Operative Management of The

Spleen
American Association for the Surgery of
Trauma
Organ Injury Scale
 Demographics Spelnic Trauma
from National Trauma Data Bank
 Mechanism
• Powel et al, 411 patients (293 adults and
118 children)
• MVC: 67%adults 24% children
• Motorcycle crash: 9%adults 1%children
• Sports injury: 2%adults 17%children
• Falls: 9% adults 25% children
• PHBC: 4% adults 11% children
• Bicycle crash 1% adults 9% children

Powell M, Courcoulas A, Gardner M, et al: Management of blunt splenic trauma:

Significant differences between adults and children. Surgery 1997; 122:654-660
 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
Management of splenic injuries
2000–2007

Miami Valley Hospital, Dayton, OH

A.P. Ekeh et al. Splenic artery embolization and splenic trauma
Current practice
 Outcomes of Intraabdominal Solid Organ
Injuries in Combination with All Other Intra-
and Extraabdominal Injuries

Tinkoff et al American Association for the Surgery of Trauma

Organ Injury Scale I: Spleen, Liver, and Kidney,
Validation Based on the National Trauma Data Bank
j.jamcollsurg.2008.06.342
 Immediate Splenectomy
• Penetrating Injury
• Patient is unstable
• Other injuries require surgical therapy
• Spleen is extensively injured with
continuous bleeding
• Bleeding is associated with hilar injury.

No longer universally accepted

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

No longer universally accepted

 Splenectomy

Peter Mucha, Jr Splenic Injury Operative Techniques in General Surgery,

Vol 2, No 3 (September), 2000: pp 192-205
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.

Khatri V, Asensio JA: Operative Surgery

Manual.
Philadelphia, WB Saunders, 2002, p. 189
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
• Overwhelming post-splenectomy sepsis is a rare
(less than l%) but potentially fatal complication of
splenectomy.
• 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.
• Otherwise Normal adults are susceptible to
similar infections following splenectomy most
common sepsis from pneumococcus but much
reduced rate
 Vaccination and chemoprophylaxis
guidelines for patients after splenectomy
 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

Merchant, P. Bhanot, and S.R.T. Evans

Management of Intraoperative Splenic Injury
optechgensurg.2008.04.003
 Grade 1-2

• Deeper
lacerations
Suture repair
• Thicker
capsule in
children holds
suture better
 Adults

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
 Grade 3-4
Mesh wrapping
provides for
tamponade. The use
of absorbable mesh 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.
 Controversy
• Expanding the role of NOM
– Re-evaluating contra-indications
– Reevaluating utility of grading system
 NOM failure
• Some criticized NOM grade 4/5 injuries
• Increased failure over age 50
• The failure rate of nonoperative
management in aggregate for a large
multi-institutional study was 10.6%, but
varied from 4.8% for grade I injuries to
75% for grade V injuries.

Current Therapy of Trauma and Surgical Critical care

 Controversy

N. Kaseje et al Splenectomy avoidance in trauma patients

The American Journal of Surgery, Vol 196, No 2, August 2008
 Management
Systems have
base treatment
decisions
• Hemodynamic
Stability/Phys
reserve
• Extent of injury
• Ongoing blood
loss
• Associated
Injuries

Cameron: Current Surgical Therapy, 9thed

 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
 East
• Neither grade of injury nor degree of
hemoperitoneum on CT predict the outcome of
nonoperative management
• The presence of a contrast blush on the vascular
phase of the CT examination of the spleen may
portend failure of nonoperative management.
• Hemodynamic status remains the most reliable
criteria for nonoperative management
 WTA
• Western Trauma Association 2008 position
• Angioembolization (AE) historic reported failure
rate of 12% to 13% have dropped to as low as
2%
• Advanced age, fear of missing a hollow viscus
injury (HVI), 2 units of packed red blood cell
transfusion, neurologic impairment, and high
grades injuries no longer contra-indications to
NOM
• Hemodynamic instability not an immediate
indication for splenectomy
WTA
 WTA Hemodynamic Instability Score
• Grade 0: No significant hypotension (systolic blood
pressure SBP<90 mm Hg) or serious tachycardia (heart
rate HR> 130)
• Grade 1: Hypotension or tachycardia by report but none
recorded in emergency department (ED)
• Grade 2: Hypotension or tachycardia responsive to initial
volume loading with no ongoing fluid or PRBC
requirement
• Grade 3: Hypotension or tachycardia responsive to initial
volume loading with modest ongoing fluid (250 mL/h) or
PRBC requirement
• Grade 4: Hypotension or tachycardia only responsive to
2 L of volume loading and the need for vigorous ongoing
fluid infusion (250 mL/h) and PRBC transfusion
• Grade 5: Hypotension unresponsive to fluid and PRBC
transfusion
 At Present
• Stable candidate for NOM
• CT
– Angio if necessary ( Blush [Grade >3])
• Failure NOM:
– Becomes HD Unstable
– Falling Hct
– Peritonitis

Current Therapy of Trauma and Surgical Critical care

Hemodynamically unstable at presentation
• Ultrasound
• Diagnostic peritoneal lavage
– intraperitoneal hemorrhage should be
explored.
• If splenic injury is found,
splenectomy/Splenoraphy

Current Therapy of Trauma and Surgical Critical care

• Angiography of the splenic artery should
be considered in patients with grade III
and higher splenic injuries
Singer DB. Post-splenectomy sepsis.
Perspectives
in pediatric pathology, 1973.
• Most pediatricians believe that children who have
undergone splenectomy before the age of 5 years
should be treated with a daily dose of penicillin until the
age of 10 years. The benefit of prophylactic penicillin is
less clear in children over 5 years old and in adults. All
patients who have undergone non-elective splenectomy
should be immunized with Pneumovax (a non-viable
pneumococcal vaccine). When planning elective
splenectomy, patients should be immunized with
Pneumovax, and against H. influenza and
meningococcus, preferably two or more weeks before
operation.
Bee TK, Croce MA, Miller PR, et al:
Failures of splenic nonoperative management: Is the glass half empty or half full?
J Trauma 50:231, 2001
N. Kaseje et al Splenectomy avoidance in trauma patients
The American Journal of Surgery, Vol 196, No 2, August 2008