Conservative Surgery for Splenic Injuries

(1)

Conservative

Surgery

for Splenic

Injuries

Neil J. Sherman, M.D.,

and

Morris J. Asch, M.D.

From Los Angeles

ABSTRACT. Splenectomy for traumatic injury of the spleen

has recently been questioned, due to the occurrence of

postsplenectomy sepsis. During the past year we have

operated on six children with splenic injuries and, by

utilizing different surgical manuevers, have successfully preserved all or part of the spleen. The following report describes the management of these children and the

opera-tive techniques that allow the injured spleen to be salvaged. Pediatrics 61:267-271, 1978, splenectomy, s-plenic repair,

trauma, sepsis.

Traumatic

rupture

of

the

spleen

in

children

continues

to be

the

most

common

injury

necessi-tating

surgical

intervention

from

blunt

abdominal

I Many splenectomies are also performed

to

aid

in

the

diagnosis

and

treatment

of

other

systemic disorders. Although the occurrence of

overwhelming

sepsis

following

splenectomy

in

childhood has been recognized for many years,

the

subject

is receiving

greater

attention,

proba-bly because recent evidence suggests that the

protective

functions

of the

spleen

may

be

more

essential

than

previously

realized.

Attempts

to repair

or partially

resect

the

spleen

are

being

reported

with

increasing

frequency.26

During

the

past

year

we

have

had

the

opportunity

to treat

six children

with

serious

splenic

injuries,

in whom

the

bleeding

was

controlled

sufficiently

at surgery

to allow

preservation

of all

or

part

of

the

spleen.

This

report

includes

the

case

summaries

of these

patients

(Table),

their

follow-up

spleen

scans,

and

a brief

review

of

splenic

function

and

the

technical

considerations

in

conservative

splenic

surgery.

CASE REPORTS

Case 1

An 8#{189}-month-old boy was a passenger in an automobile involved in an accident and was admitted with drowsiness

and

hematuria. Twenty-four hours later, because of the

patient’s progressive abdominal distention and tenderness, a

peritoneal tap was done; it yielded bloody fluid. At surgery, a retroperitoneal hematoma and clots were found, along with

two slowly bleeding superficial lacerations of the spleen, one

medially and one laterally. Hemostasis was obtained by

applying a microfibrillar collagen hemostat (Avitene). The postoperative course was uneventful and at the two-month

follow-up visit the infant remained well.

Minor

injuries

such

as those

encountered

here

often

stop

bleeding

spontaneously.

But

in

the

small

infant,

when

less

margin

for

error

exists,

operative

evaluation

and

control

did

not

result

in

loss

of the

organ,

as it might

have

in the

past.

Case 2

A 7-year-old boy was struck by a car and taken

immedi-ately to the emergency room; he had abrasions on both flanks and a distended tender abdomen. Blood pressure was 126/70

mm Hg and pulse rate was 132 beats per minute. Peritoneal

lavage returned bloody fluid and at laparotomy several hours

later, two lacerations of the spleen were found. The largest

one was 2.5 cm deep and extended laterally from the

hilus to the middle part of the convex surface. This laceration

was actively bleeding and was controlled with mattress

sutures. A second laceration on the posterior surface was 2.5

cm long, superficial, and bleeding very slowly. Topical

Avitene was placed there. The patient had no bleeding after

surgery and was discharged six days later. The spleen scans at

Received July 25; revision accepted for publication

September 27, 1977.

ADDRESS FOR REPRINTS: (N.J.S.) 933 South Sunset

(2)

TREATMENT OF Six CHILDREN WITH SPLENIC INJURIES

Patient Age Mechanism Other Hen2oglobi n (gm/100 ml) Blood Transfused

of Injury Injuries ,-

-On At Before After

Admission Discharge Surgery Surgery

1 8#{189}mo Passenger in

auto vs. pole

None 11.4 9.3 None None

2 7yr Auto vs.

pe-destrian

None 13.2 11.8 None None

4 3#{189}yr Fall Fractured femur 8.5 11.0 500 ml 250 ml

& humerus, ce-rebral & pulmo-nary contusions

6 7 yr Fall None 9.9 8.6 None None

3 7 yr Fall None 12.0 10.8 None 250 ml

5 8 yr Fall #{149} None 11.4 10.6 None None

one week and six weeks were normal, and in the ensuing year he has been well.

