Injury to the spleen is one of the more serious problems associated with trauma. Emergently there is the possibility of exsanguination. However, for the remainder of the patient's life after splenectomy, there is the possibility of catastrophic bacterial infection with encapsulated organisms, such as pneumococci, especially in the very young. This has stimulated clinicians to conserve the spleen with or without operation. Nonoperative treatment in children is often successful if careful monitoring is provided in-hospital and thereafter at home until full healing is documented. Additionally, in adults as well as in children, splenorrhaphy is often possible, as 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 the patient, but many 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 CT scans are invaluable in demonstrating 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 as occult hemorrhage may result in sudden hypotension and shock. The decision for or against nonsurgical treatment of a splenic injury should be based upon 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 as this indicates a free or noncontained rupture of the spleen.
Familiarity with the major blood supply of the spleen is required if salvage of the 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 (Plate 141). A bulldog clamp can be applied temporarily to the splenic artery and this will lessen the massive bleeding as the surgeon mobilizes up the extensively damaged spleen. The clamp is applied proximally as 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 as well as the retroperitoneal splenic artery and vein.
Evidence of shock associated with a falling hematocrit or hemoglobin should be viewed with alarm and result in early surgical intervention. The patient with a potential splenic injury should be typed and cross-matched while reserving several units of packed red cells or blood at all times. The importance of sustained observation day and night in a patient treated nonsurgically cannot be overemphasized, since the decision for surgical intervention can come at any time!
Hypotension and shock must be treated with adequate volumes of fluid and blood. A tendency to recurrent hypotension after resuscitation should be viewed with alarm and early surgical intervention undertaken. CT scans of the spleen in a stable patient can provide significant help in establishing the location, extent, and progress of the injury.
A general anesthesia is required. Large-bore venous access catheters are placed in both arms for rapid administration of blood, fluids, and medications.
Because of associated injury, the supine position may need to be altered. The patient is usually placed flat upon the table, thus preserving the option to accomplish a Trendelenburg position if shock develops.
Nasogastric intubation is useful in improving exposure by lessening gastric dilatation. Antibiotics are given, and a routine preparation of the skin of the upper abdomen and left side of the lower chest is rapidly performed.
A midline or left subcostal incision is made. The latter may provide a better exposure when the splenic trauma is severe, whereas the midline incision may be useful if other associated intra-abdominal injuries are suspect.
One of the more common minor injuries to the spleen may occur during an upper abdominal procedure when traction is placed upon adjacent structures which have attachments to the surface of the spleen. The resultant tear in the capsule of the spleen can lead to a slow loss of blood (Figure 2). Such superficial injuries should be recognized early. Compression with a gauze sponge is applied to the denuded area for several minutes, remembering that clotting times are usually in the range of 6 to 8 minutes. If the bleeding persists, microfibrillar collagen is applied directly to the spleen and further gauze compression is given.
In the presence of major fracture of the spleen, a large gauze pad or towel is placed over the spleen to enable medial traction by the surgeon's left hand (Figure 3). This left hand also compresses the spleen so as to provide some control over the bleeding. Blood in the left lumbar gutter is aspirated by suction and an incision is made in the splenorenal ligament several centimeters away from the capsule of the spleen (Figure 4). This incision is extended upward to free the spleen from the base of the diaphragm. The spleen and tail of the pancreas are mobilized and lifted anteriorly and medially, as shown on Plates 141 and 142. If splenic preservation rather than splenectomy is to be attempted, temporary control of the splenic artery is obtained with a bulldog or vascular clamp. Finger compression of the splenic pedicle may be utilized until the clamp is applied through either an anterior (Plate 141) or posterior (Plate 142) approach. Salvage of the spleen that appears to be badly injured may become feasible after control of the arterial inflow slows the bleeding such that a more thorough evaluation of the spleen and its vascular pedicle can be made.
The success of saving the spleen depends first upon the extent of damage from the trauma and second upon the effective compression of the lacerated splenic tissue with interrupted sutures. The splenic tissue is quite friable and some prefer to fill the crevice of the injury with hemostatic material such as microfibrillar collagen and then hold the cavity material in place with a series of carefully placed interrupted sutures which gently compress the spleen (Figure 5). Alternatively, the adjacent omentum may be mobilized on a viable vascular pedicle so as to fill the cavity created by the laceration. Again mattress sutures are used to hold the omentum in place so as to approximate the margins of the laceration and minimize further bleeding.
Laceration of the midportion of the spleen with extension into the hilum is usually considered an indication against splenic conservation. However, laceration involving either pole of the spleen may be controlled by isolating the appropriate artery and vein within the hilus that supplies the polar region of the organ. After dividing the gastrosplenic ligament and securely ligating the short gastric blood vessels, control of bleeding is enhanced by freeing up a segment of the splenic artery for the application of a bulldog clamp. The major arterial and venous vessels heading to the lower pole of the spleen are dissected free, ligated, and divided (Figure 6).
The devascularized section of the lower pole of the spleen is demarcated by its change in color and this ischemic damaged section is excised using cautery (Figure 7). The bulldog clamp on the splenic artery can be released after the polar splenic artery and vein branches of the major splenic vessels are divided and ligated. Active bleeding points are ligated by fine absorbable or silk sutures. Mattress sutures tied over Gelfoam pledgets may be required to control the bleeding (Figure 8). Additional hemostasis can be obtained using the argon-beam electrocoagulation system. It is desirable to have the raw splenic surface as dry as possible before microfibrillar collagen is applied.
The surface is compressed with a dry gauze sponge. If no active bleeding occurs after 5 to 10 minutes, the spleen is returned to the left upper quadrant after inspecting the cut edge of the splenorenal ligament for hemostasis.
Closure is delayed if there is any uncertainty about continued slow bleeding. Accessory spleens need not be excised, but all free splenic tissue should be removed to avoid subsequent splenosis. The tail of the pancreas is inspected to determine if pancreatic tissue has been injured. If disruption of the pancreatic tail is found, the pancreatic duct should be ligated if it is visible. Mattress sutures may be placed through the anterior and posterior capsules of the pancreas so as to compress the cut end. Alternatively, the pancreas may be divided with a stapling instrument. A Silastic closed-suction catheter may be placed in this region although, in general, catheter drainage in a splenectomy site is to be avoided as it may increase the hazard of subphrenic abscess.
It is important to evaluate the liver and other intra-abdominal organs that also may have been injured. After a final look at the spleen to verify viability and hemostasis, the abdominal incision is closed. This is done in a routine manner after all bleeding points have been ligated. Skin staples or subcuticular closure may be used for skin approximation.
Frequent monitoring is required for several days and additional transfusions may be needed. Many surgeons maintain nasogastric decompression for a few days until gastrointestinal function resumes. This lessens the chance of gastric dilation, which may dislodge ligatures on the short gastric vessels along the greater curvature of the stomach. Vigorous pulmonary toilet may be necessary to avoid atelectasis and pneumonia, especially if rib fractures are present. The patient should be observed for signs and symptoms of a subphrenic abscess or an unrecognized pancreatic leak. If the injured spleen is removed, polyvalent vaccines for pneumococcus, Haemophilus influenzae, and Neisseria meningitidis are given except to pregnant patients and children below 2 years of age. Antibiotics may be given prophylactically to the very young patient after splenectomy. Both children and adults should be advised to seek medical attention without delay if signs of infection develop at any time for the remainder of their lives.