Although protected under the bony ribcage, the spleen remains the most commonly affected organ in blunt

injury
to the abdomen in all age groups. While some references occasionally document liver injuries as being more
common, blunt injuries to the spleen are documented more frequently as the primary solid organ injury in the
abdomen. These injuries are common in both rural and urban environments and result from motor vehicle
crashes, domestic violence, sporting events, and accidents involving bicycle handlebars. See the images below.
Intra-parenchymal blush observed on helical CT scan.
Grade 4-5 splenic laceration on helical CT scan.
A general surgeon in a community hospital is just as likely to observe and treat a splenic injury as the full-time
trauma surgeon in an American College of Surgeons (ACS) verified Level 1 or Level 2 trauma center. For this
reason, all physicians involved in emergency care, especially surgeons, whether rural or urban, must keep up-to-
date on issues regarding splenic injury diagnosis, splenic salvage techniques, indications for nonoperative
treatment, and potential complications arising from both operative splenectomy and nonoperative management of
this important organ.
The spleen, weighing 75-150 g, is a highly vascular organ that filters an estimated 10-15% of total blood volume
every minute. The spleen may hold 40-50 mL of red cells in reserve on average; however, with changes in internal
smooth muscle, it can pool significantly more blood. Historically, many early shock studies performed in canine
models were invalidated when it was discovered that dogs could autotransfuse stored red cells from their spleen
with smooth muscle contraction. Humans do not have this ability. As much as 25% of the circulating platelets are
estimated to be held in reserve in the spleen. Although protected anatomically under the rib cage in the left upper
quadrant of the abdomen, it is frequently injured by blunt external trauma. It can also be iatrogenically injured in
emergency operations, especially when preexisting adhesions make mobilization of intra-abdominal structures
difficult.
Because of the immunologic function of the spleen, interest over the last century has turned to salvage of the
spleen rather than splenectomy. The advent of CT scanning has made conservative management more practical
and safer for victims of splenic injury. CT scanning has facilitated safe, nonoperative management in young and
old patients to an unprecedented degree, but deaths due to splenic rupture are still reported in hospital discharge
statistics from both Level 1 trauma centers and community hospitals.
A thorough knowledge of splenic function, anatomy, and pathophysiology is necessary to continue the progress of
the last decade and to decrease the mortality rate from this common injury in the United States and worldwide.
Splenic injury is most often observed in blunt trauma. While penetrating trauma (eg, gun shot wounds, knife
wounds) may involve the spleen, the incidence of injury is well below that of the small and large intestine. A third
mechanism that combines aspects of blunt and penetrating trauma occurs with explosive type injuries, as seen in
warfare and civilian bombing.
Although the spleen is relatively protected under the ribcage, injury due to rapid deceleration, such as occurs in
motor vehicle crashes, direct blows to the abdomen in domestic violence, or leisure and play activities such as
bicycling, frequently result in a variety of splenic injuries.
Another cause of splenic injury has been gaining notice. There have been case reports of splenic injury
following colonoscopy.
[2]
Ha and Minchin performed a literature search to identify the demographic profile, risk
factors, clinical presentations, diagnosis and management of this rare complication.
[3]
The investigators found 66
patients (median age, 65y) with a 4.5% mortality rate, the majority (n = 41, 62.1%) of which occurred in uneventful
colonoscopies. Symptoms primarily (74%) appeared within 24 hours, and workup in the form of blood tests and CT
scanning was performed in the majority (93.9%).
[3]