Major

lacerations

may

be

repaired

with

morbidity comparable to that seen with

splenec-tomy. Apparently, intrasplenic injuries heal

suffi-ciently

to escape

detection

on

spleen

scan.

Case 3

A 7-year-old boy fell onto an exercise bar, and because of

abdominal pain, was brought to the emergency room with a blood pressure of 70/0 mm Hg and a pulse rate of 106 beats

per minute. Examination revealed moderate tenderness and

rebound in the upper part of the abdomen on the left, and the following morning, the hemoglobin level had dropped 2 gm/ 100 ml. A peritoneal tap yielded pure blood. Laparot-omy revealed a ruptured spleen, with a deep laceration starting anteriorly in the hilus and extending horizontally to the posterior aspect of the dome. The splenic artery was ligated proximal to its branches with a significant decrease in bleeding. The laceration was closed with mattress sutures.

The patient received 250 ml of packed RBCs the night of the

surgery and was discharged seven days after surgery. Spleen scans one week and six weeks postoperatively showed normal uptake and distribution. In the ensuing year, he has been free

of symptoms.

Blood

transfusion

was

required

after

splenic

repair,

suggesting

either

some

continuing

bleed-ing

or simply

dilution

of the

intravascular

space.

However,

ligation

of

the

splenic

artery

signifi-cantly aids in obtaining hemostasis and does not

cause necrosis of the spleen, as shown by a normal

postoperative splenic scan.

Case 4

A 3#{189}-year-old boy was struck by a car and sustained a

cerebral concussion, fractured humerus and femur,

pulmo-nary contusion and insufficiency, and a falling hematocrit value in spite of 500 ml of whole blood transfusion. Twenty hours after the injury, the surgical consultant performed a peritoneal tap, which yielded pure blood. At laparotomy shortly thereafter, the upper third of the spleen was almost completely avulsed and active bleeding was present. The

short gastric vessels were divided, the upper pole was

removed by the finger fracture technique, and the oozing

raw surface was controlled with mattress sutures and

Avitene. Postoperatively the patient received 250 ml of

whole blood. He continued to recuperate but, because of the

spica cast, a postoperative splenic scan has not been

performed.

Case 5

An 8-year-old-boy fell out of a tree and abdominal pain developed immediately. The vital signs were normal and he exhibited marked left-sided abdominal tenderness. Pen-toneal aspiration yielded pure blood, and at surgery there was active arterial bleeding, with the upper third of the spleen almost completely separated. The short gastric vessels were divided, and the avulsed upper pole was removed. The oozing raw surface was controlled by placing mattress

(3)

Operative Findings Bleeding at Surgery Operative Procedure Complications Spleen Scan No. of Hospital Days

Superficial lacerations, me-dial & lateral

Minimal Topical hemostasis None None 7

Deep lacerations, dome to hilus, anteriorly

Capsular tear posteriorly

Active

Minimal

Mattress sutures None Normal 1 & 6 wk

af-ter operation

7

Almost complete avulsion, upper third

Active Resection avulsed

segment, mattress sutures, topical he-mostatic agent

None None 90 +

segment, ligation arterial branch, mattress sutures

None Normal 1 & 6 wk

af-ten operation

7

Laceration from deep in hi-lus to medial portion of dome

Active Mattress sutures,

ligate main splen-ic artery

None Normal 1 & 6 wk

af-ten operation

9

segment, mattress sutures, ligation splenic artery, top-ical hemostatic agent

Readmitted 16 days after operation with fever & vom-iting; all studies normal & illness resolved sponta-neously

Normal uptake & dis-tnibution, “some-what small” spleen

7 + 3

postoperative course was uncomplicated and he was

discharged on the seventh day following surgery. He was briefly neadmitted 2#{189}weeks later with fever and vomiting, but his illness resolved spontaneously, and all laboratory and x-ray studies showed normal results. A spleen scan six weeks after surgery showed normal uptake and distribution in a “somewhat small spleen,” and he has been well for the four months since surgery.

