Advertisement

Trauma Surgery pp 117-134 | Cite as

Surgical Treatment of Spleen Trauma

  • Salomone Di SaverioEmail author
  • Eleonora Giorgini
  • Andrea Biscardi
  • Andrea Sibilio
  • Silvia Villani
  • Noel Naidoo
  • Fausto Catena
  • Gregorio Tugnoli
Chapter

Abstract

In the era of nonoperative management and angioembolization surgical treatment of splenic injuries is seldomly necessary. However, NOM and angioembolization have a significant early and delayed incidence of failure and complications, especially when used for high-grade splenic injuries. Surgery remains the standard of care in hemodynamically unstable patients, when a rapid splenectomy for a rapid bleeding control is strongly advocated. Surgery is also advised for continuing blood loss from an injured spleen with need of multiple and repeated blood transfusions, as well as during a trauma laparotomy for associated intra-abdominal injuries. Splenectomy is currently the treatment of choice. It is advisable not to attempt life-threatening conservative management of severely injured spleen and/or in unstable patients and damage control situations and/or in presence of severe associated intra-abdominal injuries and/or in neurologically impaired patients. Midline is the access of choice for trauma laparotomy and splenectomy. Nowadays, operative splenic salvage techniques are almost abandoned and replaced by NOM and embolization. In the case of minor splenic injury finding during a trauma laparotomy for associated injuries, given hemodynamic stability of the patient, splenic salvage can be easily and quickly attempted with compression and use of topical hemostatic agents. If the hemostasis is not reliable and/or the patient is not stable enough, time should not be wasted in long and complex salvage procedures, and a rapid total splenectomy is rather advised. Splenectomy is preferably performed via a posterior approach in trauma setting, with a wise use of a blunt dissection and careful separate ligation of hilar vessels and short gastric vessels. In the most demanding cases, such as massive hemoperitoneum with hemodynamic instability with multiple severe associated intra-abdominal injuries, when the grade of splenic is high (IV–V) or the parenchyma is completely shattered and/or the hilar vessels difficult to recognize and ligate or the spleen is anatomically difficult to reach and hard to fully divide from its attachments and mobilize, performing a stapled splenectomy with a long stem Endo-GIA can be a safe and effective technique for a fast bleeding control. To date, minimally invasive procedures (multiport laparoscopy) play a very limited role in trauma setting.

Keywords

Fibrin Sealant Laparoscopic Splenectomy Splenic Injury Short Gastric Vessel Splenic Hilum 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Supplementary material

Rapid_Splenectomy_video_Di_Saverio_1_LOW_RES (WMV 142 MB)

Rapid_Splenectomy_video_Di_Saverio_2_LOW_RES (WMV 97.6 MB)

