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KEY POINTS

KEY POINTS

  • A high suspicion for splenic injury should exist when patients present with signs or symptoms of trauma to the left upper quadrant or thoracoabdominal region.

  • In hemodynamically stable patients, dual-phase, multidetector computed tomography scan of the abdomen with intravenous contrast allows grading of splenic injuries and aids in clinical decision making.

  • The revised Organ Injury Scale from the American Association for the Surgery of Trauma incorporates vascular injury and active bleeding as grade IV and grade V injuries.

  • For patients with splenic vascular injury or active bleeding, angiography and embolization can significantly increase the success rate of nonoperative management over observation alone.

  • If nonoperative management for splenic injury is undertaken, serial physical exams are imperative for avoiding missed injuries to the hollow viscera.

  • For patients requiring surgical intervention, mobilization of the body and tail of the pancreas with the splenic hilum allows full mobilization of the spleen for examination and appropriate surgical treatment.

  • The incidence of overwhelming postsplenectomy infection is exceptionally rare, but vaccination in the postoperative period remains the current standard of care.

Splenic injuries demonstrate themselves clinically more often than do hepatic injuries, making it the most commonly injured solid viscus requiring laparotomy. During the past 50 years, there has been increasing interest in the notion that not all splenic injuries require splenectomy. Nonoperative management with close observation is safe in appropriately identified patients. There is also increasing evidence supporting the safety of selective angioembolization; however, optimal patient selection is still critical. Although the paradigm has shifted toward frequent consideration of nonoperative management, it is important to always keep in mind that patients with splenic injury can succumb to hemorrhage.

HISTORICAL PERSPECTIVE

The spleen has been subject to injury for as long as man has suffered trauma. In ancient India, where malaria was endemic and large, fragile spleens were commonplace; intentional injury of the spleen was a method of assassination. Paid assassins called thuggee carried out their mission by delivering a blow to the left upper quadrant of the intended victim. They hoped to cause splenic rupture, and if this were severe enough, the targeted would bleed to death.

Ancient Greeks and Romans felt the spleen to play a significant role in human physiology. Aristotle thought that the spleen was on the left side of the body as a counterweight to the right-sided liver.1 He believed that the spleen was important in drawing off “residual humors” from the stomach. The close relation of the stomach and spleen and the presence of the short gastric vessels so important in present-day splenic mobilization likely encouraged this belief. The spleen was also felt to “hinder a man’s running,” and Pliny reportedly claimed that “professed runners in the race that bee troubled with the splene, have a devise to burne and waste it with a hot yron.”2 The exceptional speed of giraffes was felt to be ...

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