splenic injuries

1. SPLENIC INJURIES
PRESENTER: DR MANJUNATHA S B
MODERATOR: DR BHARATH J

2. Contents
Introduction
Epidemiology
Anatomy & Physiology
Evaluation
Management
Surgical procedures
Guidelines
Conclusion
References

3. History :
• Hippocrates in the fourth century bc was one of the
first to write on the spleen. He taught broadly on the
need for balance and equilibrium between the
patient and his environment.
• The great ancient Roman physician, surgeon and
philosopher Claudius Galen (129-216 AD) described
the spleen as “Plenum mysterii organum” or “the
organ full of mystery” as he struggled to elucidate its
function.
• In modern English, "to vent one's spleen" means to
vent one's anger, e.g. by shouting (BAD TEMPER)

4. • In 1893, Reigner published the first documented
successful splenectomy in the German literature.
• Operative mortality rates remained high until the
1950s
• Non operative care during this period was
predominantly fatal.
• With the widespread availability of computed
tomography surgeons began to focus on those
needing surgery and those who could be observed
safely.

5. Anatomy:
• Ovoid/wedge, usually purplish, pulpy mass
• Largest lymphoid organ, part of lymphoreticular system
• About size and shape of one’s fist
• Most vulnerable abdominal organ for traumatic injury
• Located in left upper quadrant or LHC
• Protected by lower thoracic cage
• Completely encircled and covered with peritoneum except
at hilum

6. 1×3×5×7×9×11 rule
• Size
1 inch thickness
3 inch wide
5 inch long
• Weight
7 ounce= 200gm.
• Related ribs
9-11 (along long axis of 10th rib)

7. ANTERIOR:
Stomach
POSTERIOR:
Left diaphragm
Lung
Costodiaphragmatic
recess
9-11 ribs
INFERIOR:
Left colic flexure
MEDIAL:
Left kidney and pancreas

9. Blood supply

11. • LIGAMENTS:
• Gastrosplenic Short gastric
vessels and left gastro-omental
vessels
• Splenorenal (lienorenal)
splenic vessels and tail of
pancreas
• Splenocolic in contact with
lower pole of spleen; at danger
during spleenectomy

13. • BORDERS:
• Superior(notched) border
• Inferior border
• Anterior border
• ENDS:
• Posterior end
• Anterior end
• SURFACES:
• Diaphragmatic
• Visceral

14. Anatomical variations:
Accessory Spleens: splenenculi
• MC congenital anomaly
• 20 -30% incidence
• More incidence in
haematological diseases
• Found near hilum >80%, and
vascular pedicle

15. Locations in decreasing order:
• Hilum 80%
• Gastrocolic ligament
• Tail of pancreas
• Greater omentum
• Greater curvature of
stomach
• Splenocolic ligament
• Mesentry
• Lt spermatic cord/ broad
lig

16. Heterotaxy Syndromes:
• Disturbance in the usual right left distribution of thoracic
and abdominal organs.
• Occurs from early embryological developmental
disturbance.
• 2 types
• Right isomerism – Presents as CHD
• Left isomerism – Intestinal malrotation / Mid gut volvulus

17. Asplenia syndrome:
• Situs ambiguus with asplenia or
Ivemark syndrome is
characterized by an absent
spleen and duplication of right-
sided structures.
• Affecting males twice as
commonly as females.

18. Polysplenia syndrome:
• Multiple small spleens.
Also referred to as
situs ambiguus with
left isomerism.
• Equally in males and
females.

19. Physiology:
• Filter of Reticulo endothelial system.
• Humoral immunity, producing Ig M, Opsonins,
tufstin and properidin.
• Activation of complement system.
• Source of extramedullary hematopoiesis.

20. Splenic injury:
• Splenic injury most commonly occurs following blunt
trauma due to motor vehicle collisions
• Penetrating splenic trauma is less common than
blunt injury
• Iatrogenic traumatic injuries to the spleen can result
from surgical or endoscopic manipulation colon,
stomach, pancreas, Kidney.
• Primary mechanism is capsular tear, laceration from
retraction devices, or tension on the spleen during
manipulation of the colon

21. • Importance of history- victims located on the left
side of car
• Type & nature of weapon is important in penetrating
injuries
• Caliber of the gun

22. • Blunt Trauma: Rapid deceleration(MVA)
Direct blows to the abdomen(domestic violence, or leisure and play
activities such as bicycling)
• Penetrating Trauma
• Combination of above
explosive type injuries
warfare and civilian bombing
• Iatrogenic: Post procedure.
• Spontaneous Rupture: Malaria, IMN