In addition, over half of (56.1%) affected patients underwent laparotomy and splenectomy, with the most common
finds of splenic hematoma (47%), laceration (47%), and rupture (33.3%).
[3]
Ha and Minchin concluded that
recognition of postcolonoscopy splenic injury as an important complication will not only rise, but it will be necessary
given the increasing numbers of colonoscopies being performed for colorectal diseases and the possibility of
delayed diagnosis resulting in adverse outcomes.
Though normally protected by its anatomic position, preexisting illness or disease can markedly increase the risks
and severity of splenic injury. Infectious mononucleosis, malaria, and hematologic abnormalities can lead to acute
or chronic enlargement of the spleen. This is often accompanied by a thinning of the capsule, making the spleen
more fragile as well as engendering a greater mass effect in decelerating trauma. Minor impact in patients with
splenomegaly reportedly results in major injury and the need for splenectomy.
The clinical presentation of splenic injury is highly variable. Most patients with minor focal injury to the spleen
complain of left upper quadrant abdominal tenderness. Left shoulder tenderness may also be present as a result of
subdiaphragmatic nerve root irritation with referred pain.
With free intraperitoneal blood, diffuse abdominal pain, peritoneal irritation, and rebound tenderness are more
likely. If the intra-abdominal bleeding exceeds 5-10% of blood volume, clinical signs of early shock may manifest.
Signs include tachycardia, tachypnea, restlessness, and anxiety. Patients may have a mild pallor noted only by
friends and family. Clinical signs include decreased capillary refill and decreased pulse pressure. With increasing
blood loss into the abdominal cavity, abdominal distension, peritoneal signs, and overt shock may be observed.
Hypotension in a patient with a suspected splenic injury, especially if young and previously healthy, is a grave sign
and a surgical emergency. This should prompt immediate evaluation and intervention either in the OR or
interventional radiology if a state of compensated shock can be maintained. Unstable patients have nearly
exsanguinated in CT scanners while in the process of documenting splenic injury, when they would have been
better served by exploration in the operating room or embolization in the IR suite.
In simple terms, unstable patients suspected of splenic injury and intra-abdominal hemorrhage should undergo
exploratory laparotomy and splenic repair or removal. A blunt trauma patient with evidence of hemodynamic
instability unresponsive to fluid challenge with no other signs of external hemorrhage should be considered to have
a life-threatening solid organ (splenic) injury until proven otherwise. Transient responders, those patients who
respond to an initial fluid bolus only to deteriorate again with a drop in blood pressure and increasing tachycardia,
are also likely to have solid organ injury with ongoing hemorrhage. Patients with compensated shock may be
managed by angioembolization but only if these services can be performed in a timely manner equivalent to that of
operative intervention.
DPL may be a valuable adjunct if time permits and multiple other injuries are present. Focused abdominal
sonographic technique (FAST) in experienced hands is helpful in documenting the presence or absence of blood in
the peritoneal cavity, which highly suggests the possibility of splenic injury. However, bedside FAST in the
resuscitation suite does not show actual splenic injury well enough to use as a diagnostic modality for solid organ
injury imaging. Rozycki et al performed a pilot study using bedside organ assessment with sonography after
trauma (BOAST) and documented its limitations in identifying solid organ injury, especially at lower grades of
injury. FAST is excellent for documenting the presence or absence of intra-abdominal fluid but should not be
viewed as an equivalent to CT scanning with regard to injury site determination.
[4]

Sirlin et al showed that patterns of fluid accumulation on FAST may be used to improve identification of specific
organ injuries, but this still does not approach the sensitivity and specificity of CT.
[5]

In the stable trauma patient, commonly defined as a patient with systolic blood pressure greater than 90 mm Hg
with a heart rate less than 120 beats per minute (bpm), CT scanning provides the most ideal noninvasive means
for evaluating the spleen. Helical or spiral scanners may provide even more information and may clarify the degree
of injury. In the cases of CT scandocumented splenic injury, the decision for operative intervention is determined
by the grade of the injury, the patient's current and preexisting medical conditions, and the facilities available at the
hospital, including the intensive care unit and the availability of operating and anesthesia services.
The availability of interventional angiographic services also impacts a surgeon's decision for or against operative
intervention. The use of MRI has also been reported in the literature as an option in the patient with an elevated
creatinine level.
[6]

