Michael LeCompte MANAGEMENT OF TRAUMATIC SPLEEN INJURY
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1 Michael LeCompte MANAGEMENT OF TRAUMATIC SPLEEN INJURY
2 History Spleen was the source of emotion Aristotle challenged this idea and argued that the spleen was unnecessary Gaius Pliny Secundus (Natural History) remove the spleen to improve the speed of athletes first splenectomy performed by Adrian Zacarellie for hypersplenism 1590 first traumatic splenectomy performed by Franciscus Rosetti. (Partial Splenectomy)
3 History Cont Senn, N Described non-operative management of the spleen. Kocher 1911 described high failure rate of NOP and advocated for surgical management for blunt traumatic injury 1950s-1970s high OPSI rates in children following splenectomy. Moved towards NOP in children 1990s successful NOP in adults
4 Trauma Patient Traumatic injury to the LUQ Rib fractures 9-12 on the left Seat belt sign Hypotension Pain referred to the left shoulder increased with inspiration (Kehr s sign) Penetrating trauma
5 Diagnostic Modalities FAST exam DPL CT scan
6 Grade I Injury Subcapsular Hematoma: < 10% of surface area Laceration: < 1cm into parenchyma
7 Grade II Injury Subcapsular Hematoma: 10-50% of surface area Laceration: 1-3cm in depth. Does not involve trabecular vessel
8 Grade III Injury Subcapsular Hematoma: >50% of surface area Ruptured >5cm Intraparenchymal Laceration: > 3cm Involving trabecular vessel
9 Grade IV Injury Laceration: Involves segmental or hilar vessels. >25% devascularization of the spleen Malays J Med Sci Jan-Mar; 18(1): PMCID: PMC Computed Tomography of Blunt Spleen Injury: A Pictorial Review
10 Grade V Injury Shatter Spleen Laceration of hilar vasculature. Devascularized Spleen Avulsion Malays J Med Sci Jan-Mar; 18(1): PMCID: PMC Computed Tomography of Blunt Spleen Injury: A Pictorial Review
11 AAST Grading Chart
12 To Operate or Not to Operate 80% of blunt splenic injuries can be managemed nonoperatively.
13 Eastern Association of Surgery for Trauma Guidlines Level 1 Data: 1. Patient s with hemodynamic instability or diffuse peritonitis should be taken urgently for laparotomy Level 2 Data: 1. A routine laparotomy is not indicated in the hemodynamically stable patient presenting with an isolated spleen injury 2. The severity of the injury, suggested by grade CT grade, neurologic status, age >55 and or the presence of associated injuries are not contraindications to a trial of NOP management. 3. NOP should only be considered in an environment that has capabilities to monitoring, serial exams and available OR.
14 Failure of Non-operative Management Based on CT Grade
15 Non- operative Management Serial Exams Serial hemoglobin/hematocrit Monitor vitals and urine output Period of immobility or bed rest +/- Follow up CT scan hours ( Weinberg et al showed repeat CT scan at hours for grades II and above diagnosed latent pseudoaneurysm that underwent embolization with improved outcomes.)
16 Embolization 1. AAST Grade III or Higher 2. Contrast Blush 3. Moderate Hemoperitoneum 4. Evidence of Ongoing Bleeding
17 Pros and Cons of Embolization Cooney et al showed use of selective arterial embolization to improve non-operative rates Preservation of functional splenic tissue Hann et al 20% complication rate including failure to control bleeding, need for repeat embolization. Failure to identify concurrent injuries Splenic Abscess
18 Surgical Management 1. Midline incision 2. Evacuation of blood Packing of LUQ Medial/Downward rotation of spleen with posterior packing Pinch Hilum for control of bleeding. Exploration for concurrent injury.
19 Spleen Mobilization
20 Splenorrhaphy Linear lacerations or capusular tears may be managed by suture ligation of bleeding vessels, figure of eight closure, pledget butress or omental patch.
21 Splenic Mesh Useful with stellate or multiple lacerations to the spleen Specialized mesh bags Wrap spleen in conventional mesh. Tighten mesh around the spleen with stay sutures to tamponade bleeding.
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