23. Types of Injury:
• Splenic Hematoma
Subcapsular
Intraparenchymal
• Lacerated wound
• Clean incised wound
• Hilar/vascualr injuries

24. Associated Injuries:
• Fracture Left lower ribs (30 %)
• Left sided hemothorax
• Left lung and diaphragm injury
• Left lobe liver injury
• Tail of pancreas injury
• Left kidney
• Left colonic injury
• Small bowel injury

25. Presentation
• Pain abdomen
• Shock
• Pain in lower part of chest on left side
• Abdominal distension
• Wound in left upper quadrent
• Symptoms of associated injuries

26. Examination :
• Tachycardia
• Feeble pulse
• Hypotension
• Tachypnea
• Anemia

27. Examination: Per Abdomen
• External bruise may be seen in LHC
• Abdominal distension
• Contusions
• Decreased movement of LHC region
• Tenderness in LHC or all over abdomen

28. Signs:
• Kehr’s sign: Hans Kher, Germany
• Clot collected under left diaphragm irritates it
and the phrenic nerve( C3, C4) causing referred
pain in left shoulder 15 minutes after foot end
elevation
• Because the supraclavicular nerves have the
same cervical nerves origin as the phrenic
nerve, C3 and C4

29. Signs:
• Seat belt sign : Abdominal wall contusion or
hematoma.

30. SIGNS:
• BALLANCE SIGN: Charles
Alfred Ballance,UK
• Persistent dullness to
percussion in the left flank due
to coagulated blood
• shifting dullness to percussion
in the right flank due to fluid
blood

31. Evaluation:
• Clinical signs.
• Hematology
• Radiology
• Prepare the team for surgery
• Reserve ICU bed

32. Investigations: USG
• FAST.
• Look for position of spleen, hematoma,
lacerration, hilar structures, vascualarity,
hemoperitoneum.
• Associated injuries to stomach, colon, Lt
Kidney, Pancreas, Lt lobe of Liver, lower
segments of Lung,

34. USG: Hematoma and Rupture

35. CECT Abdomen:
• Hemoperitoneum – Localized fluid collections around the
spleen (especially those with an elevated HU
measurement) are highly suggestive of hemoperitoneum.
• Briskly bleeding splenic lacerations may establish blood
density fluid throughout the abdomen.
• Hypodensity – Hypodense regions represent areas of
parenchymal disruption, intraparenchymal hematoma or
subcapsular hematoma.
• Contrast blush or extravasation – Contrast blush describes
hyperdense areas within the splenic parenchyma that
represent traumatic disruption or pseudoaneurysm of the
splenic vasculature. Active extravasation of contrast implies
ongoing bleeding and the need for urgent intervention

36. AAST Grading:

38. AAST 1

39. AAST 2

40. AAST 3

41. AAST 4

42. AAST 5

43. Management
Non-operative management of splenic injury (NOMSI)
• Conservative
• Interventional radiology: Splenic artery angio
embolization
Operative management
• Splenorraphy: procedure to preserve spleen done in
past, now replaced by NOMSI
• Splenectomy

45. The standard criteria for NOM are:
• Hemodynamic stability/ readily stabilizable
• Lack of rebound and guarding
• Blood transfusions ≤ 4 units
• No lack of consciousness;
• Age <55 yrs.

46. NOMSI:
• Lower hospital cost
• Earlier discharge
• Avoiding nontherapeutic celiotomies (and
their associated cost and morbidity),
• Fewer intra-abdominal complications, and
• Reduced transfusion rates

47. • The only absolute indication for emergency
laparotomy is hemodynamic instability
• Complex/severe splenic injuries, age, preexistent
splenic diseases, number of units of transfused
blood, brain injuries are no longer considered
absolute contraindications for NOM

48. Splenic artery angioembolization:
• Adjunct to NOM of high grade injuries
1. Proximal splenic artery embolization: Distal
to dorsal pancreatic artery.
2. Distal selective embolization: High failure
rate.
Indicated in pts with evidence of active
extravasation of dye or pseudo aneurysm

49. Unsuccessful NOM: Occurs in
• Hemodynamic instability (systolic BP < 90 mmHg
despite adequate resuscitation)
• Age > 55 years old
• > 4 units of transfused blood to maintain a Hblevel
over > 10 g/dl
• Persistent leucocytosis
• The onset or aggravating sings of peritoneal
irritation
• Worsening imaging signs of splenic injury (repeated
US exams)-post-traumatic splenic defect
• Intra-abdominal compartment syndrome
(intravesical pressure > 20 cm H2O).

