Spleen
RUPTURE OF SPLEENAETIOLOGY RISK FACTORS:splenic enlargement,malaria TYPES OF TRAUMA 1.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 intervention
2.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 splenectomy 1.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
Splenorrhaphy
Mesh Splenorrhaphy Delaney (1982) Autotransplantation controversialSPLENECTOYM
INDICATIONS1.Traumatic injury of the spleen2.haematological –spherocytosis-acquired haemolytic anaemia-ITP-Thalassaemia-sickle cell anaemia 3.lymphoma 4.radical surgery for stomach esophagus or pancreas5.esophageal varices6.hypersplenism7.splenic cysts8. splenic abscess9.splenic tumorsProcedure: GA Supine 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.