References

  1. 1.
    Di Saverio S, Moore EE, Tugnoli G, Naidoo N, Ansaloni L, Bonilauri S, Cucchi M, Catena F (2012) Non operative management of liver and spleen traumatic injuries: a giant with clay feet. World J Emerg Surg 7(1):3. doi: 10.1186/1749-7922-7-3 PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Tinkoff G, Esposito TJ, Reed J, Kilgo P, Fildes J, Pasquale M, Meredith JW (2008) American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg 207(5):646–655PubMedCrossRefGoogle Scholar
  3. 3.
    Watson GA, Rosengart MR, Zenati MS, Tsung A, Forsythe RM, Peitzman AB, Harbrecht BG (2006) Nonoperative management of severe blunt splenic injury: are we getting better? J Trauma 61(5):1113–1118; discussion 1118–1119PubMedCrossRefGoogle Scholar
  4. 4.
    McIntyre LK, Schiff M, Jurkovich GJ (2005) Failure of nonoperative management of splenic injuries: causes and consequences. Arch Surg 140(6):563–568; discussion 568–569PubMedCrossRefGoogle Scholar
  5. 5.
    Peitzman AB, Richardson JD (2010) Review surgical treatment of injuries to the solid abdominal organs: a 50-year perspective from the Journal of Trauma. J Trauma 69(5):1011–1021PubMedCrossRefGoogle Scholar
  6. 6.
    Skandalakis PN, Colborn GL, Skandalakis LJ, Richardson DD, Mitchell WE Jr, Skandalakis JE (1993) The surgical anatomy of the spleen. Surg Clin North Am 73(4):747–768PubMedGoogle Scholar
  7. 7.
    Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR (1995) Organ injury scaling: spleen and liver (1994 revision). J Trauma 38:323–324PubMedCrossRefGoogle Scholar
  8. 8.
    Cohn SM, Arango JI, Myers JG, Lopez PP, Jonas RB, Waite LL, Corneille MG, Stewart RM, Dent DL (2009) Computed tomography grading systems poorly predict the need for intervention after spleen and liver injuries. Am Surg 75(2):133PubMedGoogle Scholar
  9. 9.
    Becker CD, Spring P, Glättli A, Schweizer W (1994) Blunt splenic trauma in adults: can CT findings be used to determine the need for surgery? AJR Am J Roentgenol 162(2):343PubMedCrossRefGoogle Scholar
  10. 10.
    Alonso M, Brathwaite C, Garcia V et al (2002) Practice management guidelines for the nonoperative management of blunt injury to the liver and spleen. In: Practice management guidelines. East Assoc Surg Trauma. www.east.org
  11. 11.
    Bhullar IS, Frykberg ER, Siragusa D, Chesire D, Paul J, Tepas JJ 3rd, Kerwin AJ (2012) Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management. J Trauma Acute Care Surg 72(5):1127–1134PubMedGoogle Scholar
  12. 12.
    Velmahos GC et al (2010) Management of the most severely injured spleen: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Arch Surg 145(5):456–460PubMedCrossRefGoogle Scholar
  13. 13.
    Clancy AA, Tiruta C, Ashman D, Ball CG, Kirkpatrick AW (2012) The song remains the same although the instruments are changing: complications following selective non-operative management of blunt spleen trauma: a retrospective review of patients at a level I trauma centre from 1996 to 2007. J Trauma Manag Outcomes 6(1):4. doi: 10.1186/1752-2897-6-4 PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Peitzman AB, Heil B, Rivera L, Federle MB, Harbrecht BG, Clancy KD et al (2000) Blunt splenic injury in adults: multi-institutional Study of the Eastern Association for the Surgery of Trauma. J Trauma 49:177–187PubMedCrossRefGoogle Scholar
  15. 15.
    Renzulli P, Gross T, Schnüriger B, Schoepfer AM, Inderbitzin D, Exadaktylos AK, Hoppe H (2010) Management of blunt injuries to the spleen. Br J Surg 97(11):1696–1703PubMedCrossRefGoogle Scholar
  16. 16.
    Lucas CE (1991) Splenic trauma. Choice of management. Ann Surg 213(2):98–112PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Mannucci PM (1998) Hemostatic drugs. N Engl J Med 339(4):245PubMedCrossRefGoogle Scholar
  18. 18.
    Tsaroucha AK, Pitiakoudis MS, Chanos G, Chiotis AS, Argyropoulou PI, Prassopoulos P, Simopoulos CE (2005) U-stitching splenorraphy technique: experimental and clinical study. ANZ J Surg 75(4):208–212PubMedCrossRefGoogle Scholar
  19. 19.
    Morgenstern L, Shapiro SJ (1979) Techniques for splenic conservation. Arch Surg 114:449–454PubMedCrossRefGoogle Scholar
  20. 20.
    Feliciano DV, Spjut-Patrinely V, Burch JM, Mattox KL, Bitondo CG, Cruse-Martocci P, Jordan GL Jr (1990) Splenorrhaphy. The alternative. Ann Surg 211(5):569–580; discussion 580–582PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Chadwick SJ, Huizinga WK, Baker LW (1985) Management of splenic trauma: the Durban experience. Br J Surg 72(8):634–636PubMedCrossRefGoogle Scholar
  22. 22.
    Boffard K (ed) (2011) Manual of definitive surgical trauma care: London, 3 edn. CRC Press. ISBN 1444102826, 9781444102826Google Scholar
  23. 23.
    Bochicchio GV, Arciero C, Scalea TM (2005) The hemostat wrap’ a new technique in splenorraphy. J Trauma 59(4):1003–1006PubMedCrossRefGoogle Scholar
  24. 24.
    Moore FA, Moore EE, Moore GE, Millikan JS (1984) Risk of splenic salvage following trauma: analysis of 200 adults. Am J Surg 148:800–805PubMedCrossRefGoogle Scholar
  25. 25.
    Huscher CG, Mingoli A, Sgarzini G, Brachini G, Ponzano C, Di Paola M, Modini C (2006) Laparoscopic treatment of blunt splenic injuries: initial experience with 11 patients. Surg Endosc 20(9):1423–1426, Epub 2006 May 26PubMedCrossRefGoogle Scholar
  26. 26.
    Carobbi A, Romagnani F, Antonelli G, Bianchini M (2010) Laparoscopic splenectomy for severe blunt trauma: initial experience of ten consecutive cases with a fast hemostatic technique. Surg Endosc 24(6):1325–1330, Epub 2009 Dec 9PubMedCrossRefGoogle Scholar
  27. 27.
    Ren CJ, Salky B, Reiner M (2001) Hand-assisted laparoscopic splenectomy for ruptured spleen. Surg Endosc 15(3):324PubMedCrossRefGoogle Scholar
  28. 28.
    Fan Y, Wu SD, Siwo EA (2011) Emergency transumbilical single-incision laparoscopic splenectomy for the treatment of traumatic rupture of the spleen: report of the first case and literature review. Surg Innov 18(2):185–188. doi: 10.1177/1553350611403767, Epub 2011 Apr 25PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2014

Authors and Affiliations

  • Salomone Di Saverio
    • 1
    Email author
  • Eleonora Giorgini
    • 1
  • Andrea Biscardi
    • 1
  • Andrea Sibilio
    • 1
  • Silvia Villani
    • 1
  • Noel Naidoo
    • 2
    • 3
  • Fausto Catena
    • 4
  • Gregorio Tugnoli
    • 1
  1. 1.Trauma Surgery UnitMaggiore Hospital Regional Trauma CenterBolognaItaly
  2. 2.Department of Surgery, Nelson R Mandela School of MedicineUniversity of KwaZulu-NatalDurbanSouth Africa
  3. 3.Department of SurgeryPort Shepstone Regional HospitalDurbanSouth Africa
  4. 4.Emergency and Trauma Surgery DepartmentMaggiore Hospital of ParmaParmaItaly

Personalised recommendations