Splenic Preservation and Splenic Trauma
Craig P. Fischer, Frederick A. Moore
Indications and Contraindications
Indications
■Injuries to the spleen, when patients are hemodynamically stable.
Contraindications
■Hemodynamic instability
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Life-threatening concomitant injuries which are likely to cause hemodynamic compromise in the postoperative period, e.g., severe liver injuries or significant pelvic fractures
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Coagulopathy – the most common cause of coagulopathy in this patient group is hypothermia
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Grade V injuries or the pulverized spleen
Preoperative Investigation and Preparation for the Procedure
Clinical Evaluation
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Hemodynamic status, mechanism of injury, other trauma, co-morbidities, age
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Patients who fail non-operative management of blunt splenic injury are usually good candidates for attempted splenic repair. Splenic salvage may also be appropriate when laparotomy is performed for other indications such as penetrating abdominal injury or bowel injury
CT Scan
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Hemodynamically stable patients should undergo a CAT scan of the abdomen and pelvis with oral and intravenous contrast.
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Two large bore intravenous catheters should be placed as well as an indwelling
urinary catheter and nasogastric tube.
Procedure
STEP 1
Incision – midline
A subcostal incision should not be used in trauma, even if the only suspected injury on preoperative investigations is a splenic injury.
Exposure
See chapter “Open Splenectomy.” An initial exploratory laparotomy is performed.
The left upper quadrant should be initially packed with laparotomy pads, then the self-retaining retractor adjusted to facilitate exposure of the left upper quadrant. Gentle pressure on the area of splenic injury with a laparotomy pad will help decrease blood loss.
Mobilization
See splenic mobilization in the chapter “Open Splenectomy.”
STEP 2
The lesser sac is entered, somewhat to the left along the greater curvature. The use of an
endovascular stapling device will facilitate this step as it is long, and capable of angula-
tion. Generally two applications of a 45-mm stapler will allow rapid, wide access to the
lesser sac. The splenic artery superior to the pancreas should be identified and may be
temporarily clamped if significant bleeding is encountered (see chapter “Open Splenec-
tomy”). Be sure the artery is dissected away from the pancreas and does not contain
arteriosclerotic plaque before clamping.
STEP 3
With complete splenic mobilization, the spleen is grasped (A). Again, a laparotomy pad is applied to the area of injury. Initial attempts to control bleeding may include simple hemostatic agents, the use of the argon beam coagulator for surface injuries, and suture ligation for deep parenchymal injuries.
If injury is to a single pole of the spleen, the distal polar branches of the splenic artery may be ligated within the lesser sac, close to the splenic hilum (B). Again, the addition of hemostatic agents and gentle pressure is used.
If initial attempts at hemostasis are unsuccessful, a pledget repair may be used (C,
D).The splenic capsule in adults will not hold a stitch – use an appropriate pledget, such as Teflon, felt or autogenous tissue (e.g., posterior rectus sheath). A horizontal mattress technique is used with 3-0 Prolene.
Prior to tying the knots, fibrin glue should be applied to the cleft or site of injury (C).
The use of a spray applicator for the application of fibrin glue is recommended, but
not necessary.
STEP 4
An additional technique that can be used in conjunction with a pledget repair, or alone, is the use of a woven mesh (A). A sheet of appropriate material such as polyglycolic acid is obtained and a center cut is made to allow passage of the splenic vessels via the hilum.
This technique is particularly useful when capsular injury is encountered. Fibrin sealant should be applied, via an aerosolized technique, to the injured area of the spleen. For the use of a wrap to be successful, all of the short gastric vessels must be ligated to fully mobilize the superior pole and allow for a circumferential application of the wrap.
After application of fibrin glue, the woven mesh is closed circumferentially with a running absorbable suture (B). Care is taken to ensure the mesh is tightly applied to ensure hemostasis and that an adequate opening is left at the hilum that does not encumber either the splenic artery or vein.
Another technique in splenic salvage is ligation of the splenic artery and vein. This is successful in spleen preserving distal pancreatectomy, and the surgical technique is identical. The splenic artery and vein are ligated en masse with an endovascular stapler.
Care must be taken not to ligate the short gastric vessels in this case. Additional use of simple hemostatic measures will give a satisfactory result – the spleen will not infarct if the short gastric vessels are left intact.
A
B
Postoperative Tests
See chapter “Open Splenectomy.”
Postoperative Complications
See chapter “Open Splenectomy.”
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Splenic infarction or splenic abscess is uncommon after splenic repair.
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Postoperative bleeding requiring reexploration. If bleeding (or fresh clot) at site of repair, splenectomy is indicated.
Tricks of the Senior Surgeon
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Do not repair a spleen if it is not bleeding.
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When performing splenic repair early in one’s experience, choose the right patient. This generally is a young patient with few other life-threatening injuries.
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Do not accept blood loss while performing the repair – if you cannot quickly stem major hemorrhage, remove the spleen.
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If the patient continues to bleed postoperatively, reoperate promptly.
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