The major determining factors in operative intervention in the stable patient with a splenic injury include grade of
injury (American Association for the Surgery of Trauma [AAST] scale), presence of intraperitoneal blood, presence
of a blush on CT scan, calculated risk of rebleeding, presence and severity of concomitant injuries, and options
regarding blood transfusion.
Signs of persistent bleeding and hemodynamic instability unresponsive to fluid and blood administration are clear
indications for surgery. The decision for operative intervention in other cases requires the thoughtful consideration
of the surgeon. Angioembolization, once contraindicated in compensated shock, has now been reported as a safe
method of splenic salvage when immediately available in the treating facility.
[7]
A healthy 25-year-old patient who
has a CT scan grade 4 laceration with stable vital signs and minimal fluid requirements may be safe to observe
under controlled conditions, while a 55-year-old patient who is a Jehovah's Witness and who has a CT scan grade
2 oozing splenic injury and pelvic fracture would probably benefit more from early surgical intervention.
The spleen sits in the left upper quadrant of the abdomen under the diaphragm and lateral to the stomach. Left
shoulder pain, also known as the Kehr sign, results when blood from an injured spleen irritates the diaphragm and
creates referred pain. The spleen is completely encircled and covered with peritoneum except for the insertion of
the splenic artery and vein. This capsule around the spleen, especially the thicker layer in young patients, provides
added protection against blunt injury. The spleen is primarily fixated to the posterior aspect of the left upper
quadrant by gastrosplenic and splenorenal ligaments. The size and thickness of these ligaments vary greatly, with
some spleens appearing to be very mobile, while others appear fixed in the left upper quadrant.
The major arterial supply to the spleen is through the splenic artery, which branches off the celiac artery and runs
superior and posterior to the pancreas. The artery commonly bifurcates externally to the spleen, supplying upper
and lower poles separately, a finding that may make splenorrhaphy much easier for the operating surgeon. The
splenic vein courses with the artery but empties into the superior mesenteric vein and then into the portal vein. The
arterial supply and venous drainage of the spleen is augmented by the short gastric vessels that branch from the
left gastroepiploic artery. These vessels may be as short as 1 mm, thus 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, so care should be taken in dissecting these vessels away from the splenic hilum.
The tail of the pancreas is often intimately positioned near the splenic hilum and can be easily damaged during
splenectomy if adequate care is not taken to identify and protect the organ
No contraindications to operative intervention exist in a hemodynamically unstable patient with a splenic injury.
However, hypotension or unstable vital signs are a contraindication to CT scanning, and deaths due to splenic
rupture and ongoing bleeding have occurred in the radiology suite while trying to document a splenic injury.
Unstable patients can be assessed by FAST or DPL in addition to clinical examination but should not undergo CT
scanning of the abdomen for diagnosis.
http://emedicine.medscape.com/article/432823-overview#a05
While frequently obtained, a complete blood cell count or hemoglobin level is rarely helpful in the initial workup of
the suspected splenic injury. These are helpful in providing baseline values and, when performed serially, in
diagnosing ongoing blood loss or hemodilution due to volume resuscitation.
Focused abdominal sonographic technique
FAST, observing for the presence or absence of fluid in the peritoneal cavity, may be performed rapidly and
safely in trauma patients.
FAST is poor for delineating organ-specific anatomy with any reliability in the emergency setting. In addition, the
learning and interpretation curve is rather steep when compared to DPL.
In experienced hands, visualization of fluid in the right upper quadrant, the left upper quadrant, and the pelvis
suggests solid organ injury (or mesenteric injury) and the possibility of splenic injury.
CT scanning
In the stable patient, CT scanning provides structural evaluation of the spleen and surrounding organs.
Intravenous contrast injected at the time of scan improves the clinician's ability to determine the severity of injury.
Active bleeding from the splenic parenchyma can be missed with a noncontrast CT scan.
A splenic contrast blush noted by a helical CT scanner has a greater propensity to require splenic exploration in
most series.
[8, 9]
See the image below. Intra-parenchymal blush observed on helical CT
scan.
Multidetector CT scanners have improved diagnostic capabilities but may still miss some vascular injuries.
[10]

Angiography
Angiography is rarely the first choice for evaluation of the patient with a splenic injury, but it is being used more
frequently for primary therapeutic management of splenic injuries.
Angiography is usually performed after CT scanning images are obtained showing an arterial contrast blush or
active extravasation. Angiography is less of a diagnostic modality and more of a preparation for therapeutic
angioembolization of active bleeding sites.
MRI has been reported as an option in the patient with renal failure or significant contrast allergy.

