorrhaphy
and partial splenectomy
 Splenorrhaphy can be performed with
absorbable mesh (Dexon)
 Other strategies include the use of topical hemostatic
agents, including Surgicel, Avitene, and topical thrombin,
as well as the application of mattress sutures to allow
tamponade of hemorrhage.
 Partial splenectomy may be performed for polar injuries. At
least 30% of the spleen must be preserved to maintain
function.

14. SPLENIC RUPTURE
TREATMENT
Operative management
 In stable patient without
fecal contamination
- Splenic replantation
- 15 slices of spleen
implanted in greater
omentum in three rows
Triple decker omental
sandwich

15. SPLENIC RUPTURE
COMPLICATIONS
 Atelectasis which should be treated with
aggressive pulmonary toileting
 Delayed bleeding in subcapsular hematoma
 Subpherenic abscess
 Pancreatic injury resulting Pancreatic fistula
 Thrombocytosis if platelets are > 10,00,000
 OPSI- Overwhelming Post Splenectomy
Infection

16. SPLENIC RUPTURE
OPSI
 Syndrome consists of rapid development of
severe sepsis with hypotension, disseminated
intravascular coagulation, respiratory distress,
and coma within hours of presentation
 Incidence. This is a rare complication of
splenectomy. 50% to 70% of OPSI occurs less
than 2 years after splenectomy.
 Mortaltiy is 50% to 70% for patients
presenting with full-blown OPSI
 Organisms. S. pneumoniae is responsible for
50% to 90% of infections. Others include N.
meningitides, H. influenzae
 Treatment. Aggressive empiric antibiotic therapy
should be initiated awaiting pan-
culture/sensitivities.
 Prophylaxis. Presplenectomy immunization (2 weeks
before splenectomy) is optimal but most often
impossible for traumatic splenectomy.
 Immunization for Pneumococcus, Meningococcus,
and H. influenzae type B should be administered
prior to discharge Pneumovax. Pneumococcal
booster should be considered every 5 to 6 years for
high-risk patients.

17. SPLENIC RUPTURE

18. HAND-WRITTEN MINDMAP