Splenic trauma

Splenic Rupture/Trauma/Injury
(According to Eastern Association for Surgery of Trauma (EAST) 2012 guidelines)
Jibran Mohsin
Resident, Surgical Unit I
SIMS/Services Hospital, Lahore

Outline
• History
• Etymology
• Surgical Anatomy
• Etiology
• Pathophysiology
• Types of injuries
• Associated injuries
• Clinical Presentation
• Workup
• Staging
• Management
• OPSI

Identification of References of EAST 2012
Recommendations
• English-language citations between 1996 (the last year of literature used for the
previous guideline) and 2010 using the keywords splenic injury and blunt
abdominal trauma.
• The articles were limited to humans, clinical trials, randomized controlled trials,
practice guidelines, meta-analyses, and reviews.
• 223 articles were identified.
• Case reports and small case series were excluded.
• The committee chair and members then reviewed the articles for relevance and
excluded any reviews and tangential articles.
• 176 articles were reviewed of which 125 were used to create the nonoperative
management of blunt splenic injuries recommendations.

History
• 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.
• The mystery continued for over a millennium, as no
one challenged his theory that the spleen functioned
to remove the evil humor “black bile” produced by the
liver

History
• In 1893, Reigner published the first documented successful
splenectomy in the German literature.
• Operative mortality rates remained high until the 1950s
– Nonoperative care during this period was predominantly fatal.
• Prior to the advent of CT scanning,
– physical examination and diagnostic procedures such as
diagnostic peritoneal lavage (DPL) and radioisotope scans were
the only diagnostic methods.
– Minor splenic injury was probably frequently missed
– while major injury prompting laparotomy for hypotension or
physical findings was the norm.

History
• With the widespread availability of computed tomography
– surgeons began to focus on those needing surgery and
– those who could be observed safely.
• Starting with the pediatric population and expanding into the adult
population,
– nonoperative observation became more prevalent for
hemodynamically stable patients.
• Further improvements in CT sensitivity and specificity
– made vascular extravasation easier to diagnose, and
– interventional radiology became an integral part of the management
of splenic injuries, in some institutions replacing emergency operation
as the treatment of choice.

Changing Trends in management of Spleen trauma
during last century
Observation and Expectant management
(early 1900’s)
Operative intervention for all injuries
Selective operative and non -operative
management (Currently)

Etymology
• Ancient Greek ……..σπλήν (splḗn)
– idiomatic equivalent of the heart in English, i.e. to be good-
spleened means to be good-hearted or compassionate
• French
– "splénétique" refers to a state of pensive sadness
or melancholy*.
• English
– employed to characterise the hypochondriacal and hysterical
affections during 18th century
– In modern English, "to vent one's spleen" means to vent
one's anger, e.g. by shouting (BAD TEMPER)
____________________________________________________________________________*
derives from Greek "melas kholé" meaning 'black bile', from the belief that an excess of black
bile caused depression

William Shakespeare, in Julius Caesar uses the
spleen to describe Cassius' irritable nature
Must I observe you? must I stand and crouch
Under your testy humour? By the gods
You shall digest the venom of your spleen,
Though it do split you; for, from this day forth,
I'll use you for my mirth, yea, for my laughter,
When you are waspish.

Etymology
• Talmud (central text of rabbinic Judaism)
– refers to the spleen as the organ of laughter.
• In 18th and 19th century England,
– women in bad humor were said to be afflicted by
the spleen, or the vapours of the spleen

Surgical Anatomy
• Ovoid/wedge, usually purplish, pulpy mass
• About size and shape of one’s fist
• MOST VULNERABLE ABDOMINAL ORGAN
• Located in left upper quadrant or LHC
• Protected by lower thoracic cage
• Completely encircled and covered with peritoneum except
at hilum

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

Relations
ANTERIOR:
Stomach
POSTERIOR:
Left diaphragm
Lung
Costodiaphragmatic recess
9-11 ribs
INFERIOR:
Left colic flexure
MEDIAL:
Left kidney

LIGAMENTS:
Gastrosplenic  Short gastric vessels and left gastro-omental vessels
Splenorenal (lienorenal)  splenic vessels and tail of pancreas
Phrenicocolic in contact with lower pole of spleen; at danger during spleenectomy
BORDERS: ENDS: SURFACES:
Superior(notched) border Posterior end (Medial end) Diaphragmatic
Inferior border Anterior end (Anterior border) Visceral
Anterior border (anterior end) (3 areas)

