Overview
Definition:
Splenic salvage refers to surgical techniques aimed at preserving the spleen in the setting of trauma or disease, as opposed to splenectomy
Splenorrhaphy is a specific reconstructive surgical technique used in splenic salvage, involving suturing or other methods to repair a lacerated spleen, thus avoiding its removal
The spleen plays vital roles in immune function (producing antibodies and removing opsonized bacteria) and hematologic function (filtering old red blood cells).
Epidemiology:
Splenic injuries account for approximately 50% of all abdominal injuries
They are most commonly seen in blunt trauma (e.g., motor vehicle accidents, falls) and less frequently in penetrating trauma (e.g., stab wounds, gunshot wounds)
The incidence of splenic salvage has increased significantly over the past few decades with advancements in surgical techniques and a better understanding of the spleen's immunological importance, reducing the rate of elective splenectomy for trauma.
Clinical Significance:
Preserving the spleen is crucial due to its role in immunity
Post-splenectomy patients are at increased risk of overwhelming post-splenectomy infection (OPSI), a life-threatening condition caused by encapsulated bacteria
Splenic salvage is therefore the preferred management strategy for hemodynamically stable patients with splenic injuries, aiming to maintain immune function and avoid the long-term complications associated with splenectomy.
Clinical Presentation
Symptoms:
Left upper quadrant abdominal pain, often radiating to the left shoulder (Kehr's sign)
Abdominal distension
Nausea and vomiting
Signs of hypovolemic shock: hypotension, tachycardia, pallor, altered mental status
History of trauma (blunt or penetrating).
Signs:
Tenderness to palpation in the left upper quadrant
Guarding and rigidity of abdominal muscles
Distended abdomen
Palpable abdominal mass
Signs of hemorrhagic shock: cool clammy skin, weak peripheral pulses, delayed capillary refill
Bruising over the left flank (Grey Turner's sign) or around the umbilicus (Cullen's sign) may indicate retroperitoneal hemorrhage.
Diagnostic Criteria:
Diagnosis is primarily based on clinical suspicion in the setting of trauma and confirmed by imaging
There are no specific "diagnostic criteria" for splenic injury, but a high index of suspicion in trauma patients with compatible symptoms and signs is paramount
Imaging findings of splenic laceration, hematoma, or active bleeding confirm the injury.
Diagnostic Approach
History Taking:
Detailed mechanism of injury (speed of impact, direction, seatbelt use for blunt trauma
weapon type, depth, location for penetrating trauma)
Time since injury
Presence of associated injuries (e.g., head, chest, pelvic injuries)
Previous abdominal surgeries
Coagulation status
Medications (e.g., anticoagulants).
Physical Examination:
Assess hemodynamic stability (ABCDE approach)
Perform a thorough abdominal examination: inspection for distension, bruising, or surgical scars
auscultation for bowel sounds
percussion for tympany or dullness
palpation for tenderness, guarding, rigidity, and masses
Examine for signs of associated injuries.
Investigations:
FAST (Focused Assessment with Sonography for Trauma) scan: rapid bedside ultrasound to detect free fluid in the peritoneal cavity
CT scan of the abdomen and pelvis with intravenous contrast: the gold standard for diagnosing splenic injuries, grading their severity, and identifying associated injuries
Grade of splenic injury (e.g., American Association for the Surgery of Trauma - AAST classification)
Complete blood count (CBC) to assess hemoglobin and hematocrit, and platelet count
Coagulation profile (PT/INR, PTT)
Blood type and screen for potential transfusion.
Differential Diagnosis:
Gastric or duodenal perforation
Pancreatic injury
Renal injury
Left lower lobe pneumonia
Diaphragmatic rupture
Mesenteric tear
Colonic injury
Splenic vein thrombosis.
Management
Initial Management:
Resuscitation is paramount: establish intravenous access, administer crystalloids or colloids, provide blood products if hemodynamically unstable
Oxygenation and ventilation support
Pain control
Prompt consultation with trauma surgery.
