Injury to the spleen is one of the more serious problems associated with trauma. Serious splenic injury can lead to emergent possible exsanguination. Splenectomy, however, confers a small but measurable risk of catastrophic bacterial infection with encapsulated organisms such as pneumococci, especially in children, for the remainder of the patient’s life. This risk has stimulated clinicians to conserve the spleen with or without operation. Nonoperative treatment in children and adults is often successful if careful monitoring is provided in hospital and thereafter at home until full healing is documented. In addition, angiographic embolization may be used to control splenic bleeding. In adults as well as in children, splenorrhaphy is often possible because it is desirable to salvage as much of the traumatized spleen as possible. It is uncertain how much retained spleen is essential to provide normal protection for patients, but many surgeons recommend preservation of half or more if possible. The surgeon must appreciate that it is essential to control exsanguination and that total splenectomy should be performed for splenic fractures that are massive or that cannot be easily controlled in the presence of continued major hemorrhage.
Rib fractures (especially those in the left lower and posterior region) and an elevated left diaphragm on roentgenograms of the chest are suggestive of splenic injury. Abdominal computed tomography scans are invaluable to demonstrate splenic injury, and their findings may support a decision for or against immediate splenectomy. Early operation should be considered when the scan shows a fracture that extends into the hilum of the spleen. The patient with splenic injury who is managed with observation must be evaluated frequently because occult hemorrhage may result in sudden hypotension and shock. The decision for or against nonsurgical treatment of a splenic injury should be based on clinical judgment rather than solely on radiographic findings. If the diagnosis is not clear, a peritoneal tap or lavage yielding an obviously bloody return can be helpful in supporting surgical intervention because this indicates a free or noncontained rupture of the spleen.
Familiarity with the major blood supply of the spleen is required if salvage of a portion of the spleen is to be successful (FIGURE 1). The major splenic artery and vein run just under the peritoneum along the top of the pancreas. The easiest accessibility to the vessels occurs through an opening in the gastrocolic omentum (see Chapter 94). A bulldog clamp can be applied temporarily to the splenic artery, and this will lessen the massive bleeding as the surgeon mobilizes the extensively damaged spleen. The clamp is applied proximally because the splenic artery within the hilum divides into three terminal vessels, each supplying approximately one-third of the spleen. It is important to remember that the spleen has a dual blood supply, namely the short gastric vessels from the greater curve of the stomach in the gastrosplenic ligament and the retroperitoneal splenic artery and vein.