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362 Atlas of Gastrointestinal Surgery: Spleen
The sequence of events for managing a massively enlarged spleen that has been outlined above is what we generally
follow. With a massively enlarged spleen, however, the order of these steps may need to be changed. One obviously does
that part of the dissection that is the easiest at the time. Even though these massively enlarged spleens are often peritonealized and may be easily delivered into the wound, this may not be the case and the order of the dissection may need to
be modified.
Even though the risk of massive hemorrhage may be more substantial from a massively enlarged spleen than a normalsized spleen, because of the peritonealization, a splenectomy may actually be easier under these circumstances. Because
inadvertent and unrecognized injury to the tail of the pancreas may occur during splenectomy, particularly when the spleen
is massively enlarged, drainage of the tail of the pancreas with a closed suction Silastic drain is recommended (9). Each
patient undergoing splenectomy should obviously be vaccinated against encapsulated bacterial organisms.
Splenic a. and v.
Liver
Stomach
9
Tail of pancreas
Management of Splenic Trauma by
Splenorrhaphy
Operative Indications:
In the past, splenic injuries, whether operative or from blunt or penetrating trauma, were routinely treated with splenectomy. Even minor capsular tears often resulted in splenectomy to eliminate the presumed danger of subsequent hemorrhage.
But experience has demonstrated that splenectomy generally is not necessary in these circumstances. The spleen clearly plays
a role in the defense against a variety of encapsulated bacterial organisms. Today, every reasonable effort is made to preserve the spleen, and with many injuries it is generally possible. The spleen plays a more important role in infants and young
children and is less important as the individual grows older. In virtually all patients, however, a reasonable attempt to preserve the spleen and avoid splenectomy is probably appropriate. This not only preserves the role that the spleen plays in
fighting infection with encapsulated organisms, but it also eliminates the morbidity that can result from splenectomy. The
morbidity of splenectomy, which includes injury to the tail of the pancreas, hemorrhage, and abscess formation, is virtually nonexistent if an injured spleen is successfully repaired. The feared complication of late splenic rebleeding is almost never
seen. Repair of a splenic injury should not be attempted in the presence of other serious organ injuries or if the patient is
unstable. In addition, one should not persist if initial efforts have not been completely successful. But in most instances in
a stable patient with only splenic trauma, an effort should be made to repair the spleen and avoid splenectomy.
Operative Technique:
Most patients with abdominal trauma are explored through a long midline incision.
Wide exposure of the abdomen is required. The entire abdomen should be carefully explored to assess all injuries. In the instance demonstrated here, only splenic trauma is present. In attempting splenic repair, excellent exposure is absolutely necessary. In this instance, the left subcostal margin is elevated with a retractor connect-
364 Atlas of Gastrointestinal Surgery: Spleen
Capsular tear
ed to a frame attached to the operating table. The abdominal wall
Liver
Deep stenic
laceration
Superficial
splenic
lacerations
Omental
attachments
divided
Stomach
Spleen
is widely retracted. The stomach is grasped with a Babcock
clamp. Areolar attachments to the splenic capsule are divid-
ed to avoid further injury (1). Bleeding from splenic
injuries is controlled with Mikulicz’s pads placed over the
spleen and held firmly with the operator’s left hand (2).
The spleen is then mobilized out of the retroperitoneum
1
by dividing the lateral peritoneal attachments. The lesser
sac is entered by removing the omentum from the left
transverse colon. The omentum is then divided anterior to
the splenic hilum, so that the splenic hilar vessels can be
carefully examined (3). In this instance, there are three
injuries to the spleen. There is a superficial capsular tear
along the superior pole of the spleen, a superficial laceration
to the lower pole of the spleen, and a deep laceration in the
Colon
The capsular tear can be controlled by a
variety of means. The argon beam coagulator is
superb for small capsular tears. This is generally preferable to the electrocautery.
Avitene
®
(Davol Inc., Cranston, RI) on a
small segment of absorbable gelatin sponge
(Gelfoam™, Pharmacia & UpJohn,
Kalamazoo, MI) and applied pressure for
several minutes will also often be success-
midportion of the body of the spleen (1).
Lateral peritoneal
attachments divided
ful (4, 5). The remaining two splenic
injuries are controlled with pressure during
the initial attention to the superior pole of
the spleen.
Bleeding controlled
with Mikulicz pad
Spleen
2
Management of Splenic Trauma by Splenorrhaphy 365
Stomach
3
Spleen
Hilar vessels examines
Avitene on Gelfoam
4
5
Manual
compression
366 Atlas of Gastrointestinal Surgery: Spleen
The superficial laceration can be controlled with a
variety of techniques. The argon beam coagulator is
6
often excellent (6). Avitene (Davol Inc.) and
Gelfoam (Pharmacia & Upjohn), along with pres-
sure, might also be effective in this wound.
Spleen
Stomach
The deep laceration can be controlled with a variety
of techniques. One may place a series of horizontal
mattress sutures approximating the tear, using strips of
Argon beam
coagulator
Dacron
the laceration to prevent sutures from pulling through the
®
(Invista Inc., Wichita, KS) felt on each side of
capsule (7). Generally, 2-0 synthetic monofilament non-
absorbable sutures are used for this purpose.