Radioisotope studies
These are 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.

Diagnostic peritoneal lavage
DPL is a method of rapidly determining if free intraperitoneal blood is present. This test is especially useful in the
hypotensive patient.
DPL is fast and inexpensive. It has a low complication rate in experienced hands.
FAST has replaced DPL in many institutions because it is less invasive, but it has not yet been shown to be more
sensitive or specific than DPL in most published studies.

Histologic findings may help to explain why a minor trauma resulted in a major splenic injury. Splenic rupture may
follow after a seemingly minor transfer of kinetic energy because of organ expansion with capsular thinning or an
abnormal internal architecture with reduced elasticity to the parenchyma. Such events may happen with
splenomegaly due to hematologic abnormalities (eg, hereditary spherocytosis), infectious diseases (eg, malaria),
and liver disease (eg, portal and splenic hypertension).
Splenic injury is graded using the standards published by the Organ Injury Scaling Committee of the AAST.
Categories range from grade I (minor) to grade V (major) and correlate to the need for laparotomy. These grades
are used in conjunction with nonoperative assessment (eg, CT scanning, angiography), operative intervention by
laparotomy, or postmortem by autopsy. Some studies comparing CT staging with operative staging indicate that
CT scanning overestimates the injury by as much as 10%. However, CT scan findings correlate well with the need
for operative intervention.
Medical Therapy
The trend in management of splenic injury continues to favor nonoperative or conservative management. This
varies from institution to institution but usually includes patients with stable hemodynamic signs, stable hemoglobin
levels over 12-48 hours, minimal transfusion requirements (2 U or less), CT scan injury scale grade of 1 or 2
without a blush, and patients younger than 55 years. For instances in which patients have significant injury to other
systems, surgical intervention may be considered even in the presence of the previously noted findings. Patients
on anticoagulants, such as warfarin (Coumadin), and antiplatelet drugs, such as clopidogrel (Plavix), are clinically
considered to be at an increased risk for delayed bleed, but this has not yet been confirmed in the surgical
literature.
Recombinant factor VIIa has been used to avoid surgery in a pediatric patient but in light of both the cost of the
drug and the lack of randomized clinical trials should be used only in extreme circumstances where risk of surgery
outweighs the risk of massive thrombosis.
[11]

Interventional radiology
Splenic angioembolization is increasingly being used in both stable responders and transient responders for fluid
resuscitation under constant supervision by a surgeon with an operating room on standby. Femoral artery access
with embolization of the splenic artery or its branches can be accomplished with gel foam or metal coils. Such
treatment requires intimate cooperation between the trauma surgeon and the interventional radiologist. Not all
hospitals will have the proper facilities for such treatment, and any surgeon contemplating splenic
angioembolization for a patient should first make sure the hospital interventional radiology suite and personnel are
set up for rapid response at any hour of the day
Surgical therapy is usually reserved for patients with signs of ongoing bleeding or hemodynamic instability. In
some institutions, CT scanassessed grade V splenic injuries with stable vitals may be observed closely without
operative intervention, but most patients with these injuries will undergo an exploratory laparotomy for more
precise staging, repair, or removal. Adult surgeons may be more likely to operate in cases of splenic injury but less
likely to transfuse than their pediatric surgical colleagues.
[12]