Surgical Management:
Indications for surgery include hemodynamic instability unresponsive to resuscitation, large (>5 cm subcapsular hematoma), active arterial bleeding on CT, shattered spleen, or associated hollow viscus injury requiring operative repair
The goal is splenic salvage when feasible
Techniques include: Splenorrhaphy: repair of splenic lacerations with sutures, often using omentum or mesh to buttress the repair
Partial splenectomy: removal of only the injured portion of the spleen
Embolization: angioembolization of bleeding splenic vessels, often performed percutaneously by interventional radiology, can be used as an adjunct to surgical repair or as a primary treatment for active bleeding in stable patients.
Supportive Care:
Close hemodynamic monitoring
Serial abdominal examinations
Serial hemoglobin and hematocrit monitoring
Antibiotic prophylaxis, especially if splenectomy is performed or there is concern for non-operative management failure
Vaccination against encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenzae type b, Neisseria meningitidis) is crucial post-splenectomy or in patients with severely compromised splenic function.
Non Operative Management:
Considered for hemodynamically stable patients with isolated splenic injuries, particularly those with lower-grade injuries (AAST grades I-III)
Requires close monitoring in an intensive care unit setting
Success rates are high, often exceeding 90% for blunt splenic trauma
Failure of non-operative management is defined by hemodynamic instability or ongoing bleeding, requiring delayed surgical intervention.
Complications
Early Complications:
Hemorrhagic shock
Hemoperitoneum
Splenic abscess
Subphrenic abscess
Pneumonia
Atelectasis
Acute pancreatitis (if associated pancreatic injury)
Pseudoaneurysm formation.
Late Complications:
Overwhelming post-splenectomy infection (OPSI)
Portal hypertension (rare, usually associated with major venous injury or extensive thrombosis)
Splenic cyst formation
Post-traumatic splenic cyst
Adhesions.
Prevention Strategies:
Judicious use of non-operative management for stable patients
Careful surgical technique during splenorrhaphy or partial splenectomy to achieve hemostasis
Prompt recognition and management of bleeding
Timely angioembolization for active bleeding
Post-splenectomy vaccination
Patient education regarding OPSI risks and prompt medical attention for febrile illness.
Prognosis
Factors Affecting Prognosis:
Hemodynamic stability at presentation
Grade of splenic injury
Presence and severity of associated injuries
Promptness and appropriateness of management
Development of complications.
Outcomes:
Splenic salvage, when successful, preserves immune function and leads to excellent long-term outcomes
Patients who undergo successful splenorrhaphy or partial splenectomy typically have a good prognosis with minimal long-term sequelae related to the spleen itself
For patients requiring splenectomy, the primary concern is the lifelong risk of OPSI, which can be mitigated by vaccination and prompt treatment of infections.
Follow Up:
For successfully managed splenic injuries (both operative and non-operative), follow-up typically involves serial clinical assessments and imaging (CT scans) to ensure resolution and monitor for complications
Patients undergoing splenectomy require lifelong follow-up for vaccination status and education on OPSI prevention.
Key Points
Exam Focus:
Splenic salvage is the preferred approach for hemodynamically stable patients with splenic injuries to preserve immune function
AAST grading of splenic injuries is crucial for management decisions
FAST and CT scans are essential diagnostic tools
Angioembolization is a key adjunct or primary treatment for active bleeding.
Clinical Pearls:
Remember Kehr's sign (left shoulder pain) in splenic injury
OPSI is the major life-threatening risk post-splenectomy
emphasize vaccination and patient education
Non-operative management is safe and effective for many stable splenic injuries, but requires vigilant monitoring.
Common Mistakes:
Delaying resuscitation in hypotensive patients
Performing elective splenectomy in stable patients with salvageable spleens
Failing to consider splenic injury in the context of multisystem trauma
Inadequate follow-up and vaccination in post-splenectomy patients.