50. Splenorrhaphy:
• Parenchyma saving surgery of spleen
• The technique is dictated by the magnitude of
the splenic injury
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

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

56. Total Splenectomy: Open
Position: Supine
GA
Inciscion: midline, Left
subcostal.
In large spleens and
trauma of other organs
full midline laparotomy
inciscions.

57. • Incision deepened to access the peritoneal cavity.
• Pack the 4 quadrant of the peritoneal cavity
• Suck out all free blood and clot
• Remove packs starting from least area of bleeding.
• Use your fingers to temporarily secure hemostasis at
the hilum(to prevent clamping of the tail of pancreas)
• Place the left hand on the spleen and draw it down to
divide the lieno renal ligament lying posteriorly
• Deliver the spleen into the abdominal incision
• Then a non-crushing clamp is applied at the hilum
safeguarding the pancreas
• Examine the spleen for grade of injury
• Ligate and divide; the short gastric arteries, left
gastroepiploic arteries. Slightly away from the stomach
with non absorbable suture

58. Approaches:

59. Ligation of the Splenic Pedicle:Anterior Approach
• Clamp, incise, and ligate the left part of the
gastrocolic ligament and the gastroepiploic
artery and vein.
• Locate the splenic artery at the superior
border of the body of the pancreas. Carefully
ligate the artery in continuity and doubly, with
ligatures being placed as distally as possible

61. Ligation of the Splenic Pedicle:
Posterior Approach
• Hold the spleen medially.
• Divide the splenorenal, splenophrenic, and
splenocolic ligaments
• Lift the spleen outside the peritoneal cavity,
• being particularly careful with the tail of the
pancreas.
• Dissect rapidly and mobilize the bleeding
spleen immediately.

62. • Bleeding can be controlled by manually
compressing the splenic artery and vein and the
tail of the pancreas between the thumb and
index finger or with a non crushing clamp
• Ligate the arterial and venous branches close to
the hilum using 2–0 and 3–0 ligatures. Doubly
ligate the splenic artery
• Ligate the short gastric vessels.
• Remove the spleen and secure any bleeding
points.
• Close the abdominal wall.

65. Complications:
INTRAOPERATIVE
• Haemorrhage
• Pancreatic injury
• Bowel injury(stomach & colon)
• Diaphragmatic injury

66. Complications
EARLY POST OP
• Hematoma/seroma
• Wound infection
• Subphrenic abscess
• Atelectasis
• Pneumonia
• Pleural effusion
• Portal vein thrombosis
• DVT
• Paralytic ileus

67. Complications
LATE
• OPSI
• splenosis

68. OPSI
• A rapidly fatal infection following removal of spleen
• Incidence: 0.23-0.42% per year
• Most Occur 1st 2 years after splenectomy
• Lifetime risk <1-5%,
• Common organisms
• 1.S.pneumonia-50-90%
• 2.H.influenza
• 3.N.meningitis
• Mortality rate : 50-80%

69. • 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
• Starts with flu like symptoms, Meningitis or
sepsis
• Rapidly progressive 12-48 hrs

70. • Other organisms include: streptococcus
species, salmonella, Capnocytophaga
canimorous, Babesiosis.
High risk:
• children<5yrs old/>50 yrs,
• Splenectomy for Haemoglobiniopathies
[Thalasemeia, sickle cell a], Myelodysplasia,
malignancies.

71. Prevention:
Immunoprophylaxis:
• Vaccines aganst Strepto Pneumoniae [PPV23], H.Infl [H
influenza type B], Meningococcus
• Elective: At least 2 wks prior
• Emergency: PPV 23 immediate post op & Other two 2 wks
after surgery.
• [All 3 delayed for at least 2wks; because transient immune
suppression post op]
Antibody titre:
• No correlation between ab titre & clinical immunity
• Only in about 50% cases protective levels abs formed against
pneumococci
• Revaccination: CDC [united statescommunicable disese
control & prevention] to be revaccinated ppv 232-6 yrs after
splencetomy.

72. Antibiotic prophylaxis:
• Children: Until 5 yrs of age or at least 5 yrs
after surgery
• Penicillin, Amox, amoxyclav
• Adults: scanty evidence. Provided with
antibiotics to be taken at the sign of infection.

