Splenic trauma

The majority of splenic injuries are now treated non-operatively.

Natural history:

• Most non-op management fails within 24 hours, if it is going to fail
• Therefore reasonable to give 24 hours of bed rest and NBM, with gradual escalation after that - but no hard evidence to guide these durations - a Delphi consensus study from 2013 had most trauma surgeons agreeing on 1-3 days of monitored setting with regular Hb checks
• Varied triggers for abandoning conservative management - maybe two units of blood
• Routine follow-up imaging seems to be a bit controversial in non-op management - some sources say repeat CT in 6 weeks for grade I and II, and 10-12 weeks for grades III-V before allowing patients to return to normal activity.
• Patients with subcapsular haematoma or history of portal HTN are at increased risk for delayed rupture about a week after injury. Therefore, portal HTN or cirrhosis are relative contraindications to non-op management.

Grading:

• Either blunt or penetrating
• Producing either a subcapsular haematoma, laceration or vascular injury

AAST Spleen Injury Scale (2018 revision)

Grade*	AIS Severity	Imaging Criteria (CT Findings)	Operative Criteria	Pathologic Criteria
I	2	Subcapsular hematoma <10% surface area	Subcapsular hematoma <10% surface area	Subcapsular hematoma <10% surface area
		Parenchymal laceration <1 cm depth	Parenchymal laceration <1 cm depth	Parenchymal laceration <1 cm depth
		Capsular tear	Capsular tear	Capsular tear
II	2	Subcapsular hematoma 10-50% surface area; intraparenchymal hematoma <5 cm	Subcapsular hematoma 10-50% surface area; intraparenchymal hematoma <5 cm	Subcapsular hematoma 10-50% surface area; intraparenchymal hematoma <5 cm
		Parenchymal laceration 1-3 cm	Parenchymal laceration 1-3 cm	Parenchymal laceration 1-3 cm
III	3	Subcapsular hematoma >50% surface area; ruptured subcapsular or intraparenchymal hematoma ≥5 cm	Subcapsular hematoma >50% surface area or expanding; ruptured subcapsular or intraparenchymal hematoma ≥5 cm	Subcapsular hematoma >50% surface area; ruptured subcapsular or intraparenchymal hematoma ≥5 cm
		Parenchymal laceration >3 cm depth	Parenchymal laceration >3 cm depth	Parenchymal laceration >3 cm depth
IV	4	Any injury in the presence of a splenic vascular injury or active bleeding confined within splenic capsule	Parenchymal laceration involving segmental or hilar vessels producing >25% devascularization	Parenchymal laceration involving segmental or hilar vessels producing >25% devascularization
		Parenchymal laceration involving segmental or hilar vessels producing >25% devascularization
V	5	Any injury in the presence of a splenic vascular injury with active bleeding extended beyond the spleen into the peritoneum	Hilar vascular injury with devascularizes the spleen	Hilar vascular injury with devascularizes the spleen
		Shattered spleen	Shattered spleen	Shattered spleen

Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula and appears as a focal collection of vascular contrast that decreases in attenuation with delayed imaging. Active bleeding from a vascular injury presents as vascular contrast, focal or diffuse, that increases in size or attenuation in delayed phase. Vascular thrombosis can lead to organ infarction.

Grade based on highest grade assessment made on imaging, at operation or on pathologic specimen.

More than one grade of splenic injury may be present and should be classified by the higher grade of injury.

Advance one grade for multiple injuries up to grade III.

Management:

• Indications for immediate splenectomy:
  • Haemodynamically unstable or diffuse peritonitis (Level I evidence)
  • Penetrating splenic trauma
    • Even relatively minor injuries should be treated with splenectomy, to prevent delayed haemorrhage once coagulopathy develops/hypotension resolves/arterial vasospasm resolves.
• Indications for splenic artery embolization: (Alfred trauma radiology guidelines 2021)
  • Active leak of contrast medium
  • Predisposing factors for secondary haemorrhage, i.e.:
    • AAST grade 4 or 5
    • Ongoing splenic bleeding/contrast blush (grade IV)
    • Splenic pseudoaneurysms (grade IV)
    • Splenic AVFs (grade IV)
    • Moderate/large haemoperitoneum
  • At Alfred, they go on to have prophylactic embolisation with grade 3 injury and blood in 3 or 4 quadrants too
• Requirements for non-operative management: (EAST 2003)
  • Haemodynamic stability
  • Documented CT classification of injury
  • Absence of additional injuries requiring operative intervention
  • Transfusion of fewer than two units pRBC

SPLASH trial (2020) enrolled stable patients with grade 3 and 4, and grade 5 with persisting vascularisation, traumatic injuries, and found no difference in splenic rescue rate with or without prophylactic embolisation.

