د . صدام جراحه عامة 12 / 10 /2015
Lec 3
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د . صدام جراحه عامة 12 / 10 /2015
Lec 3
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ؤؤؤؤؤؤؤؤؤؤؤؤؤؤؤؤفل
Ruptur7e of spleen
AETIOLOGY
RISK FACTORS: splenic enlargement,malaria
TYPES OF TRAUMA1.Non penetrating trauma
2. penetrating trauma
3.Operative
CLINICAL TYPES
1.Fatal type the tear is deep or the pedicle is ruptured &haemorrhage is so massive that the patient is severely shocked with rapid death occurring before any surgical intervention2.CLASSICAL TYPE
Commonest
1.Internal hemorrhage increasing pallor weak&rapid pulse low B.P & air hunger
2.Abd. Examination tenderness &rigidity in Lt hypochondrium spread to abd. Distension
Special signs
-Balances` sign shifting dullness on Rt side & fixed dullness on Lt side
-Kehrs` sign referred pain in Lt shoulder due to irritation of diaphragm specially if put patient on Trendlenburg position
-Cullens` sign bluish discoloration around umblicus
3.DELAYED RUPTURE
Initial shock is followed by long lucid interval .about 2wk after accident ,patient present with picture of internal haemorrhage .causes
-subcapsular hematoma
-greater omentum seals the injury
-clot block tear
The American Association for the Surgery of Trauma( AAST) splenic injury grading system is as follows:
grade I
subcapsular haematoma < 10 % of surface area
capsular laceration < 1 cm depth
grade II
subcapsular haematoma 10-50 % of surface area
intraparenchymal haematoma < 5 cm in diameter
laceration 1 - 3 cm depth not involving trabecular vessels
grade III
subcapsular haematoma > 50 % of surface area or expanding
intraparenchymal haematoma > 5 cm or expanding
Laceration> 3 cm depth or involving trabecular vessels
ruptured subcapsular or parenchymal haematoma
grade IV
laceration involving segmental or hilar vessels with major devascularization (> 25% of spleen )
grade V
shattered spleen
hilar vascular injury with devascularised spleen
Management
Investigations
1.blood picture declining Hb &pcv denote haemorrhage
2.U/S or CT
3.Plain X-ray of abd
-obliteration of psoas shadow
-indentation of Lt side of gastric air bubble
-fracture lower ribs
-elevation of Lt side of diaphragm
- obliteration of splenic outline
4.peritoneal lavage reveals blood
NOTE :no need for Investigations in severe shock.laparotomy immediately
TREATMENT
The standard treatment is urgent splenectomy1.rapid correction of hypovolaemic shock by crystalloid & blood transfusion
2.laparotomy mid line incision: splenectomy
3.In children <15 try to preserve spleen due to its vital role in immune mechanism through:
-suture of asmall laceration
-partial splenectomy
-compression of lacerated spleen in polygalactin mesh
-if splenectomy is necessary in children ,antipneumococcal vaccine is recommended every 5years until age of 18
Splenectomy
INDICATIONS
1.Traumatic injury of the spleen
2.haematological
–spherocytosis
-acquired haemolytic anaemia
-ITP
-Thalassaemia
-sickle cell anaemia
3.lymphoma
4.radical surgery for stomach esophagus or pancreas
5.esophageal varices
6.hypersplenism
7.splenic cysts
8. splenic abscess
9.splenic tumors
Procedure:
GASupine position
Lt paramedian or Lt subcostal or midline incision
COMPLICATIONS
A.complications that are common to all operations
1.reactionary haemorrhage slip ligature
2.atelectasis& pneumonia
3.DVT
4.wound infection,burst abdomen&incisional hernia are uncommon
B.Specific complications
1.Acute gastric dilatation
2.portal vein thrombosis due to rise WBC &platelets
3.pancreatic fistula
4.gastric fistula
5.haematemesis
6.subphrenic haematoma or abscess
7.post-splenectomy bacterial infection (streptococcus pneumonia,neisseria meningitdes&haemophilus influenzae) risk is higher in children.Aserious form is overwhelming
post-splenectomy sepsis which is fatal.therefore ,splenectomized children should receive antipneumococcal vaccine(pneumovax) cover until the age of 18