Surgical management of splenic injury in the adult trauma patient
- Adrian A Maung, MD, FACS
Adrian A Maung, MD, FACS
- Associate Professor of Surgery
- Yale University School of Medicine
- Lewis J Kaplan, MD, FACS
Lewis J Kaplan, MD, FACS
- Associate Professor of Surgery
- Perelman School of Medicine, University of Pennsylvania
Surgical management is required in approximately 20 to 40 percent of patients sustaining splenic injury. Open surgical techniques are the current standard of care and are typically used to manage the injured spleen, though laparoscopic techniques have been described in case reports and small series.
This topic will discuss the indications and techniques of exploratory laparotomy in the setting of trauma, hemorrhage control from the spleen, splenic salvage and splenectomy.
Nonoperative management of splenic injury is discussed elsewhere. (See "Management of splenic injury in the adult trauma patient".)
INDICATIONS FOR EXPLORATION
We perform initial resuscitation, and diagnostic evaluation of the trauma patient is based upon the Advanced Trauma Life Support (ATLS) program established by the American College of Surgeons Committee on Trauma. Emergent abdominal surgical exploration is indicated for the hemodynamically unstable trauma patient who has a positive focused assessment with sonography in trauma (FAST exam) or diagnostic peritoneal aspiration/lavage (DPA/DPL) to control life-threatening hemorrhage, which may be due to an injured spleen. (See "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial evaluation and management of abdominal gunshot wounds in adults" and "Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and management of blunt thoracic trauma in adults".)
The hemodynamically stable trauma patient with splenic injury identified on computerized tomography (CT scan) may be initially observed or undergo angiographic embolization as an adjunct to observational management. However, observational management requires adequate resources, and if unavailable, initial surgical management should be considered depending on the patient’s medical comorbidities. (See "Management of splenic injury in the adult trauma patient", section on 'Management approach'.)
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- INDICATIONS FOR EXPLORATION
- ANATOMY OF THE SPLEEN
- - Type and crossmatch
- - Prophylactic antibiotics
- - Prophylactic immunization
- - Patient/family counseling
- EXPLORATORY LAPAROTOMY
- Abdominal exploration
- - Mobilization of the spleen
- SPLENECTOMY VERSUS SALVAGE
- SPLENIC SALVAGE
- Partial splenectomy
- Replantation of splenic tissue
- LAPAROSCOPIC APPROACH
- POSTOPERATIVE CARE
- POSTOPERATIVE ISSUES
- Postsplenectomy identification
- SURGICAL OUTCOMES AND COMPLICATIONS
- Postoperative bleeding
- Gastric perforation
- Vascular thrombosis
- Pancreatic fistula
- Perioperative infection
- Postsplenectomy sepsis
- Risk for malignancy
- SUMMARY AND RECOMMENDATIONS