• Complications to embolisation were around 10%, and necrosis to >50% of spleen was rare.
• Idea is to embolise proximally, rely on collaterals only, and decrease splenic perfusion pressure. Distal embolisation is possible for specific injury sites.
• In conclusion - both strategies are reasonable, but prophylactic embolisation should be favoured in patients that are less reliable at follow-up or wish for definitive management.

In my opinion, if patients are stable with no active contrast leak, they can wait until morning to decide re: embolisation.

Non-op management

• VTE prophylaxis - low-grade in 24 hours, high-grade 48-72 hours
• Bed rest is controversial
• No contact sports 6-12 weeks

General trauma laparotomy (see 'Trauma Laparotomy' for details)

• Consent
• Supine, GA, prep, drape, IV Abx, TEDs
• Midline laparotomy
• Pack all four quadrants
• Let anaesthetist catch up
• Remove packing one by one, starting with quadrant least likely to have bleeding
• Inspect bowel, mesentery, all other structures

Step-up approach to bleeding from spleen (if potential to avoid splenectomy)

• Direct pressure
• Diathermy to capsular tears
• Haemostatic agents and more direct pressure
• Suture splenorrhaphy
• Splenectomy

Standard splenectomy:

• First, need to mobilise spleen towards midline: (spleen usually auto-dissects itself away from the wall)
  • Me on patient's right, assistant on other wide with a body wall retractor under the costal margin
  • Put left hand over spleen, pull towards midline, and divide adhesions to the abdominal wall
  • Start laterally on spleen - divide splenophrenic, splenocolic, splenorenal ligaments with ligasure/diathermy/scissors
  • Blunt dissection of plane between spleen and kidney/pancreatic tail. Pancreas most easily seen from behind.
  • Medialise spleen, then divide gastrosplenic ligament with ligasure (watch out for short gastric vessels - will need to be clamped and tied off if no Ligasure ready)
• Clamp splenic hilum with a Roberts
• Avoid tail of pancreas (if you think you've injured it, leave a drain)
• Divide between clamps, remove spleen and pass off to nurse
• 0 vicryl to suture ligate splenic hilum vessels - double ligate

If spleen is too damaged/large to attack in the normal way:

• Could try accessing lesser sac through gastrocolic omentum, then identify splenic artery and clamp it early
• Could try going directly at hilum and then taking spleen from the front

Splenorrhaphy

• 'Reasonable to try one thing in a local injury with a stable patient'
• Main options are monofilament suture + bolster, APC, stapling
  • Small capsular and parenchymal injuries: electrocautery/APC, with topical agents on top
  • Deeper lacerations: haemostatic mattress sutures using 2-0 polypropylene or 0 chromic catgut, perhaps incorporating a tongue of omentum, can use Dacron strips to buttress
  • Splenic lacerations that can't be repaired in other ways MAY be amenable to wrap mesh repair
• Don't try a second time if it doesn’t stop the bleeding
• Kate Martin says she has never done it in 12 years as a consultant

Partial splenectomy

• Appropriate option if at least half the splenic parenchyma is viable, and ligating a splenic artery branch results in a major reduction in haemorrhage rate
• Ligate relevant branches of artery and vein
• Divide parenchyma either with linear stapler of electrocautery, and oversew margin

Completion

• Further inspection of all four quadrants
• 19Fr Blakes drain in LUQ
• 1 loop PDS to fascia
• LA - 0.75% ropivicaine
• Skin with staples

Post-op orders:

• Post-op ICU - monitoring Hb and drain outputs (look for pancreatic leak)
• Mechanical DVT prophylaxis then chemoprophylaxis 2-3 days post-op
• Spleen registry, vaccinations at one week, prophylactic antis
• IV PPI
• NBM with IVF
• NGT
• Tertiary as per trauma protocols

Management after splenic artery embolisation:

• Immunosupression does not seem to occur. Vaccination is not routinely performed.