Splenic injuries
Executive Summary
The spleen is the second most commonly injured abdominal solid organ following blunt trauma and the second most commonly injured after penetrating trauma. Modern surgical management prioritizes splenic preservation where feasible; nearly 80% of blunt trauma patients who are hemodynamically stable and without peritonitis can be managed non-operatively. However, when surgical intervention is required—whether for splenectomy or salvage—a deep understanding of splenic anatomy, particularly its ligamentous attachments and proximity to the pancreas, is critical to prevent iatrogenic injury. This briefing outlines the anatomical foundations, general principles of management, and specific surgical techniques for treating splenic injuries.
1. Surgical Anatomy
The spleen is located under the ninth to eleventh ribs, lateral to the stomach and superior to the left kidney. Successful surgical intervention depends on navigating its complex attachments and vascular supply.
1.1 Ligamentous Attachments
The spleen is held in place by four primary ligaments. Mobilization of these structures is the first step in most splenic operations.
Caution: Undue traction on the stomach or splenic flexure can easily tear the splenic capsule, causing troublesome bleeding and potentially necessitating an unplanned splenectomy.
1.2 Vascular Supply and Pancreatic Proximity
Splenic Artery: A branch of the celiac axis. In 70% of patients, it exhibits medusa-like branching 5–10 cm from the spleen. In 30%, simple branching occurs within 1–2 cm of the hilum.
Splenic Vein: Courses posterior and inferior to the artery, eventually joining the superior mesenteric vein to form the portal vein.
Pancreas Tail: The tail of the pancreas is in close anatomical proximity to the splenic hilum. The distance between the two varies by individual, making the pancreas highly susceptible to injury during hilar clamping or splenectomy.
2. General Principles of Management
2.1 Non-Operative Management (NOM)
Hemodynamically stable patients without peritonitis are candidates for NOM.
Adjuncts: Angioembolization is utilized for high-grade injuries, particularly when contrast-enhanced CT scans show active extravasation.
Contraindications: NOM is generally not recommended for patients with traumatic head injuries, coagulopathy, or significant injury burdens that make them hemodynamically unstable.
2.2 Surgical Requirements
Incision: Midline incision starting high at the xiphoid process.
Positioning: Supine position with arms out; prepped from nipples to knees.
Mandatory Prophylaxis: All patients undergoing emergent splenectomy must receive vaccinations for encapsulated organisms prior to discharge.
2.3 Special Instrumentation
Standard trauma laparotomy tray with vascular instruments.
Bookwalter Retractor: Highly helpful for fixed self-retaining retraction.
LigaSure Device: An electrothermal bipolar vessel sealing system is desirable for safe ligation.
Mesh: Absorbable mesh or pre-formed mesh splenic pouches should be available for preservation attempts.
3. Surgical Techniques
3.1 Exposure and Initial Hemostasis
Upon entering the peritoneal cavity, the surgeon must remove blood and pack the left upper quadrant with laparotomy pads to temporarily control bleeding.
Digital Compression: Profuse bleeding can be temporarily controlled by compressing the hilum between the fingers or by digital compression of the splenic parenchyma.
Mobilization: Required for complex repairs or splenectomy. This involves the sharp division of the avascular splenophrenic and splenorenal ligaments to allow en-bloc medial mobilization of the spleen and the tail of the pancreas.
3.2 Splenectomy (Total)
Splenectomy is indicated when the injury is too severe for repair or the patient is unstable.
Vascular Ligation: Short gastric vessels should be ligated close to the spleen to avoid gastric wall necrosis. The splenic artery and vein should be ligated individually as close to the hilum as possible.
Mass Ligation: Only considered in unstable patients, though it carries a risk of arteriovenous fistula.
Pancreatic Management: If the pancreas tail is intimately related to the hilum, a small portion of the distal pancreas may need to be resected (stapled en-masse resection) to safely complete the splenectomy.
3.3 Splenic Preservation (Splenorrhaphy)
Preservation is preferred for stable patients with amenable injuries.
Superficial Lacerations: Repaired using figure-of-eight or horizontal mattress absorbable sutures. If the parenchyma is fragile, pledgets may be used to prevent sutures from tearing through.
Omental Patch: Can be sutured into areas of tissue loss.
Splenic Mesh: Absorbable mesh wraps or "bean-shaped" pouches are used for multiple stellate parenchymal injuries or extensive capsular avulsions to provide compression and structure.
3.4 Partial Splenectomy
Because the spleen has a segmental blood supply with vessels traveling in parallel, partial resection is a viable option for injuries localized to one pole.
Procedure: Individual vessels to the injured pole are ligated at the hilum. A capsular incision is made, followed by blunt finger dissection or the use of a TA stapling device (e.g., TA-90) to remove the injured segment.
4. Critical Tips and Pitfalls
Iatrogenic Injury: Excessive medial rotation or traction on the spleen can cause avulsion of the capsule, decreasing the possibility of preservation.
Pancreatic Protection: During hilar dissection, surgeons must take care not to injure the tail of the pancreas. If pancreatic tissue is removed, the area should be overseen with Lembert sutures to prevent leaks.
Postoperative Monitoring: For severe injuries managed with preservation, a postoperative CT scan with intravenous contrast is recommended to rule out false aneurysms or arteriovenous fistulas.
Hemostasis Inspection: After removal or repair, the tail of the pancreas and the greater curvature of the stomach must be inspected for ischemic damage or iatrogenic injury.
Drains: Routine use of closed suction drains is controversial but advisable if there is concern regarding incomplete hemostasis or potential injury to the pancreatic tail.
