The document discusses splenic injuries, providing details on the surgical anatomy, blood supply, assessment, investigations including FAST scan and CT scan, grading of injuries, and management approaches including conservative management, splenorrhaphy, splenectomy, embolization, and complications like overwhelming post-splenectomy infection. Splenic injuries are most commonly caused by blunt trauma to the abdomen and can range from minor injuries to severe lacerations requiring surgical intervention.

1. SPLENIC INJURIES
DR.M.GUNASEKARAN M.S.,
S2 UNIT

2. SPLEEN
 2nd most commonly
injured solid organ in
blunt injury abdomen
after liver
 Situated against 9-11
ribs

3. 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

4.  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

5.  Posteriorly related to
left iliopsoas muscle &
left adrenal glands
 Posteriormedial
surface related to body
& tail of pancreas
 Antromedially related
to great curvature of
stomach

6.  Inferiorly related to distal
transverse colon & splenic flexure
 Lower pole attached to colon
through splenicocolic ligament
 These attachments require
devision during mobilisation

7. BLOOD SUPPLY
 Receives blood supply from
celiac axis
1.spleenic artery
2.short gastric
vessels that connect left
gatroepiploic A. & splenic
circulation along greater
curvature of stomach

8. BLOOD SUPPLY

9.  Drains through splenic vein & confluence with
inferior mesentric vein
 Through short gastric veins into left gastro
epiploic vein

10. 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

11. 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

12. 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)

13. INVESTIGATIONS
 In unstable patients necesesary investigation
is hemoglobin,blood grouping and
reservation of blood
 No specific labaratory studies specific to
splenic injuries

14. 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)

15. 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,

16.  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%

17. 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%

19.  DISADVANTAGES
1.not reliably detect less than 100ml of
blood
2.not identify injured hollow viscus
3.cannot reliably exclude in penetrating
trauma

20. 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

21.  MRI has also been used,in unstable patients
which is less important
 Radio isotope scintigraphy & angiography are
also used
 Diagnostic laparoscopy

22. AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA
SPLENIC INJURY GRADING SCALE

24. MANAGEMENT
SPLENIC INJURY
STABLE UNSTABLE
GR 5-
GR 1-4- SPLENECTOMY/ STABILISE THE
CONSERVATIVE ART PATIENT
EMBOLISATION
LAPAROTOMY
SPLENORRAPH ART
Y/SPLENECTOM EMBOLISATION
Y

25. Indications for initial
nonoperative management
 hemodynamic stability
 absence of peritonitis
 CT scan
 No contrast
extravasation
 absence of other
injuries
 Transfusions - >2 PRBC’s

26. 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

27. 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

28. SPLENORRHAPHY

29. SPLENECTOMY
 indications
-Gr 5 injury
-delayed rupture
-increasing hematoma
-clinically unstable of any grade
-actively bleeding
 Open splenectomy with midline incision
prefered

30. AUTOTRANSPLANTATION
 implanting multiple 1-mm slices of the spleen
in the omentum after splenectomy.
 This technique remains experimental
role controversial

31. 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

32. SPLENIC ARTERY EMBOLISATION

33. POST OPERATIVE COMPLICATIONS
INTRAOPERATIVE EARLY POST OP LATE POST OP
• haemorrhage • Hematoma/seroma • OPSI
• Pancreatic injury • Wound infection • splenosis
• Bowel • Subphrenic abscess
injury(stomach & • Lung complication
colon) • Atelectasis
• Diaphragmatic • Pneumonia
injury • Pl effusion
• Portal vein thrombosis
• DVT
• Paralytic ileus

34. 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.pneumonia
2.h.influenza
3.n.meningitis
 Mortality rate -50-80%

35.  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

36. SYMPTOMS
 Starts with flu like symptoms
 Meningitis or sepsis
 Rapidly progressive 12-48 hrs

37. OPSI

38. 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)