Splenic trauma - Causes, Complications, Management

Mechanism of Injury
• Powel et al, 411 patients (293 adults and 118
children)
• Motor Vehicle Collisions: 67%adults 24%
children
• Motorcycle crash: 9%adults 1%children
• Sports injury: 2%adults 17%children
• Falls: 9% adults 25% children
• Pedestrian Hit By Car: 4% adults 11% children
• Bicycle crash 1% adults 9% children

Signs & Symptoms
• Complaints of left upper quadrant pain or of
pain referred to the left shoulder (Kehr sign)
• Physical Examination :
– Hypotension (SBP<90mmhg) & tachycardia
(PR>120bpm)
– evidence of peritoneal irritation (tenderness,
guarding, rebound)
– Percussion tenderness
– Evidence of bruising and soft tissue contusion in the
posterior left lower costal margin.

• FAST (Focused Assessment Sonogram for Trauma)
• DPL - A positive DPL
– 10 mL of gross blood aspirated with catheter insertion
– microscopically positive examination.
• Red blood cell count higher than 100,000/mm3
(30-40 ml of blood in peritoneal Cavity for 100,00/mm3)
• white blood cell count higher than 500/mm3
• CT Scan with iv contrast is the Gold standard in
hemodynamically stable or stabilized trauma patients
• Doppler US and contrast-enhanced US are useful to
evaluate splenic vascularization and in follow-up
Diagnostic Modalities

American Association for
Surgery of Trauma

Grade I Injury
• Subcapsular
Hematoma:
– < 10% of
surface area
• Laceration:
– < 1cm into
parenchyma

Grade II Injury
• Subcapsular
Hematoma:
10-50% of surface area
• Laceration:
1-3cm in depth.
Does not involve
trabecular vessel

Grade III Injury
• Subcapsular
Hematoma:
– >50% of surface area
– Ruptured
– >5cm
Intraparenchymal
• Laceration:
– > 3cm
– Involving trabecular
vessel

Grade IV Injury
• Laceration:
– Involves segmental
or hilar vessels.
– >25%
devascularization
of the spleen

Grade V Injury
• Shattered Spleen
• Laceration of hilar
vasculature.
• Devascularized
Spleen
• Avulsion

WSES Spleen Trauma Classification
for Adult & Pediatric patients
• SBP < 90 mmHg and PR >120bpm with evidence of skin vasoconstriction
(cool, clammy, decreased capillary refill), altered level of consciousness
and/or shortness of breath,
• SBP > 90 mmHg but requiring bolus infusions/transfusions and/or
vasopressor drugs
• Transfusion requirement of at least 4–6 units of packed red blood cells
within the first 24 h
Advanced
Trauma Life
Support
(ATLS)
definition
considers as
“unstable”

Treatment
• Approximately 70% to 90% of children with splenic injury
receive Non-operative management (NOM)
• Approximately 40% to 50% of adult patients with splenic injury
receive NOM
• Rates NOM and success rates increasing over time
• 85% patient receive NOM in some centers
• NOM in splenic injuries is contraindicated in the setting of
unresponsive hemodynamic instability or other indicates for
laparotomy
• In patients being considered for NOM, CT scan with
intravenous contrast should be performed to define the
anatomic spleen injury and identify associated injuries

NOM of Splenic Trauma
• NOM is considered the gold standard for the treatment of patients with
blunt splenic trauma (BST)
– who are hemodynamically stable after an initial resuscitation,
– in the absence of peritonitis and associated injuries requiring
laparotomy
• Patients with hemodynamic stability and absence of other abdominal
organ injuries requiring surgery should undergo an initial attempt of NOM
irrespective of injury grade
• AG/AE may be considered the first-line intervention in patients with
hemodynamic stability and arterial blush on CT scan irrespective from
injury grade
• In WSES classes II–III spleen injuries with associated severe traumatic
brain injury, NOM could be considered only if rescue therapy (OR and/or
AG/AE) is rapidly available; otherwise, splenectomy should be performed

EAST
• Eastern Association for the Surgery of Trauma
(EAST) practice management guidelines 2003
for patients with blunt liver or spleen injuries
• Nonoperative management of blunt adult and
pediatric splenic injuries is the treatment
modality of choice in hemodynamically stable
patients, irrespective of the grade of injury.
• Age, neurologic status, or associated injuries do
not preclude NOM in a hemodynamically stable
patient

Grade of Splenic Injury
correlated with success of NOM

Embolization
• 1. AAST Grade III or Higher
• 2. Contrast Blush
• 3. Moderate Hemoperitoneum
• 4. Evidence of Ongoing Bleeding

Immediate Splenectomy

Penetrating Injury

Patient is “unstable” -hemodynamic instability

Spleen is extensively injured with continuous bleeding

Patients who do not respond to NOM . (failure of
conservative management)

Bleeding is associated with hilar injury .

Severe coexisting injuries necessitating intervention
and peritonitis, bowel evisceration,

Splenic preservation (at least partial) should be
attempted whenever possible.

Delayed Splenectomy
(Failed NOM)
(Adults)
• Hemodynamic instability
• Bleeding > 1000 mL
• Transfusion of more than 2 units of blood
• Other evidence of ongoing blood loss

Conditions permitting,
mobilization of the spleen
and the tail of the
pancreas from their
posterior peritoneal
attachments begins with
takedown of the lienocolic
ligament using
electrocautery or sharp
dissection.

