splenic injuries
TRANSCRIPT
SPLENIC INJURIES
DR.M.GUNASEKARAN M.S., S2 UNIT
SPLEEN
2nd most commonly injured solid organ in blunt injury abdomen after liver
Situated against 9-11 ribs
SURGICAL ANATOMY
Developed from dorsal mesogastrium
In children,necessary for both reticuloendothelial and RBC production
Pediatric spleen has thicker capsule and tough parenchymal consistency which implies reduced need of operative intervention
Adult spleen weight about 100-250g
Situated posteriorly left upper abdomen
Covered by peritoneum except at the hilum
Posterior and lateral surface related to left hemidiaphragm and posterolateral lower ribs
Lateral surface attached through splenophrenic ligament
Posteriorly related to left iliopsoas muscle & left adrenal glands
Posteriormedial surface related to body & tail of pancreas
Antromedially related to great curvature of stomach
Inferiorly related to distal transverse colon & splenic flexure
Lower pole attached to colon through splenicocolic ligament
These attachments require devision during mobilisation
BLOOD SUPPLY
Receives blood supply from celiac axis
1.spleenic artery2.short gastric
vessels that connect left gatroepiploic A. & splenic circulation along greater curvature of stomach
BLOOD SUPPLY
Drains through splenic vein & confluence with inferior mesentric vein
Through short gastric veins into left gastro epiploic vein
INITIAL ASSESMENT
Importance of history- 1.victims located on the left side of car
2.type & nature of weapon is important in penetrating injuries
3.caliber of the gun
ON EXAMINATION
Vitals are most important r/o left lower rib
tenderness 14% patients with left
lower rib tenderness have splenic injury
In children plasticity of chest will have splenic injury without rib #
Ecchymoses or abration over LUQ
SIGNS
Kehr sign-is symptom of pain near tip of left shoulder,bcz of reffered pain from the diaphragmatic irritation
P/A-generalised tenderness or LUQ tenderness
May present with tachycardia ,Tachypnea, anxiety , Hypotension (shock)
INVESTIGATIONS
In unstable patients necesesary investigation is hemoglobin,blood grouping and reservation of blood
No specific labaratory studies specific to splenic injuries
PLAIN RADIOGRAPH
The most common finding associated with splenic injury is left lower rib fracture. Rib fractures signify that adequate force has been transmitted to the LUQ to cause splenic pathology.
classic triad indicative of acute splenic rupture (ie, left hemidiaphragm elevation, left lower lobe atelectasis, and pleural effusion)
DIAGNOSTIC PERITONEAL LAVAGE In the past Mainstay
of diagnostic technique for abdominal trauma
Peritoneal lavage useful when USG not available
10ml of blood or enteric contents (stool, food, etc.) constitutes a positive DPL,
Other positive findings include more than 100,000 RBCs/mm3, 500 WBCs/mm3, amylase 175 IU, and detection of bile, bacteria or food fibers.
Levels of 10,000 RBCs/mm3 are typically used in cases of penetrating trauma
Sensitivity-97-98% for blood Complication rate 1%
FAST (FOCUSED ABDOMINAL SONOGRAPHY IN TRAUMA)
1.non invasive procedure 2.quickly asseses viceral injuries,intra/retro peritoneal fluid collections 3.sensitivity varies from 42-93% due to operator dependency 4.specificity 90-98%
DISADVANTAGES
1.not reliably detect less than 100ml of blood
2.not identify injured hollow viscus
3.cannot reliably exclude in penetrating trauma
CT SCAN
IOC ,even for clinically unstable patients
Sensitivity-100% Specificity-98% “blush” which is
due to ongoing blood loss and extravasation of contrast
Pseudo aneurysms
MRI has also been used,in unstable patients which is less important
Radio isotope scintigraphy & angiography are also used
Diagnostic laparoscopy
AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA SPLENIC INJURY GRADING SCALE
MANAGEMENT
SPLENIC INJURY
STABLE
GR 1-4-CONSERVAT
IVE
GR 5-SPLENECTO
MY/ ART EMBOLISATI
ON
UNSTABLE
STABILISE THE PATIENT
LAPAROTOMY SPLENORRAPHY/SPLENEC
TOMY
ART EMBOLIS
ATION
Indications for initial nonoperative management
hemodynamic stability absence of peritonitis CT scan
No contrast extravasation
absence of other injuries
Transfusions - >2 PRBC’s
CONSERVATIVE
Gr 1-4(stable)-hospitalisation -strict bed
rest -vitals monitoring -serial USG &CT monitoring
-tranfuse blood if necessary
Measures taken to find out delayed splenic rupture, (48-72 hrs) in 4% of patients
SPLENORRHAPHY
Parenchyma saving surgery of spleen The technique is dictated by the
magnitude of the splenic injury Nonbleeding grade I splenic injury may
require no further treatment. 1.superficial hemostatic strategies like
fibrin glue,gel foam,argon beem coagulation,diathermy,topical thrombin
2.non absorbable suture repair 3.absorbable mesh wrap(poly galactin) 4.resectional debridement
SPLENORRHAPHY
SPLENECTOMY
indications -Gr 5 injury -delayed rupture -increasing hematoma -clinically unstable of any
grade -actively bleeding Open splenectomy with midline
incision prefered
AUTOTRANSPLANTATION
implanting multiple 1-mm slices of the spleen in the omentum after splenectomy.
This technique remains experimental role controversial
EMBOLISATION
Tc99/sulphur colloid labeled contrast angiogram to detect vascular damage
Presence of extravasation of contrast in arterial phase (blush sign)
Pseudo aneurysm pattern needs transarterial embolisation using polyvinyl alcohol/silicone/acrylic embolic spheres
Can be given to reduce blood loss preoperatively
SPLENIC ARTERY EMBOLISATION
POST OPERATIVE COMPLICATIONS
INTRAOPERATIVE
•haemorrhage•Pancreatic injury•Bowel injury(stomach & colon)•Diaphragmatic injury
EARLY POST OP
•Hematoma/seroma•Wound infection•Subphrenic abscess•Lung complication•Atelectasis•Pneumonia•Pl effusion•Portal vein thrombosis•DVT•Paralytic ileus
LATE POST OP
•OPSI•splenosis
OPSI(OVERWHELMING POST SPLENECTOMY INFECTION) A rapidly fatal infection following
removal of spleen Incidence-0.23-0.42% per year Occurs 1st few years after splenectomy Common organisms
1.s.pneumonia2.h.influenza3.n.meningitis
Mortality rate -50-80%
Mechanism-organism with polysaccharide capsules need OPSONIZATION with IGg3 or C3B which attaches to special macrophages found in the spleen
Post splenectomy patients lack of macrophages
SYMPTOMS
Starts with flu like symptoms Meningitis or sepsis Rapidly progressive 12-48 hrs
OPSI
MANAGEMENT
PREVENTION-pneumococcal
vaccine(>2 yrs) administered within 24 – 48 hrs after splenectomy
Meningococcal & H.influenza vaccine only in endemic areas
Antibiotics- PENICILIN V 125mg bd(<3 yrs),250mg bd(3-14 yrs),500 mg bd (adults)