Blood Supply
ORIGIN COURSE END
Splenic Artery
(blood flow=
300 ml/min)
Largest branch
of celiac trunk
( OR aorta,
SMA)
Tortuous course
• posterior to omental bursa
• anterior to left kidney
• along superior border of
pancreas
bifurcates externally
(in splenorenal
ligament), supplying
upper and lower poles
separately*
Splenic Vein Formed by
several
tributaries that
emerge from
hilum
Joined by IMV
Runs posterior to body and tail
of pancreas
Unites with SMV at
900 posterior to neck
of pancreas to form
portal vein
_____________________________________________________________________
*Lack of anastomsis of arterial vessels  formation of VASCULAR SEGMENTS of spleen:
2 in 84 % spleens and 3 in the others, with relatively avascular planes between them,
enabling subtotal splenectomy/splenorraphy

Blood Supply
• Short gastric vessels
– Branch from the left gastroepiploic artery.
– May be as short as 1 mm
• creating a challenge during emergency operative intervention.
• Notably, the splenic artery and vein may have small
branches feeding the body and tail of the pancreas
– care should be taken in dissecting these vessels away from
the splenic hilum.

Inspite of size and the many useful
and important functions,
Spleen is not a vital organ
( not necessary to sustain life)

Etiology
• Blunt Trauma
– rapid deceleration(motor vehicle crashes)
– 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 Colonoscopy (66 patients in literature with 4.5 % mortality rate)
• Spontaneous Rupture
– Malaria, infectious mononucleosis

Pathophysiology
• Injury is more common and severe in enlarged
spleen, i.e. malaria, tropical splenomegaly,
infectious mononucleosis.
_______________________________________
Larang (blunt metal object) was used to kill by murderers in far east where malaria
was endemic leading to splenomegaly which ruptured more easily: with little in the
way of external marks being left on body.

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

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

Clinical Presentation
• Hilar injury
– Rapid development of shock and deteriorates fast
(even death can occur)
• Other injuries
– Features of shock (pallor, tachycardia, restlessness, tachypnea, anxiety,
hypotension, decreased capillary refill and decreased pulse pressure)
– Pain, tenderness and abdominal rigidity in LUQ
– Free intraperitoneal blood diffuse abdominal pain, peritoneal
irritation, rebound tenderness- abdominal distension

• Kehr’s sign
– 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
• Ballance’s sign
K
Hans Kehr (1862-1916)
German Surgeon
Charles Alfred Ballance (1856 – 1936)
English surgeon
BALLANCE SIGN
Persistent dullness to percussion in the left flank due to coagulated blood
shifting dullness to percussion in the right flank due to fluid blood

Splenosis
• Autotransplantation of fragments of splenic
tissue within peritoneal cavity following
rupture of spleen

Delayed Presentation
• Missed splenic injury
• Delayed Splenic Rupture(DSR)

Delayed Splenic Rupture(DSR)
• Latent period of Baudet(1907)
• Incidence (Before advent of CT scan 15-33 %; afterwards 1 %)
• Tends to occur 4-8 days after trauma(days-months)
• Mortality 5-15 % Œ
• Potential mechanisms
– ŒExpanding subcapsular hematoma Œ
– Clot disruption
– Pseudocyst rupture Œ
– Pseudoaneurysm/AV fistula rupture
• Treatment: splenectomy

Workup
• Hematological investigations
• Radiological investigations

Hematological investigations
• CBC (Hb; Hct)
– rarely helpful in the initial workup of the
suspected splenic injury.
– helpful in providing baseline values and,
– Performed serially, in diagnosing ongoing blood
loss or hemodilution due to volume resuscitation.

Radiological Investigations
Focused Assessment with Sonography for Trauma (FAST)
– routine diagnostic adjunct in the initial assessment of blunt trauma
victims BUT
– lacks the ability to reliably predict which patients require laparotomy.
– Poor for delineating organ-specific anatomy with any reliability in the
emergency setting
• Physiologic data (hemodynamic state) play a major role in decision
making regarding the need for emergent laparotomy versus further
diagnostic testing or observation.

Interpretation
• Score >3 cm
– Indicates 1 liter or more hemoperitoneum
– 96 % probability of laparotomy
• Score < 3 cm
– 37 % probability of laparotomy

SSORTT
(Sonographic Scoring for Operating Room Triage in
Trauma)

• Multidetector helical CT scan with IV contrast
– In the stable patient, CT scanning provides structural
evaluation of the spleen and surrounding organs.
– Active bleeding from the splenic parenchyma can be
missed with a noncontrast CT scan.

• Angiography
– rarely the first choice for evaluation of the patient
with a splenic injury
– use more frequently for primary therapeutic
management of splenic injuries
(angioembolisation)
• after CT scanning images show an arterial contrast
blush or active extravasation.

• MRI
– as an option in the patient with renal failure or
significant contrast allergy.

• Radioisotope studies
– rarely helpful in this day of rapid, detailed, high-
resolution CT scanners.
– These studies should probably be eschewed as a
diagnostic option in the trauma patient unless no
other confirmatory tests are available.