Case 6

A 7-year-old boy fell out of a parked car onto his abdomen

and immediately had abdominal pain. When seen in the

emergency room one hour later, blood pressure was 118/82

mm Hg, pulse rate was 1 12 beats per minute, and the

abdomen was diffusely tender. A penitoneal tap yielded pure blood. At laparotomy shortly thereafter, the superior third of

the spleen was discolored and attached loosely to the

remainder of the spleen by the capsule posteriorly and a small amount of splenic pulp. There was active arterial and

venous hemorrhage. The superior pole of the spleen was removed after ligating the splenic artery branches to this

segment and the raw surface was closed with mattress

sutures. The patient’s postoperative course was uneventful, and he was discharged six days later. Spleen scans one week and six weeks postoperatively were interpreted as normal. In the past year he has been healthy.

These three cases demonstrate that resection of

the spleen is technically possible, utilizing

selec-tive

arterial

ligation,

mattress

sutures,

and

a

topical hemostatic agent. Because the spleen is a

fairly large organ, at least a

third

of

it

can

be

removed

and

still

appear

to be

relatively

normal

size

as shown

by

isotope

scanning.

DISCUSSION

The

prevailing

concept

among

many

physi-cians,

especially

pediatricians

and

surgeons,

is

that

splenectomy

for

traumatic

injury

in children

more

than

2 years

old

is

a benign

procedure

attended

#{149}by

low

morbidity

and

mortality.

To

justify

a change

in

this

approach,

most

surgeons

would

insist

that

the

technical

aspects

of

conser-vative

surgery

be

both

feasible

and

safe

and

that

preserving

the

spleen

has

definite

advantages

to

the

child’s

future

health.

We

believe

that

many

of

the

past

reasons

for

performing

splenectomies

no

longer

apply.

We

would

also

argue

that

repair

of

any injured, but otherwise normal, spleen is far

superior

to splenectomy;

the

following

discussion

reviews

the

basis

for

this

recommendation.

In

1952,

King

and

Schumaker7

first

reported

an

increased

susceptibility

to serious

and

often

fatal

infections

in patients

who

had

undergone

splenec-tomy. Subsequent larger series8 ‘#{176}

suggested

that

splenectomy

for

trauma

was

not

responsible

for

any increased risk of infection; but, when

(4)

such

as

spherocytosis,

idiopathic

thrombocyto-penic

purpura,

thalassemia,

and

Hodgkin’s

stag-ing,

patients

were

clearly

more

prone

to

sepsis.

Singer’s

comprehensive

review”

concluded

that

when

splenectomy

was

done

for

trauma,

the

incidence

of postsplenectomy

sepsis

was

58 times

higher

than

in the

general

population.

Postsplen-ectomy

sepsis,

though

more

common

in

young

children,

has

been

reported

in adolescents’2

‘

and

adults.

The

spleen

represents

approximately

25%

of

the

lymphoid

tissue

in

the

body

and

reaches

its

maximum

weight

at puberty.’5

Accessory

spleens

occur

in

20%

of

the

population

but

are

usually

very

small

and

apparently

not

sufficient

to

prevent

postsplenectomy

16

The

functions

of the

spleen

can

be

categorized

as

follows:

(1)

clearance

of particulate

antigens

from

the

blood-stream;

(2)

elaboration

of

specific

immune

response;

and

(3)

production

of

opsonins.

The

detailed

functions

and

role

of the

spleen

are

not

within

the

scope

of this

article,

and

several

recent

comprehensive

reviews

have

been

8

Surgical

Considerations

Splenectomy

for

traumatic

rupture

of

the

spleen

achieved

popularity

early

in this

century’”

and

resulted

in significantly

improved

survival.

In

1945,

Mazel2#{176}and

Foster

and

Prey2’

advocated

repair,

even

though

no

successful

operative

repairs

were

reported.

In

the

laboratory

animal,

suturing

the

lacerated

222

and

partial

splenectomy2425

have

proved

technically

feasible

without

apparent

sequelae.

In

1966,

Morganstern

et

al.2”

performed

a partial

splenectomy

in

an

adult

patient

with

myelofibrosis,

without

compli-cation.

The

first

report

of splenic

repair

in a child

was by Mishalaney.2 In 1974, he described one

patient

in detail,

with

preoperative

and

postoper-ative

angiography,

but

stated

that

in eight

of ten

consecutive

children

with

splenic

injury,

repair

was

successful.