Emergency celiotomy for hemoperitoneum with suspected splenic injury is performed through a midline abdominal
incision. Subcostal or chevron incisions do not provide the opportunity to easily explore the lower abdomen for a
hemorrhage site and cannot be performed as rapidly as a midline incision under emergency circumstances.
Intestinal and mesenteric injuries may be missed, or they may be difficult to repair appropriately with subcostal
incisions.
The splenic ligamentous attachments are taken down sharply or bluntly to allow for rotation of the spleen and the
vasculature to the center of the abdominal wound and to identify the splenic artery and vein for ligation. Medial
rotation also makes exposure of the hilum of the spleen easier and allows for possible identification of the splenic
artery bifurcation. Once the splenic artery and vein are identified and controlled by ligation, the short gastric
vessels are identified and ligated in similar fashion.
Ligating the splenic artery first, followed by the splenic vein, has the theoretical advantage of allowing some
conservation of intrasplenic blood. In an emergency life-threatening situation, the amount of blood conserved is not
worth the extra time it may take to isolate the vessels. Drains are typically unnecessary unless concern exists over
injury to the tail of the pancreas during operation.
In less emergent situations, splenorrhaphy is the preferred method of surgical care. Multiple techniques are
described in the literature, but they all attempt to tamponade active bleeding either by partial resection and
selective vessel ligation or by putting external pressure on the spleen via an absorbable mesh bag or sutures. Both
"make it yourself" and commercial products are available for this purpose. In patients with capsular injury, the
electrocautery or argon beam coagulator device may provide adequate hemostasis and allow for splenic
preservation
As most operations for splenic injury are a result of patient instability, standard emergency protocols are instituted,
including obtaining 2 wide-bore (16F or larger) IVs for vascular access, 4-6 units of blood for surgery, nasogastric
or orogastric tubes for decompression, and a Foley catheter to monitor urine output. Extensive blood work or
coagulation profiles are rarely helpful in the emergent setting.
Good communication with the anesthesiologist minimizes the chances for iatrogenically induced problems.
Opening the midline fascia on entry into the belly often results in decreasing pressure on the damaged spleen and
increased bleeding with hypotension. Keeping the anesthesiologist informed of surgical progress and actions can
minimize potential complications of this nature. In most trauma situations, all 4 quadrants of the abdomen are
packed with laparotomy pads, which are removed as the search for the bleeding site commences. Presence of a
splenic injury on CT scan does not preclude the potential of a bleeding mesenteric tear, consequently, all patients
should have a thorough examination of the abdomeneven if preoperative studies show an isolated splenic injury.
The postoperative course is usually 5-14 days, depending on associated injuries. Recurrent bleeding in the case of
splenorrhaphy or new bleeding from missed or inadequately ligated vascular structures should be considered in
the first 24-48 hours. The author's practice is to maintain a nasogastric tube on low intermittent suction for 48 hours
to minimize the risk of a ligature failure on short gastrics with a distended stomach. Other authors prefer to suture
ligate the short gastric vessels and to keep a nasogastric tube on low continuous suction to avoid this problem.
Patients should also be evaluated for immunizations against Pneumococcusspecies as a routine of postoperative
management. Some authors and some centers also routinely vaccinate
for Haemophilus and Meningococcus species. Various authors suggest immunization should be administered
anywhere from 24 hours after injury to 2 weeks, citing studies of the improved physiologic response from
vaccination after the immediate postoperative period. This must be weighed against the possibility of loss of follow-
up care and missing the vaccination entirely. The author's practice is to immunize all patients prior to discharge.
The US Centers for Disease Control and Prevention (CDC) recommends revaccination with pneumococcal vaccine
after 4-5 years one time only. A third booster is not recommended because there is no proof it improves protection
from postsplenectomy sepsis, but there is proof that it may cause serious adverse effects. Splenic function is
difficult and expensive to measure. Unfortunately, little current data exist regarding the efficacy of surgical
treatment, whether operative or conservative.
Patients should be warned about the increased risk of postsplenectomy sepsis and should consider lifelong
antibiotic prophylaxis for invasive medical procedures and dental work. Although the lifelong incidence of
postsplenectomy sepsis has been estimated to be 0.03-0.8%, the mortality rate of those developing the
complication approaches 70%. Adequate education of the signs and symptoms of pneumococcal infection should
be stressed.
Complications of nonoperative care include delayed bleeding, splenic cyst formation, and splenic necrosis.
Complications of splenorrhaphy include rebleeding and thrombosis of the residual spleen as well as complications
related solely to the laparotomy.
Complications of splenectomy include bleeding from short gastrics or splenic vessels and the most feared but most
rare complication, infection by encapsulated organisms such as Pneumococcus.
Material used for compression wrap of the spleen in splenorrhaphy is often woven and may mimic bubbles in an
abscess on postoperative CT scans. Gel foam used for angioembolization may also falsely mimic an abscess on
CT scans. Communication with the radiologist about the presence of splenic wrapping material on any
postoperative CT scans will decrease the chance of this false-positive result.
Accessory splenic tissue and reimplantation of splenic tissue have never been reliably proven to minimize the risk
of postsplenectomy sepsis. Once the spleen has been removed, patients should be considered to be at risk for
encapsulated organism infections for the rest of their lives. Shatz et al noted improved postoperative response to
immunization at day 14, with subsequent studies showing no further improvement at day 28.
[13, 14]