Other diagnostic Procedure
• Diagnostic peritoneal lavage(DPL)
– MERIT
• fast and inexpensive.
• low complication rate in experienced hands.
• more sensitive or specific than FAST
– Demerit
• Invasive

American Association for the Surgery of Trauma (AAST)
Spleen Organ Injury Scale*
(1994 Revision)
GRADE I II III IV V
Subcapsular Hematoma
( % of total surface area)
<10% 10-50% >50% or
expanding or
Ruptured
Capsular laceration
(depth)
<1 cm 1-3 cm >3 cm
Intraparencymal Hematoma
(Diameter)
<5 cm >5 cm or
expanding or
Ruptured
Vessels involved in
laceration
Not
involving
trabecular
Trabecular Segmental or hilar
(>25 %
devascularization)
Hilar
(Devascularized
shattered )
*used in conjunction with nonoperative assessment (eg, CT scanning, angiography),
operative intervention by laparotomy, or postmortem by autopsy

Staging
• CT scanning overestimates the injury by as
much as 10%
– However, CT scan findings correlate well with the
need for operative intervention.

Management
• Non-operative management of splenic injury (NOMSI)
– Conservative
– Interventional radiology
• Splenic angioembolization
• Operative management
– Splenorraphy
• procedure to preserve spleen done in past, now replaced by NOMSI
– Splenectomy

Why NOMSI?
• Splenic fractures following blunt abdominal trauma are
most frequently perpendicular (transverse) on the
organ’s long axis
– therefore the risk of segmental vascular damage is quite
small(the intersegmental avascular planes)
• Important immunological role of the spleen
– (risk of OPSI)
• Improvement of non-invasive diagnostic methods
(especially CT).

Advantages of NOMSI
• lower hospital cost
•
• earlier discharge
• avoiding nontherapeutic celiotomies (and their associated cost and
morbidity),
• fewer intra-abdominal complications, and
• reduced transfusion rates
_____________________________________________
associated with an overall improvement in mortality of these injuries

NOMSI
• 65% of all blunt splenic injuries could be managed
nonoperatively with minimal transfusions, morbidity, or
mortality, with a success rate of 98%

EAST 2012 Recommendations
LEVEL 1
• Patients who have diffuse peritonitis or who are
hemodynamically unstable(a positive FAST examination result
or positive DPL) after blunt abdominal trauma should be taken
urgently for laparotomy.
________________________________________________________________________
LEVEL 1: Recommendation is convincingly justifiable based on the available scientific
information alone

LEVEL 2
1. A routine laparotomy is not indicated in the
hemodynamically stable patient without peritonitis
presenting with an isolated splenic injury.
_________________________________________________________________________
LEVEL 2: Recommendation is reasonably justifiable by available scientific evidence and
strongly supported by expert opinion

LEVEL 2
• 2. Following parameters are NO LONGER contraindications to a trial of
nonoperative management in a hemodynamically stable patient
– The severity of splenic injury (as suggested by CT grade or degree
of hemoperitoneum),
– neurologic status,(ASOC, head injury)
– age >55
– Number of tranfusions
– Blush on CT and/or
– the presence of associated injuries.
_________________________________________________________________________

LEVEL 2
3. In the hemodynamically normal blunt abdominal trauma
patient without peritonitis, an abdominal CT scan with IV
contrast should be performed to identify and assess the severity
of injury to the spleen
__________________________________________________________________________

LEVEL 2
4. Angiography should be considered for patients with
– AAST grade > III injuries,
– presence of a contrast blush,
– moderate hemoperitoneum, or
– evidence of ongoing splenic bleeding
_____________________________________________________________________________
LEVEL 2: Recommendation is reasonably justifiable by available scientific evidence and strongly
supported by expert opinion

LEVEL 2
5. Nonoperative 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.
____________________________________________________________________________

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 hemoglobin
should dictate the frequency of and need for follow-up
imaging for a patient with blunt splenic injury.
_______________________________________________________________________
The recommendation is supported by available data, but adequate scientific evidence is
lacking

LEVEL 3
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.
________________________________________________________________________
lacking

LEVEL 3
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.
_______________________________________________________________________
lacking

4. Pharmacologic prophylaxis to prevent venous thromboembolism can
be used for patients with isolated blunt splenic injuries without
increasing the failure rate of nonoperative management, although the
optimal timing of safe initiation has not been determined
_______________________________________________________________________
lacking

Unanswered Queries
• According to EAST 2012 guidelines, there was not enough
literature available to make recommendations regarding
the following:
1. Frequency of hemoglobin measurements
2. Frequency of abdominal examinations
3. Intensity and duration of monitoring
4. Is there a true transfusion threshold after which operation or
angiography should be considered?
5.Optimal time to reinitiating oral intake

Unanswered Queries
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. Necessity of postsplenectomy vaccination for patients with severe injuries/or
embolized injuries
11. Is there an immunologic deficiency after splenic embolization?
12. What exactly constitutes a ‘‘failure’’ of nonoperative management?

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