Spleen Trauma

Spleen Trauma

David Ray Velez, MD

Table of Contents

Background
Initial Evaluation and Management
Nonoperative Management (NOM)
Surgical Management
Vaccination

Background

Vasculature

  • Splenic Artery: From the Celiac Trunk
    • Runs Superior to the Pancreas
    • Very Tortuous and Divides into 5-6 Branches
  • Splenic Vein: Drains into the Portal System
    • Runs Posterior/Inferior to the Artery (Posterior or Within the Pancreas)

Ligaments

  • Gastrosplenic Ligament: Hilum to Stomach
    • Contains the Short Gastric Vessels
  • Splenorenal Ligament (Lienorenal Ligament): Hilum to Left Kidney
    • Contains the Splenic Artery/Vein and Tail of the Pancreas
  • Splenophrenic Ligament: Superior Pole to Diaphragm
    • Avascular
  • Splenocolic Ligament: Inferior Pole to Colon
    • Avascular
  • Phrenicocolic Ligament (Hensing’s Ligament): Diaphragm to Splenic Flexure of the Colon
    • Supports Spleen but Not Directly Associated

Physiology/Function

  • Red Pulp (75-85%)
    • Filters Old/Senescent or Damaged Red Blood Cells
    • Traps Bacteria
  • White Pulp (15-25%)
    • Produces Lymphocytes and Antibodies

Etiology

  • Blunt Abdominal Trauma:
    • Most Common Organ Injury in Blunt Abdominal Trauma (40-55%)
      • *Remains Controversial and Reports Vary Between Spleen and Liver
    • Most Common Injury Requiring Intervention in Blunt Abdominal Trauma
  • Penetrating Abdominal Trauma:
    • Less Common After Penetrating Abdominal Trauma

AAST Spleen Injury Scale (2018 Revision)

Spleen Injury

Initial Evaluation and Management

Unstable: Laparotomy

  • First Perform a FAST (Focused Assessment with Sonography in Trauma) to Confirm Abdominal Source
    • Diagnostic Peritoneal Lavage (DPL) is Rarely Performed but May Be Considered if FAST is Inconclusive
    • Search for Oher Sources if Negative
  • Diffuse Peritonitis Indicates Bowel Injury and Warrants Laparotomy – Diffuse Peritonitis Should Never be Attributed to Solid Organ Injury as Isolated Hemoperitoneum Should Not Cause Diffuse Peritoneal Irritation

Stable: CT Imaging

Indications for Angiography and Embolization (93% Success Rate)

  • Transient Responder
  • Active Extravasation (“Blush”)
  • Pseudoaneurysm
  • Arteriovenous Fistula (AVF)

Stable Patients Generally Undergo a Trial of Nonoperative Management (With or Without Angioembolization) Unless There are Other Indications for Surgery

Surgery Solely for Washout of Blood is Generally Not Indicated Unless for Severe Refractory Pain

*Historically Severe Traumatic Brain Injury (TBI) and Altered Mental Status (AMS) Were Contraindications to Nonoperative Management of the Spleen (Concern for Hypotension and Secondary Brain Injury) – Now Shown to Be Effective and Safe

Nonoperative Management (NOM)

The Exact Definitions for Nonoperative Management are Poorly Defined

Admission

  • Consider ICU Admission for 24-72 Hours for Injuries ≥ Grade III
  • Consider an Initial NPO Status for up to 24 Hours if Closely Monitoring
  • Exact Hospital Length of Stay is Poorly Defined

Activity Restrictions

  • Bedrest: Consider for 24-48 Hours
    • Previously Defined as Injury Grade + One Day (1999 APSA Guidelines)
  • Activity Restriction: Return to Unrestricted Activity at Injury Grade + 2 Weeks
    • Defined as “Normal” Age-Appropriate Activities
    • Longer Restrictions for Contact Sports (Football, Wrestling, Hockey, etc.) – Less Well Defined but Often Range from 2-6 Months

Indications for Surgery (After a Trial of Nonoperative Management)

  • Angioembolization Failure
  • Hemodynamic Instability
  • Persistent Bleeding
  • Refractory Abdominal Pain
  • *May Consider Angiography and Embolization if Stable and Not Already Attempted

Start DVT Prophylaxis Early (Within 24-48 Hours) for Solid Organ Injury if Otherwise Clinically Appropriate

Repeat CTA – Controversial

  • Routine Use without Clinical Indication is Not Useful
  • Most Studies Show that Routine Use is Not Necessary and Rarely Changes Clinical Management
  • Some Advocated for Repeat CTA After 2-7 Days, Before Discharge, to Evaluate for Pseudoaneurysm or Arteriovenous Malformation

Surgical Management

Small and Minimal Bleeding (Grade I): Topical Hemostasis

  • Options:
    • Manual Compression
    • Electrocautery
    • Argon Beam Coagulation
    • Arista
    • Surgical (Original, Powder, Fibrillar, Nu-Knit)
    • Fibrin Glue
  • Do Not Need to Explore Subcapsular Hematomas if Stable and Not Expanding

Simple Laceration (Grade II-III): Splenorrhaphy (Primary Repair)

  • Generally Use Monofilament or Chromic Suture
  • Spleen Does Not Hold Suture Well – Consider Pledgets (Felt, PTFE) or Absorbable Mesh
  • May Consider Splenectomy vs. Partial Splenectomy Depending on the Severity of Injury and Patient Stability

Shattered or Vascular/Hilar Injury (Grade IV-V): Splenectomy

Vaccination

Loss of Antibody-Mediated Immunity to Capsulated Bacteria in the Spleen Creates a Risk for Overwhelming Post-Splenectomy Infection (OPSI)

Vaccinations

  • Hemophilus influenzae Type B (HiB) – Single Dose Only
  • Meningococcus (MCV) – Multiple Doses with a Booster After 5 Years
  • Pneumococcus (PCV) – Single Dose with a Booster After 5 Years

Timing

  • Elective Splenectomy: Finish Course 2 Weeks Before (Start 10-12 Weeks Prior)
  • Emergent Splenectomy: Start Course 2 Weeks After (Impaired Functional Antibody Responses Prior)
    • Give Just Prior to Discharge if Unreliable or Concerned for Loss to Follow Up

Always Recommended After Splenectomy

Recommend Against Routine Vaccination After Splenic Artery Embolization in Adults – Fewer Infectious Complications and Greater Preservation of Splenic Immune Function