Angioembolization of the spleen can result in noninfectious-related febrile events, sympathetic pleural effusions,
and left upper quadrant abscesses. Femoral arteriovenous fistulas and iliofemoral pseudoaneurysms have also
been reported.
[15, 16]

Posttraumatic splenic pseudocysts are being reported more frequently now that nonoperative management has
become the norm.
[17]
Optimal management is still unknown but probably requires partial or complete splenectomy
to minimize morbidity and mortality.
Splenic abscesses and pancreatitis with sterile abscesses are being reported more frequently with Gelfoam
embolization and with more proximal embolization procedures.
[18, 19]

Thrombocytosis with platelet counts above 1 million/mm
3
have been linked to thrombotic vascular events such as
deep vein thrombosis, pulmonary embolus, or occlusive stroke. Although very little good data exist, many surgeons
treat persistent thrombocytosis with a daily baby aspirin.
Pancreatic injury, pancreatitis, subphrenic abscess, gastric distension, and focal gastric necrosis have also been
reported after both angioembolization and splenectomy for trauma.
Recent multi-institutional studies by the Eastern Association for the Surgery of Trauma demonstrate that mortality
from splenic injury still occurs, even in Level 1 trauma centers. Overall, outcome from grade 1-2 splenic injuries
remains excellent but not perfect, and outcome worsens as the injury grade increases.
Prognosis is usually excellent, but those patients left asplenic by their injuries and surgery increase the risk of fatal
and debilitating infection for the remainder of their lives.
Numerous papers have recently emerged in the literature comparing the practice and the outcome in different
levels of trauma centers and comparing trauma and nontrauma centers.
[20, 21, 22]

The risk of complications or failure of nonoperative management appears to be worse in patients older than 55
years, and women older than 55 years are significantly more likely to fail nonoperative management with an
increased mortality.
Multisystem injury or concomitant liver, pancreas, or bowel injury increases the likelihood of splenectomy.
Improved splenic trauma care and salvage rates can be shown in both trauma centers and nontrauma centers,
though treatment pattern differences are evolving. Operative treatment with isolated injury is more likely at low-
volume centers, but overall salvage rates for nonoperative management are similar between low- and high-volume
centers.
Isolated splenic injury is more likely to have nonoperative or interventional radiologic management in a trauma
center, but observant management is also more costly in these centers. Patients with multisystem injury in informal
and formal trauma systems are more likely to be transferred to a trauma center, and splenic salvage rates in these
patients are less than with isolated injury
Improvements in diagnostic technology, such as helical CT scanners and portable ultrasound, will go far to
diagnose and stratify risk in patients with splenic injury. Future multi-institutional trials and data collection may
make it possible to better identify those patients at risk for persistent bleeding and to minimize the need for
operative intervention and splenectomy in all but a few patients. Improvements in knowledge of immunology may
lead to more effective immunizations for patients who are asplenic and further minimize their risk of deadly
infection.
Increased availability and ease of access to interventional radiologic equipment and personnel, especially in rural
hospitals, may salvage splenic injuries that previously required operative intervention and splenectomy.
The controversy over when to operate, when to embolize and when to observe will likely continue for the next
millennium, but the debate will spur the continued development of diagnostic and evaluative tools, further
minimizing morbidity and mortality caused by splenic injury
http://emedicine.medscape.com/article/432823-treatment#a28