Gelfoam
Dacron felt
strips
Stomach
Mattress
sutures
approximate
a deep
laceration
7
Management of Splenic Trauma by Splenorrhaphy 367
Alternative
Omental
pedicle
buttresses
mattress
sutures
An alternative is to use two pedicles of omentum in place
of Dacron (Invista Inc.) (8). We prefer autologous tissue
to synthetic tissue. Finally, some surgeons prefer to place
a piece of omentum into the deep laceration to act as a
hemostatic agent before approximating the laceration with
mattress sutures (9).
Omentum
8
The surgeon can be innovative in controlling the variety of capsular tears and parenchyma lacerations that
are found during surgery. Generally, the younger the
patient the more elastic and firm is the capsule, with
less concern of a suture tearing through. In most
adults, however, sutures have to be buttressed
with omentum or Dacron felt (Invista Inc.) when
deep sutures and firmer approximation are
required. During all of these maneuvers, if bleeding persists, the splenic artery should be mobilized
along the superior border of the body and the tail of
the pancreas, and temporarily clamped with a bulldog
Alternative
9
Omental
pedicle
packed
into deep
laceration
Dacron
felt
clamp. This will often be enough to allow these hemostatic steps to be effective. One then removes the bulldog
clamp to be certain the hemostasis persists.
Management of Splenic Trauma By
Partial Splenic Resection
Operative Indications:
Many splenic injuries are minor and consist of capsular tears, or superficial or deep lacerations. In a stable patient without
other serious organ injuries, such splenic trauma can often be managed with a variety of hemostatic and splenic suture techniques. If the splenic laceration is more substantial and extends deeply into splenic parenchyma, particularly towards the
hilum, such maneuvers may not be sufficient to control hemorrhage and salvage the spleen. In such instances, a partial splenic
resection can be performed, removing that portion of the spleen that is not salvageable but retaining a portion of functioning spleen. It is far more important to salvage the spleen in a young person than in an older individual, and this procedure
often is relegated to the young.
Because there will be additional blood loss and operative time in performing partial splenic resection, the patient should
be absolutely stable with no other organ injury. In the younger patient, the splenic capsule is generally more elastic and
holds sutures better. This procedure should be considered in such a patient.
Operative Technique:
As with all patients undergoing laparotomy for abdominal trauma, a generous midline
incision should be performed. The abdomen should be thoroughly examined to rule
out other injuries. If the only injury is to the spleen and the patient is stable and has
not lost a great deal of blood, then splenic salvage should be considered.
Liver
Management of Splenic Trauma By Partial Splenic Resection 369
1
Stomach
Omental
attachments
to spleen
divided
Spleen
Attachments of the omentum to the spleen should be divid-
ed to avoid further capsular injury (1). The lesser sac is
entered by removing the omentum from the transverse
colon. At this point, the splenic artery can be dissected
out along its course along the superior aspect of the body
and the tail of the pancreas, and occluded with a
DeBakey bulldog clamp (2). This will help control the
bleeding from the splenic laceration and allow one more
time to decide exactly how to manage it.
Splenic a.
temporary
occluded
Manual
compression
of spleen
2
370 Atlas of Gastrointestinal Surgery: Spleen
Vasa brevia
divided
Stomach
Spleen
Splenic
laceration
extends into
hilum
The omentum should then be divided anterior to the
splenic hilum between Kelly clamps and ligated with
2-0 silks. The vasa brevia can be divided between
Reinhoff clamps and ligated with 2-0 silks (3).
Omentum
3
At this point, the spleen has been exposed and
one can examine the splenic laceration and the extent
to which it has extended into the splenic hilum.
During these maneuvers, it is obviously important
to control blood loss and achieve temporary
hemostasis. This is best done by placing a
Mikulicz’s pad over the spleen and compressing
4
it by hand (4). To fully evaluate the splenic
injury, the retroperitoneal attachments should be
divided (4) so that the spleen can be mobilized
and delivered up into the wound. When it is
determined that there is a major laceration deep
into the parenchyma and extending into the hilum,
Retroperitoneal
attachments
divided
Colon
Management of Splenic Trauma By Partial Splenic Resection 371
attempts should be made to mobilize and expose the entire spleen
adequately so a decision can be made concerning management.
During this dissection, the combination of having a bulldog
clamp on the splenic artery and compressing the area of the
injury with a Mikulicz’s pad will allow one to maintain satisfactory hemostasis. In this case, examination of the completely
mobilized spleen reveals that the deep laceration into the hilum
has avulsed the lower one third of the spleen. The branch of the
splenic artery to the lower pole of the spleen is triply ligated and
divided (5). Before doing this, it may be helpful to temporarily
release the bulldog clamp on the splenic artery to carefully examine
and determine the splenic artery anatomy in the hilum. The corresponding splenic vein branch draining that segment of the spleen is likewise doubly ligated and divided.
Splenic a.
Splenic v.
branch to
lower pole
Mikulicz pad
on spleen
5
Tail of
pancreas
After the splenic vessels have been controlled, the remaining
splenic parenchyma of the lower pole of the spleen is divid-
ed with the electrocautery (6).
Paranchyma
divided
Lower pole
resected
6