Surgical Treatment of Spleen Trauma
Executive Summary
The management of splenic injury has undergone a significant paradigm shift over the last two decades, moving from a standard of mandatory splenectomy to a focus on splenic preservation. This evolution is driven by the need to prevent overwhelming postsplenectomy infection (OPSI). Currently, Nonoperative Management (NOM) is the standard for blunt splenic injuries in both children (90–95% success rate) and stable adults (60–77% success rate).
However, the pursuit of splenic preservation must be balanced against the risks of bleeding and late complications. In high-grade (Grade IV–V) injuries, NOM failure rates reach 55%, and mortality in failed NOM cases is nearly sevenfold higher than in successful cases. Surgical intervention remains the treatment of choice for hemodynamically unstable patients, those with significant associated intra-abdominal injuries, or those who fail a trial of NOM. While splenic salvage techniques (such as splenorrhaphy and mesh wraps) are utilized for minor injuries in stable patients, total splenectomy remains the most frequent surgical outcome in trauma cases, often facilitated by modern techniques like hilar stapling to reduce operative time.
1. Anatomical Considerations and Injury Risk
The spleen is located in the left hypochondrium, protected by the lower rib cage and the left hemithorax. This proximity makes it highly susceptible to damage from fractured ribs.
Surface Anatomy: The spleen has a smooth, convex diaphragmatic surface and an irregular, concave visceral surface with impressions from neighboring organs.
Organ Contact: The visceral surface contacts the anterior left kidney, the left flexure of the colon, the stomach (greater curvature and fundus), and the tail of the pancreas.
Suspension: Four main ligaments connect the spleen to the abdominal cavity: splenophrenic, lienorenal (containing the splenic artery and vein), splenocolic, and gastrosplenic (containing short gastric vessels).
Vascular Supply: The splenic artery is a large branch of the celiac trunk. It travels through the splenorenal ligament, giving rise to superior polar and short gastric arteries before branching into terminal vessels at the splenic hilum. The splenic vein runs behind the pancreas to join the superior mesenteric vein, forming the portal vein.
2. American Association for the Surgery of Trauma (AAST) Splenic Injury Scale
The AAST grading system is the primary tool for assessing injury severity via radiological study (CT scan), laparotomy, or laparoscopy. While the degree of hemoperitoneum on CT relates to NOM success, it does not consistently predict the immediate need for surgery.
3. Nonoperative Management (NOM)
NOM is preferred for isolated splenic injuries in hemodynamically stable patients (Grades I–III) who lack associated injuries requiring surgery and have no significant comorbidities.
3.1 Advantages and Adjuncts
Benefits: Avoidance of nontherapeutic laparotomies, reduced intra-abdominal complications, and lower transfusion risks.
Angioembolization (AE): A critical adjunct that increases NOM rates to 80% and reduces failure rates to 2–5%. Indications for AE include CT evidence of active contrast extravasation, pseudoaneurysm formation, or tachycardia/dropping hemoglobin in stable patients.
3.2 Risks and Contraindications
Failure Rates: NOM fails in approximately 55% of Grade IV–V injuries. Mortality is significantly higher when NOM fails compared to when it succeeds.
Delayed Rupture: Rebleeding or delayed splenic rupture can occur from 5 days to 2 months post-injury.
Contraindications: Hemodynamic instability, suspected hollow organ injury, or significant brain injury.
4. Surgical Management
Surgical intervention is mandatory for unstable patients or those with signs of peritonitis.
4.1 Indications for Urgent Surgery after NOM Trial
Hemodynamic instability.
Evidence of continued splenic hemorrhage.
Need for more than 4 units of blood or replacement of >50% of total blood volume.
Associated intra-abdominal injuries requiring surgical repair.
4.2 Surgical Access
A generous long midline incision is the preferred access method. It provides rapid entry, allows for thorough exploration of the abdominal cavity, and ensures good visualization of the spleen and associated injuries.
4.3 Splenic Salvage Techniques (Intraoperative)
Salvage is prioritized only for stable, younger patients with minor injuries (≤ Grade III) where hemostasis can be achieved quickly.
Topical Hemostatic Agents: Used for superficial lacerations. These include physical agents (oxidized cellulose, gelatin matrix) and biologically active agents (thrombin, fibrin sealants, collagen tamponade).
Splenorrhaphy: Involves U-stitching or figure-eight absorbable sutures. This is often delicate and time-consuming.
Compressive Mesh Wrap: The spleen is mobilized and wrapped in absorbable mesh (e.g., Vicryl) to tamponade bleeding. This is viable for deep lacerations but carries a failure risk for high-grade injuries.
Partial Resection: Applicable in stable patients where injury is limited to one pole. Resection is performed after ligating segmental vessels.
4.4 Splenectomy
Total splenectomy is currently the treatment of choice in most trauma cases, particularly for unstable patients or complex Grade IV–V injuries.
Standard Technique: Involves mobilizing the spleen from lateral attachments (splenophrenic and splenorenal ligaments) and ligating the splenic artery and vein separately. Care must be taken to avoid injuring the tail of the pancreas.
Stapled Splenectomy: Using a long endo-stapler (endo-GIA) to staple the splenic hilum. This technique is faster, allows for time-saving in unstable conditions, and can be performed with fewer surgical assistants. It helps avoid blind placement of clamps and minimizes risk to the pancreatic tail.
5. Minimally Invasive and Miscellaneous Procedures
Laparoscopy: Has a limited role in trauma. It is primarily used for diagnostic purposes (e.g., suspected diaphragmatic injury in stable patients) or for isolated injuries in stable patients with specific surgical skills available. It is strongly contraindicated in cases of hemodynamic instability.
Autotransplantation: Consists of placing excised splenic fragments into omental pockets. This technique is considered anecdotal due to risks of abscess, sepsis, and necrosis of the implanted tissue.
Drainage: Placing a closed-suction or soft corrugated drain in the splenic bed is advisable after surgery. This allows for early detection of postoperative bleeding and complications involving the tail of the pancreas.