INTRODUCTION
The spleen is a hematopoietic organ capable of supporting elements of the erythroid, myeloid, megakaryocytic,
lymphoid, and monocyte-macrophage (ie, reticuloendothelial) systems [1]. As such, it is important in the following
situations:
The spleen participates in cellular and humoral immunity through its lymphoid elements. (See "The adaptive
cellular immune response" and "The humoral immune response".)
The spleen is involved with the removal of senescent red blood cells, bacteria, and other particulates from
the circulation through elements of the monocyte-macrophage system. An increase in this function (ie,
hypersplenism) may be associated with varying degrees of cytopenia, while removal of the spleen (ie,
asplenia) may render the patient susceptible to bacterial sepsis, especially with encapsulated organisms [2].
(See "Extrinsic nonimmune hemolytic anemia due to mechanical damage: Fragmentation hemolysis and
hypersplenism", section on 'Extravascular nonimmune hemolysis due to hypersplenism' and "Clinical features
and management of sepsis in the asplenic patient" and "Prevention of sepsis in the asplenic patient".)
Splenectomy in patients with various hematologic disorders (eg, polycythemia vera, essential
thrombocythemia, thalassemia, stomatocytosis) has been associated with an increased incidence of vascular
complications, including venous and arterial thrombosis and pulmonary hypertension [2,3].
Normally, approximately one-third of circulating platelets are sequestered in the spleen, where they are in
equilibrium with circulating platelets.

INTRODUCTION
Surgical management is required in approximately 20 to 40 percent of patients sustaining splenic injury. Open
surgical techniques are the current standard of care and are typically used to manage the injured spleen, though
laparoscopic techniques have been described in case reports and small series.
This topic will discuss the indications and techniques of exploratory laparotomy in the setting of trauma,
hemorrhage control from the spleen, splenic salvage and splenectomy.
Nonoperative management of splenic injury is discussed elsewhere. (See "Management of splenic injury in the
adult trauma patient".)
INDICATIONS FOR EXPLORATION
We perform initial resuscitation, and diagnostic evaluation of the trauma patient is based upon the Advanced
Trauma Life Support (ATLS) program established by the American College of Surgeons Committee on Trauma.
Emergent abdominal surgical exploration is indicated for the hemodynamically unstable trauma patient who has a
positive focused assessment with sonography in trauma (FAST exam) or diagnostic
peritoneal aspiration/lavage (DPA/DPL) to control life-threatening hemorrhage, which may be due to an injured
spleen. (See "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial evaluation and
management of abdominal gunshot wounds in adults" and "Initial evaluation and management of abdominal stab
wounds in adults"and "Initial evaluation and management of blunt thoracic trauma in adults".)
The hemodynamically stable trauma patient with splenic injury identified on computerized tomography (CT scan)
may be initially observed or undergo angiographic embolization as an adjunct to observational management.
However, observational management requires adequate resources, and if unavailable, initial surgical management
should be considered depending on the patients medical comorbidities. (See "Management of splenic injury in the
adult trauma patient", section on 'Management approach'.)

The spleen is a hematopoietic organ capable of supporting elements of the erythroid, myeloid, megakaryocytic,
lymphoid, and monocyte-macrophage (ie, reticuloendothelial) systems [1]. As such, it is important in the following
situations:
The spleen participates in cellular and humoral immunity through its lymphoid elements. (See "The adaptive
cellular immune response" and "The humoral immune response".)
The spleen is involved with the removal of senescent red blood cells, bacteria, and other particulates from
the circulation through elements of the monocyte-macrophage system. An increase in this function (ie,
hypersplenism) may be associated with varying degrees of cytopenia, while removal of the spleen (ie,
asplenia) may render the patient susceptible to bacterial sepsis, especially with encapsulated organisms [2].
(See "Extrinsic nonimmune hemolytic anemia due to mechanical damage: Fragmentation hemolysis and
hypersplenism", section on 'Extravascular nonimmune hemolysis due to hypersplenism' and "Clinical features
and management of sepsis in the asplenic patient" and "Prevention of sepsis in the asplenic patient".)
Splenectomy in patients with various hematologic disorders (eg, polycythemia vera, essential
thrombocythemia, thalassemia, stomatocytosis) has been associated with an increased incidence of vascular
complications, including venous and arterial thrombosis and pulmonary hypertension [2,3].
Normally, approximately one-third of circulating platelets are sequestered in the spleen, where they are in
equilibrium with circulating platelets