SPLENIC INJURIES

DR.M.GUNASEKARAN M.S., S2 UNIT

SPLEEN

2nd most commonly injured solid organ in blunt injury abdomen after liver

Situated against 9-11 ribs

SURGICAL ANATOMY

Developed from dorsal mesogastrium

In children,necessary for both reticuloendothelial and RBC production

Pediatric spleen has thicker capsule and tough parenchymal consistency which implies reduced need of operative intervention

Adult spleen weight about 100-250g

Situated posteriorly left upper abdomen

Covered by peritoneum except at the hilum

Posterior and lateral surface related to left hemidiaphragm and posterolateral lower ribs

Lateral surface attached through splenophrenic ligament

Posteriorly related to left iliopsoas muscle & left adrenal glands

Posteriormedial surface related to body & tail of pancreas

Antromedially related to great curvature of stomach

Inferiorly related to distal transverse colon & splenic flexure

Lower pole attached to colon through splenicocolic ligament

These attachments require devision during mobilisation

BLOOD SUPPLY

Receives blood supply from celiac axis

1.spleenic artery2.short gastric

vessels that connect left gatroepiploic A. & splenic circulation along greater curvature of stomach

BLOOD SUPPLY

Drains through splenic vein & confluence with inferior mesentric vein

Through short gastric veins into left gastro epiploic vein

INITIAL ASSESMENT

Importance of history- 1.victims located on the left side of car

2.type & nature of weapon is important in penetrating injuries

3.caliber of the gun

ON EXAMINATION

Vitals are most important r/o left lower rib

tenderness 14% patients with left

lower rib tenderness have splenic injury

In children plasticity of chest will have splenic injury without rib #

Ecchymoses or abration over LUQ

SIGNS

Kehr sign-is symptom of pain near tip of left shoulder,bcz of reffered pain from the diaphragmatic irritation

P/A-generalised tenderness or LUQ tenderness

May present with tachycardia ,Tachypnea, anxiety , Hypotension (shock)

INVESTIGATIONS

In unstable patients necesesary investigation is hemoglobin,blood grouping and reservation of blood

No specific labaratory studies specific to splenic injuries

PLAIN RADIOGRAPH

The most common finding associated with splenic injury is left lower rib fracture. Rib fractures signify that adequate force has been transmitted to the LUQ to cause splenic pathology.

classic triad indicative of acute splenic rupture (ie, left hemidiaphragm elevation, left lower lobe atelectasis, and pleural effusion)

DIAGNOSTIC PERITONEAL LAVAGE In the past Mainstay

of diagnostic technique for abdominal trauma

Peritoneal lavage useful when USG not available

10ml of  blood  or  enteric  contents (stool, food, etc.) constitutes a positive DPL,

Other positive findings include more than 100,000 RBCs/mm3, 500 WBCs/mm3, amylase 175 IU, and detection of bile, bacteria or food fibers.

Levels of 10,000 RBCs/mm3 are typically used in cases of penetrating trauma

Sensitivity-97-98% for blood Complication rate 1%

FAST (FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA)

1.non invasive procedure 2.quickly asseses viceral injuries,intra/retro peritoneal fluid collections 3.sensitivity varies from 42-93% due to operator dependency 4.specificity 90-98%

DISADVANTAGES

1.not reliably detect less than 100ml of blood

2.not identify injured hollow viscus

3.cannot reliably exclude in penetrating trauma

CT SCAN

IOC ,even for clinically unstable patients

Sensitivity-100% Specificity-98% “blush” which is

due to ongoing blood loss and extravasation of contrast

Pseudo aneurysms

MRI has also been used,in unstable patients which is less important

Radio isotope scintigraphy & angiography are also used

Diagnostic laparoscopy

AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA SPLENIC INJURY GRADING SCALE

MANAGEMENT

SPLENIC INJURY

STABLE

GR 1-4-CONSERVAT

IVE

GR 5-SPLENECTO

MY/ ART EMBOLISATI

ON

UNSTABLE

STABILISE THE PATIENT

LAPAROTOMY SPLENORRAPHY/SPLENEC

TOMY

ART EMBOLIS

ATION

Indications for initial nonoperative management

hemodynamic stability absence of peritonitis CT scan

No contrast extravasation

absence of other injuries

Transfusions - >2 PRBC’s

CONSERVATIVE

Gr 1-4(stable)-hospitalisation -strict bed

rest -vitals monitoring -serial USG &CT monitoring

-tranfuse blood if necessary

Measures taken to find out delayed splenic rupture, (48-72 hrs) in 4% of patients

SPLENORRHAPHY

Parenchyma saving surgery of spleen The technique is dictated by the

magnitude of the splenic injury Nonbleeding grade I splenic injury may

require no further treatment. 1.superficial hemostatic strategies like

fibrin glue,gel foam,argon beem coagulation,diathermy,topical thrombin

2.non absorbable suture repair 3.absorbable mesh wrap(poly galactin) 4.resectional debridement

SPLENORRHAPHY

SPLENECTOMY

indications -Gr 5 injury -delayed rupture -increasing hematoma -clinically unstable of any

grade -actively bleeding Open splenectomy with midline

incision prefered

AUTOTRANSPLANTATION

implanting multiple 1-mm slices of the spleen in the omentum after splenectomy.

This technique remains experimental role controversial

EMBOLISATION

Tc99/sulphur colloid labeled contrast angiogram to detect vascular damage

Presence of extravasation of contrast in arterial phase (blush sign)

Pseudo aneurysm pattern needs transarterial embolisation using polyvinyl alcohol/silicone/acrylic embolic spheres

Can be given to reduce blood loss preoperatively

SPLENIC ARTERY EMBOLISATION

POST OPERATIVE COMPLICATIONS

INTRAOPERATIVE

•haemorrhage•Pancreatic injury•Bowel injury(stomach & colon)•Diaphragmatic injury

EARLY POST OP

•Hematoma/seroma•Wound infection•Subphrenic abscess•Lung complication•Atelectasis•Pneumonia•Pl effusion•Portal vein thrombosis•DVT•Paralytic ileus

LATE POST OP

•OPSI•splenosis

OPSI(OVERWHELMING POST SPLENECTOMY INFECTION) A rapidly fatal infection following

removal of spleen Incidence-0.23-0.42% per year Occurs 1st few years after splenectomy Common organisms

1.s.pneumonia2.h.influenza3.n.meningitis

Mortality rate -50-80%

Mechanism-organism with polysaccharide capsules need OPSONIZATION with IGg3 or C3B which attaches to special macrophages found in the spleen

Post splenectomy patients lack of macrophages

SYMPTOMS

Starts with flu like symptoms Meningitis or sepsis Rapidly progressive 12-48 hrs

OPSI

MANAGEMENT

PREVENTION-pneumococcal

vaccine(>2 yrs) administered within 24 – 48 hrs after splenectomy

Meningococcal & H.influenza vaccine only in endemic areas

Antibiotics- PENICILIN V 125mg bd(<3 yrs),250mg bd(3-14 yrs),500 mg bd (adults)