Subsequent

authors

have

clearly

substantiated

that

literally

hundreds

of

traumati-cally

injured

spleens

are

now

being

repaired,

and

significant

complications

have

yet

to be seen.36

In

1975, Gellis’ strong statement27 that “only the

most

severely

damaged

spleen

should

be

removed”

seemed

radical

at the

time,

but

today

is

becoming

an acceptable

surgical

approach

in the

pediatric

patient.

There

are

instances

when

surgeons28

have

avoided

laparotomy

in

selected

patients

with

splenic

injury,

documented

by

isotope

scanning

or

angiography.

But

this

approach

has

limited

value

when

bleeding

is

massive,

or

potential

pancreatic,

liver,

or

bowel

injury

coexist.

Successful splenic repair for trauma should

stimulate a complete reevaluation of other

condi-tions for which splenectomy has been

recom-mended,

such

as

congenital

hemolytic

anemia,

spherocytosis, idiopathic thrombocytopenic

pur-pura,

and

hypersplenism.

Splenectomy

as

an

adjunct in staging for Hodgkin’s disease has

recently been questioned and challenged.2” For

all

these

conditions,

the

possibility

of

splenic

biopsy or partial splenectomy is real. It will

require

a few

years

to determine

if partial

splen-ectomy can provide the clinical response or

diagnosis desired, and if the remaining splenic

tissue is sufficient to protect the child from the

overwhelming sepsis syndrome. In any event, the

surgeon is now obligated to become more familiar

with

the

anatomical

variations

and

technical

maneuvers necessary to allow for repair or

resec-tion of the spleen.

Most

of the

blood

supply

to the

spleen

is direct

from the splenic artery, as the collateral arterial

supply is unimportant as a source of operative

bleeding.’ Although the splenic artery branches

are highly variable, bifurcation almost always

occurs

outside

the

spleen

itself,

allowing

for

easy

control to a particular segment, and temporary or

permanent control of the main artery. The

branches of the splenic artery are arranged along

the longitudinal axis of the spleen, essentially

dividing the organ into small transverse segments.

Because most lacerations of the spleen occur

along the horizontal axis, control of the arterial

supply to one or more segments is technically

possible, as would be the amputation of either

pole

(cases

3, 4, and

6).

Multiple

septa

directed

from

the

capsule

inward

divide

the

spleen

into

parenchymatous subsequents of spongy tissue

with few blood vessels. Suturing this tissue is not

possible due to the lack of tensile strength,

but

the

low

pressure

within

the

splenic

sinuoids

allows

hemostatic control by reducing arterial inflow

and

placing

capsular

sutures.

The

suturing

may

be

somewhat

more

effective

in

children

than

in

adults because of the greater ratio of capsule to

splenic pulp.3’

Significant bleeding from the spleen

necessi-tating surgical intervention is arterial and can be

controlled by direct ligation of the arterial

branch, as divisions of the splenic artery are end

arteries. The main splenic artery may be ligated

in instances of hilar disruption or stellate

lacera-tions. It is too early to assess all functions of the

spleen

after

arterial

ligation,

but

survival

of the

organ is not an apparent problem. In cases 5 and

6, the splenic artery was ligated, and isotope

(5)

demonstrated normal uptake and distribution in

the spleen. This technique has precedence in liver

injuries and hemangiomas, where hepatic artery

ligation is utilized rather routinely. In certain

instances the bleeding may be controllable by

placing mattress sutures with Teflon bolsters,

and/or applying a recently developed and highly

effectiv&’ topical agent such as Avitene.

Simi-larly, complete or almost complete avulsion of a

part of the spleen should be attempted, and the

raw

surface

oozing

controlled

by

the

same

tech-nique.

If the

spleen

becomes

totally

separated

from

its

blood supply, splenectomy is probably indicated.

Venous hemorrhage can be stopped by the same

methods but is rarely a problem in the normal

spleen.

All

of these

techniques

require

more

time

than

is needed in simply removing the spleen, since

meticulous attention to each bleeding site is

needed to achieve satisfactory hemostasis. But if

the surgeon views the injured spleen as an

essen-tial organ, safe and effective techniques are now

available and sufficient experience has been

achieved so that the spleen can be preserved.

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1978;61;267

Pediatrics

Neil J. Sherman and Morris J. Asch

Conservative Surgery for Splenic Injuries

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