Surgical treatment of spleen trauma

Abstract

In the era of nonoperative management and angioembolization surgical treatment of splenic injuries is seldomly necessary. However, NOM and angioembolization have a significant early and delayed incidence of failure and complications, especially when used for high-grade splenic injuries. Surgery remains the standard of care in hemodynamically unstable patients, when a rapid splenectomy for a rapid bleeding control is strongly advocated. Surgery is also advised for continuing blood loss from an injured spleen with need of multiple and repeated blood transfusions, as well as during a trauma laparotomy for associated intra-abdominal injuries. Splenectomy is currently the treatment of choice. It is advisable not to attempt life-threatening conservative management of severely injured spleen and/or in unstable patients and damage control situations and/or in presence of severe associated intra-abdominal injuries and/or in neurologically impaired patients. Midline is the access of choice for trauma laparotomy and splenectomy. Nowadays, operative splenic salvage techniques are almost abandoned and replaced by NOM and embolization. In the case of minor splenic injury finding during a trauma laparotomy for associated injuries, given hemodynamic stability of the patient, splenic salvage can be easily and quickly attempted with compression and use of topical hemostatic agents. If the hemostasis is not reliable and/or the patient is not stable enough, time should not be wasted in long and complex salvage procedures, and a rapid total splenectomy is rather advised. Splenectomy is preferably performed via a posterior approach in trauma setting, with a wise use of a blunt dissection and careful separate ligation of hilar vessels and short gastric vessels. In the most demanding cases, such as massive hemoperitoneum with hemodynamic instability with multiple severe associated intra-abdominal injuries, when the grade of splenic is high (IV-V) or the parenchyma is completely shattered and/or the hilar vessels difficult to recognize and ligate or the spleen is anatomically difficult to reach and hard to fully divide from its attachments and mobilize, performing a stapled splenectomy with a long stem Endo-GIA can be a safe and effective technique for a fast bleeding control. To date, minimally invasive procedures (multiport laparoscopy) play a very limited role in trauma setting.