• Dissection
continues with
take down of
peritoneal
attachments

With the left hand
retracting the spleen
medially, fingers of
the right hand bluntly
dissect and separate
the spleen and the
tail of the pancreas
away from the
underlying left kidney
and adrenal gland.

Conditions permitting, careful isolation of the splenic
artery is performed

After controlling artery, define remaining vessels and
take down the remaining attachments

Ligation splenic vein and
short gastrics follows
Caution against
incorporating the gastric
wall

Secure, safe, and separate
ligation of both the splenic
artery, short gastrics, and
vein while avoiding injury to
the pancreas can be
technically difficult,
depending on the anatomy
and condition of the patient.

For critical bleeding
patient the spleen can
be brought bluntly to
midline. Vessels are
controlled in mass. The
vessels may than be
ligated or left clamped
while other issues are
addressed. If pancreas
is injured, leave a
drain.

Hemostasis is
ensured closure
when performing
any type of
operation on the
spleen to avoid
life-threatening
postoperative
hemorrhage and
the need for
reoperation.

OPSI
• OPSI are defined as fulminant sepsis, meningitis, or pneumonia
triggered mainly
– by Streptococcus pneumoniae (50% of cases)
– followed by H. influenzae type B and N. meningitidis.
• Most common in children younger than age 6 who have not yet
developed extra-splenic specific immunity to encapsulated
organisms such as pneumococcus and meningococcus and those
hematologic disease.
• The risks of OPSI and associated death are
– highest in the first year after splenectomy, at least among young
children,
– but remain elevated for more than 10 years
• The incidence of OPSI is 0.5–2%; the mortality rate is from 30 to
70%, and most death occurs within the first 24 h

Vaccination and Antibiotic prophylaxis
Post Splenectomy

Ideally, the vaccinations against S. pneumoniae, H. influenzae B,
and N. meningitidis should be given at least 2 wks before
splenectomy

In traumatic patients,

Currently, the standard of care for postsplenectomy patients
includes immunization with PPV23, H. influenzae type b
conjugate, and meningococcal polysaccharide vaccine within
2 weeks of splenectomy

Most healthy adults show a twofold or greater rise in type-specifi c
antibody within 2 to 3 weeks of vaccination.

Most episodes of severe infections occur within the first 2 years
after splenectomy, hence at least 2 years of prophylactic
antibiotics after splenectomy is recommeneded

Splenorraphy
• Largely replaced by Non-Operative
Management (NOM)
• May still be useful some isolated iand
iatrogenic injuries

Graded response
Graded response
Grades 1-2
Small surface lacerations
Topical hemostatics; fibrin glue
or other readily available
products

Grade 1-2
• Deeper
lacerations
Suture repair
• Thicker
capsule in
children holds
suture better

After, deep bleeding points are controlled, horizontal sutures
with the use of a buttress material are placed. The sutures
incorporate the splenic capsule and approximately 1 cm depth
of parenchymal tissue in adults
Adults

Grade 3-4
Mesh wrapping provides
for tamponade. The use
of absorbable mesh
(polyglycolic acid or
polyglactin) is preceded
by the complete
mobilization of the
spleen from its
ligamentous
attachments.

●
The mesh must be
well approximated to
take advantage of its
tamponade effect.
●
Too loose it cannot
provide effective
tamponade.
●
Too tight it may
place enough tension
on the suture line to
come apart, resulting
in hemorrhage

Some deep
lacerations may
be treated with
segmental
resection.
Involvement of
the center of the
spleen and/or
hilum is a
contraindication
to this approach

Partial splenectomy or hemisplenectomy is possible
due to segmental "pancake" anatomy of the splenic
vasculature.

Return to Activity
(Acc to American Association for the Surgery of Trauma)

Grade I to Grade II injuries have activity
limitations for 4 to 8 weeks

Grade III to Grade V injuries,

contact restrictions for more than 8 weeks
or

until healing is demonstrated by CT or USG

Conclusion

The management of spleen trauma must be multidisciplinary and
must keep into consideration the physiological and anatomical
derangement together with the immunological effects

Patients with hemodynamic stability and absence of other
abdominal organ injuries requiring surgery should undergo an
initial attempt of NOM irrespective of injury grade

Splenectomy should be performed when NOM with AG/AE failed
and patient remains hemodynamicaly unstable

Patients should be advised for vaccination and antibiotic
prophylaxis to prevent OPSI

References
• Lee J Skandalakis – Surgical Anatomy and Technique
• Sabiston Textbook Of surgery, 18th
Edition
• Schwartz Principles Of Surgery, 10th
Edition
• Splenic trauma: WSES classification and guidelines for adult and pediatric
patients , World Journal of Emergency Surgery 2017
• American Association for the Surgery of Trauma – Blunt Splenic Trauma
Guidelines. Authors: Nimitt Patel M.D and Louis Alarcon M.D. (May 2012)
• Diagnosis and Management of Splenic Trauma – Journal Of Lancaster
General Hospital Eric H. Bradburn, D.O , Acute Care Surgeon, Lancaster
General Hospital
• N. Kaseje et al Splenectomy avoidance in trauma patients The American
Journal of Surgery, Vol 196, No 2, August 2008
• Khatri V, Asensio JA: Operative Surgery Manual. Philadelphia, WB
Saunders, 2002, p. 189
• Peter Mucha, Jr Splenic Injury Operative Techniques in General Surgery,
Vol 2, No 3 (September), 2000: pp 192-205
• Powell M, Courcoulas A, Gardner M, et al: Management of blunt splenic
trauma: Significant differences between adults & children.

Splenic trauma - Causes, Complications, Management

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