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Injuries of the Spleen

  • The spleen is the most commonly affected organ in blunt injury to the abdomen

Etiology

  • Blunt trauma – direct blows to abdomen e.g. seat belt injuries motor vehicle accidents
  • Penetrating trauma – gunshot, stab wounds
  • Combination of blunt and penetrating – explosives

Pathophysiology

  • Though normally protected by its anatomical position (under bony ribcage), pre-existing illness can increase risk and severity of splenic injury
  • Conditions such as infectious mononucleosis, malaria, hematologic abnormalities etc can cause acute or chronnic enlargement of the spleen – leads to thinning of capsule which makes the spleen more fragile
  • As a result, a minor impact in patients with splenomegaly can result in major injury
 Types of injury
  • Splenic subcapsular haematoma – after initial injury patient remains asymptomatic for a short time
    • But haematoma ruptures later, causing torrential haemorrhage (latent period of Bandet – see below)
  • Clean incised wound over the surface
  • Lacerated wound
  • Splenic hilar injury – causes torrential haemorrhage and death
    • Immediate surgical intervention and splenectomy is needed

Classification – AAST Classification

Grade I

  • Capsular tear <1cm parenchymal depth
  • Subcapsular hematoma <10% surface area

Grade II

  • Capsular tear 1-3cm parenchymal depth
  • Subcapsular hematoma 10-50% surface area or intraparenchymal <5cm

Grade III

  • Capsular tear >3cm parenchymal depth or any tear involving trabecular vessels
  • Subcapsular hematoma >50%, or intraparenchyma >5cm, or any expanding/ruptured hematoma

Grade IV

  • Laceration involving segmental or hilar vessels, devascularising >25% of spleen

Grade V

  • Completely shattered spleen or hilar vascular injury, devascularising the entire spleen

Clinical features

  • Left upper quadrant pain
  • Kehr’s sign – referred pain to the left shoulder due to sub-diaphragmatic nerve root irritation
  • Ballance’s sign – dullness in the left flank which doesn’t shift as a result of clotting of the collected blood
  • Latent period of Bandet – delayed presentation because subcapsular haematoma initially seals off bleeding, but then eventually dislodges and causes torrential bleeding
  • Free intraperitoneal blood – diffuse abdominal pain, peritoneal irritation, rebound tenderness (Blumberg sign), tachycardia, pallor
  • Hypotension in a patient with suspected splenic injury is a potential surgical emergency

Complications

  • Blood loss, disseminated intravascular coagulation, sepsis
  • Splenic artery pseudoaneurysm

Investigations

  • Blood – FBC, Hb
  • CT
  • FAST Ultrasound –presence/absence of peritoneal fluid
  • MRI – for patients with renal failure or contrast allergy
  • Diagnostic peritoneal lavage (DPL) – rapidly determines if intraperitoneal blood is present

Treatment

  • Assessment and resuscitation – advanced trauma life support (ATLS) and ABCDE
  • There are two categories of patients
    • Haemodynamically stable – patients can be treated conservatively in the ICU with close observation
    • Haemodynamically unstable – low blood pressure and high heart rate
      • Important to identify cause and location of bleeding by exploratory laparotomy

Splenectomy

  •   Total splenectomy – through a midline/left subscostal incision

    • There is a risk of overwhelming post-splenectomy infection (OPSI) – because patient cannot accumulate a normal immunological response to bacteria
    • Post-splenectomy vaccination needed – against pneumococcus, meningiococcus, H. influenza
    • Prophylactic penicillin V
  • Partial splenectomy – where either the upper or lower branch of the splenic artery is retained

Splenorrhaphy

  • For clean, incised wounds
  • Suturing of wound with placement of gel foam, topical thrombin and mesh wrap
  • Advantage – avoids OPSI
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