Managing Injuries to the Spleen

Chapter 77 Managing Injuries to the Spleen



Adil H. Haider, MD, Edward E. Cornwell, III, MD



INTRODUCTION


Management of splenic injuries, whether iatrogenic or traumatic, has one common principle: Never jeopardize a patient’s life in an attempt to preserve the spleen; some patients with splenic injury are best served by an expeditious splenectomy. This chapter describes common pitfalls in the operative management of the injured spleen along with a discussion about nonoperative management (NOM) of traumatic splenic injuries.


The decision to save rather than remove an injured spleen requires consideration of the clinical presentation of the patient. Splenic salvage should not be attempted in an unstable patient with significant injuries. Similarly, a patient who has an iatrogenic injury to the spleen during a complex abdominal surgery for cancer may not be a candidate for splenorrhaphy. If splenic repair inordinately prolongs the trauma laparotomy or requires the transfusion of 2 or more units of packed red blood cells, splenorrhaphy should be aborted and a splenectomy should be performed.




Attempting Splenorrhaphy without Adequate Mobilization/Exposure



• Consequence



Attempting to repair an incompletely mobilized spleen is a frustrating exercise for both the surgeon and the assistant. Struggling in the operative field usually leads to increased surgical complications; it also may further increase blood loss.

Grade 2/3 complication


• Repair/Prevention



Division of the avascular ligaments (lienophrenic, lienorenal, and lienocolic) is essential in mobilizing the spleen medially out of its bed and up into the operative field close to the midline position of its embryologic origin (Fig. 77-1). Once the spleen is mobilized and assessed, hemostasis may be achieved by a combination of topical hemostatic agents such as microfibrillar collagen (e.g., Avitene), methylcellulose (e.g., Surgicel), or mattress sutures (e.g., 3-0 Prolene) placed either directly or over Teflon pledgets.

image

Figure 77-1 After division of avascular ligaments, the spleen can be mobilized medially, up into the operative field, close to the midline position.


(Adapted from Trunkey DD. Spleen. In Blaisdell FW, Trunkey DD [eds]: Trauma Management, Vol 1: Abdominal Trauma. New York: Thieme, 1982; pp 149–163.)


Partial splenectomy may be selected when early ligation of a branch of the splenic artery to a segment of the spleen results in major progress toward hemostasis (Fig. 77-2). Provided that 50% of the splenic parenchyma attached to an identifiable vessel is viable, partial splenectomy may be performed and splenic immune function can be expected to be maintained. Early demarcation of the segment of the spleen to be removed with the electrocautery device facilitates exposing intrasplenic vessels for individual suture ligation, which should proceed meticulously. Occasionally, cross-clamping the splenic hilum may be temporarily required if manual compression does not produce adequate hemostasis. The resected margin of the spleen is then oversewn with mattress sutures with or without pledgets (Fig. 77-3). If needed, a blunt liver needle may be used to place such mattress sutures.


image

Figure 77-2 To achieve hemostasis, the splenic artery branch to the lower pole of the spleen is ligated. Subsequently, an anatomic resection of the lower pole of the spleen is performed.


(Courtesy of Corrine Sandone, MA, CMI 2007.)


image

Figure 77-3 Manual compression and, if necessary, clamping of the splenic artery provide the hemostasis required to oversew the margin of the retained spleen. Teflon pledgets are employed to prevent suture from cutting through the otherwise friable tissue.


(Courtesy of Corrine Sandone, MA, CMI 2007.)



ADJUNCTS TO SPLENORRHAPHY



Argon Beam Coagulator


The argon beam coagulator (ABC) is an electrocoagulation system that should not be confused with the argon laser. No eyewear is required. The instrument achieves hemostasis by using inert gas as a medium to conduct radiofrequency energy (Fig. 77-4). The gas is emitted as a constant flow at room temperature from a handpiece and nozzle, which blows away blood and debris to optimize visualization. The first large clinical series utilizing the ABC for splenic salvage was published in 1991.1 This report concluded that most spleens with superficial lacerations are easily salvaged with standard topical maneuvers and that the ABC offers a technical advantage in patients with deep parenchymal injuries. In the ensuing decade, the ABC achieved wide acceptance in the management of both spleen and other solid organ injuries.


image

Figure 77-4 Argon beam coagulator (ABC).


(Courtesy of Corrine Sandone, MA, CMI 2007.)



Absorbable Mesh Wrap


Polyglycolic mesh wrap is another modality reported to be useful in splenic salvage. The injured spleen is passed through an enlarged hole in the mesh fashioned for this purpose. The mesh is then wrapped around the spleen and sutured to itself to provide tamponade (Figs. 77-5 and 77-6).2,3 More recent reports also suggested incorporating methylcellulose into the mesh to help “bulk it up.” In this technique, multiple layers of methylcellulose are placed directly onto the injured surfaces, after which the mesh is secured around the spleen, enhancing the tamponade effect. Previous concerns of possible mesh infection, especially in the setting of hollow viscus injury, have proved to be unfounded based on large series of patients.4


image

Figure 77-5 Mesh splenorrhaphy. The injured spleen is passed through an enlarged hole in the mesh. The mesh is then wrapped around the spleen and sutured to itself.


(Courtesy of Corrine Sandone, MA, CMI 2007.)


image

Figure 77-6 Mesh splenorrhaphy in situ with Surgicel placed directly over the injured portion of the spleen, prior to suture-securing the mesh.


(Courtesy of Horacio A. Massotto, MD, Costa Rica; reproduced with permission from www.trauma.org.)



Fibrin Glue


Early impressive laboratory experience with fibrin glue, which consists of fibrinogen, dried thrombin, and calcium chloride, prompted its emergence in the clinical area. Commonly available fibrin sealants like Tisseal and Crosseal may be applied directly to the injured surfaces of the spleen to achieve immediate hemostasis, especially on linear tears and cracks. Recent reports have demonstrated application of fibrin sealants to “glue together” massively injured spleens and then performing mesh splenorrhaphy. Using this approach, grade 3 and 4 injured spleens have been salvaged.5



Pancreatic Injury



• Consequence



The pancreatic tail is in close proximity to the splenic hilum and is particularly prone to iatrogenic injury during splenectomy, which may lead to a pancreatic fistula.

Grade 3/4 complication


• Repair/Prevention



The pancreatic tail is in close proximity to the splenic hilum and is particularly prone to iatrogenic injury during splenectomy. The splenic hilum and its vessels should not be clamped until the spleen is completely mobilized. After the splenic ligaments and the necessary short gastric vessels are divided, the spleen is brought upward and toward the midline, as described in Figure 77-1. Upward traction elevates the spleen away from the tail of the pancreas. In this position, the spleen is attached only by the splenic artery and vein. The artery should be taken first by clamping it and then dividing it close to the hilum. The splenic vein is very delicate and should not be clamped. It is easier to just tie it off in continuity as a final step and then transect it at the hilum, delivering the spleen. If the procedure is unusually difficult or if pancreatic injury is considered, a drain should be left at the tail of the pancreas to aid with long-term management of this injury.

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. Isolated Limb Perfusions and Extremity Amputations
  2. Traumatic Brain Injury
  3. Open Inguinal Hernia Repair with Plug and Patch Technique
  4. Bronchial and Vascular Sleeve Lobectomy

Stay updated, free articles. Join our Telegram channel
Tags:
Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Managing Injuries to the Spleen

Full access? Get Clinical Tree
Get Clinical Tree app for offline access