73. Prevention

74. EAST Guidelines:
• Level 1
Patients who have diffuse peritonitis or who
are hemodynamically unstable after blunt
abdominal trauma should be taken urgently
for laparotomy.

75. EAST Guidelines:
• Level 2
1. A routine laparotomy is not indicated in the
hemodynamically stable patient without peritonitis
presenting with an isolated splenic injury.
2. The severity of splenic injury (as suggested by CT grade
or degree of hemoperitoneum), neurologic status, age
>55 and/or the presence of associated injuries are not
contraindications to a trial of nonoperative
management in a hemodynamically stable patient.
3. In the hemodynamically normal blunt abdominal
trauma patient without peritonitis, an abdominal CT
scan with intravenous contrast should be performed to
identify and assess the severity of injury to the spleen.

76. EAST Guidelines:
4. Angiography should be considered for patients
with AAST grade of greater than III injuries,
presence of a contrast blush, moderate
hemoperitoneum, or evidence of ongoing splenic
bleeding.
5. Non operative management of splenic injuries
should only be considered in an environment that
provides capabilities for monitoring, serial clinical
evaluations, and an operating room available for
urgent laparotomy.

77. EAST Guidelines:Level 3
1. After blunt splenic injury, clinical factors such as a persistent
systemic inflammatory response, increasing/persistent abdominal
pain, or an otherwise unexplained drop in Hb should dictate the
frequency of and need for follow-up imaging for a patient with
blunt splenic injury.
2. Contrast blush on CT scan alone is not an absolute indication for an
operation or angiographic intervention. Factors such as patient
age, grade of injury, and presence of hypotension need to be
considered in the clinical management of these patients.
3. Angiography may be used either as an adjunct to nonoperative
management for patients who are thought to be at high risk for
delayed bleeding or as an investigative tool to identify vascular
abnormalities such as pseudoaneurysms that pose a risk for
delayed hemorrhage.
4. Pharmacologic prophylaxis to prevent venous thromboembolism
can be used for patients with isolated blunt splenic injuries
without increasing the failure rate ofnonoperative management,
although the optimal timing of safe initiation has not been
determined.

78. Unanswered questions:???
1. Frequency of Hb measurements
2. Frequency of abdominal examinations
3. Intensity and duration of monitoring
4. Is there a transfusion trigger after which operative or angiographic
intervention should be considered?
5. Time to reinitiating oral intake
6. The duration and intensity of restricted activity (both in hospital
and after discharge)
7. Optimum length of stay for both the intensive care unit (ICU) and
hospital
8. Necessity of repeated imaging
9. Timing of initiating chemical deep venous thrombosis (DVT)
prophylaxis after a splenic injury
10. Should patients with severe injuries/or embolized injuries receive
postsplenectomy vaccines?
11. Is there an immunologic deficiency after splenic embolization?

79. Conclusion:
• Spleen is important organ, try to conserve it.
• Clinical examination has vital role in diagnosing and
treating splenic injuries.
• Activate the team as soon as splenic injury is
suspected.
• CECT is the investigation of choice.
• Hemodynamically unstable patient : Directly to OR
• Keep adequate blood ready before opening the
abdomen.
• Splenic artery embolisation has got definitive role.

80. • Enlarged spleens are more susceptible to injury.
• Hemodynamic instability is the only absolute
contraindication for NOMSI
• Left LL Pneumonia is the MCC following
splenectomy.
• OPSI is the devastating sequelae of asplenia.
• Prophylaxis against OPSI is must.

81. References:
1. Bailey & Love Short practice of Surgery,26th ed.
2. Sabiston Textbook of Surgery, 20th ed.
3. Schwartz Principles of Surgery, 9th ed.
4. Fischers Mastery of Surgery, Vol2, 6th ed.
5. Kirk’s General Surgical Operations, 6th ed.
6. Shakelford’s Surgery of Alimentary Tract, 7th ed.
7. EAST Guidelines.
8. Amith Ashish Surgery for PGMEE, 10th ed.
9. Velmahos GC, Chan LS, Kamel E, Murray JA, Yassa N, Kahaku
D, Berne TV, Demetriades D. Nonoperative management of
splenic injuries; have we gone too far ? Arch Surg. 2000; 135:
674-681.
10. Cocanour CS, Moore FA, Ware DN, Marvin RG, Clark M, Duke
JH. Delayed complications of nonoperative management of
blunt adult splenic trauma. Arch Surg. 1998;133: 619-625.

82. ...Thank you...