Version May 2024
INTRODUCTION — 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 computed 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'.)
Indications for surgical exploration in the hemodynamically stable trauma patient with splenic injury who is being nonoperatively managed (ie, observation with or without splenic embolization) include:
●Signs of other intra-abdominal injury (eg, free air, peritonitis) necessitating exploration.
●Failure of nonoperative management. (See "Management of splenic injury in the adult trauma patient", section on 'Failure of nonoperative management'.)
ANATOMY OF THE SPLEEN — The spleen is located posterolaterally in the left upper quadrant of the abdomen (figure 1) beneath the left hemidiaphragm and lateral to the greater curvature of the stomach. The spleen is surrounded by a fibrous capsule composed of collagen, elastin, and smooth muscle. The spleen is important for opsonization of encapsulated organisms. Splenic physiology is discussed in detail separately. (See "Splenomegaly and other splenic disorders in adults", section on 'Properties of the normal spleen'.)
The spleen is predominantly perfused by the splenic artery, which is a branch of the celiac trunk. Collateral splenic blood flow is also derived from the short gastric arteries, which can have contributions from the left gastric and left gastroepiploic artery. The splenic artery, which can be quite tortuous, traverses along the superior margin of the pancreas, supplying branches to it, before continuing to the spleen (figure 2). The splenic artery branches to form up to six major arteries before entering the splenic hilum (figure 3). Each branch runs in the transverse axis of the spleen, progressively branching to peripheral arterioles that open freely into the splenic pulp. The blood flows through the reticular tissue and is collected in the terminal venules, which join to form larger veins (figure 4).
The veins do not accompany the arteries within the spleen. At the hilum, up to six major veins unite to form the splenic vein (figure 3). The splenic vein joins the superior mesenteric vein to form the portal vein (figure 2).
PREPARATION
Preoperative
Type and crossmatch — At least 4 units of packed red blood cells (RBCs) should be available for transfusion in the event the patient becomes hemodynamically unstable. A "massive transfusion protocol" should be immediately available for all hemodynamically unstable patients and include preparation of packed RBC, fresh frozen plasma (FFP) or similar products (eg, PF24), and platelets. Some trauma patients may be candidates for tranexamic acid within three hours of injury. (See "Massive blood transfusion" and "Initial management of moderate to severe hemorrhage in the adult trauma patient".)
Prophylactic antibiotics — Prophylactic antibiotics are administered to prevent surgical site infection. For emergent trauma surgery, antibiotic selection is the same as for elective surgery with administration of a first-generation cephalosporin (eg, cefazolin) [1]. If there is concern for or confirmed enteric or colorectal contamination, anaerobic coverage with metronidazole or, alternatively, a higher-generation cephalosporin is appropriate. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
Prophylactic immunization — The urgent/emergent nature of a trauma laparotomy precludes the ability to immunize the patient prior to possible splenectomy. In general, patients are immunized in the postoperative period if splenectomy is required. (See "Management of splenic injury in the adult trauma patient", section on 'Immunocompetence after splenic injury'.)
Informed consent — The patient or family/caregivers (if the patient is intubated/unresponsive) is informed that trauma laparotomy will be necessary to control bleeding, as well as to identify and treat other related intra-abdominal injuries that may be unknown prior to surgery. (See "Management of splenic injury in the adult trauma patient", section on 'Associated injuries'.)
Intraoperative — Standard trauma laparotomy preparation is performed. Hypothermia adversely impacts enzyme kinetics, including those important for clotting, and therefore measures to impede heat loss should be instituted [2]. These include elevating the operating room temperature (>85ºF [25ºC]), administering warmed fluids through an appropriate infusion device, and using other warming devices, such as a warm water heating pad or forced air convective heating blanket (eg, Bair hugger).
The skin is prepared (eg, chlorhexidine-alcohol) from the suprasternal notch to the mid-thighs, encompassing the entire anterior and lateral surfaces of the abdomen and chest. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Skin antisepsis'.)
Autotransfusion devices may be used for red blood cell scavenging from extra-abdominal cavities (eg, pleural spaces) and combined with red cell scavenging devices in the operating room (eg, cell saver) provided gross peritoneal soilage from intestinal injury is absent. These techniques are part of a patient blood management program to minimize allogeneic exposure to nonautologous blood. (See "Surgical blood conservation: Intraoperative blood salvage".)
EXPLORATORY LAPAROTOMY — An exploratory laparotomy should be performed whenever the spleen requires surgical intervention due to trauma. All intraperitoneal structures are inspected, and the retroperitoneum explored as needed, depending upon the zone of retroperitoneal injury (eg, mandatory exploration for central [zone 1] injuries) and whether the mechanism is blunt or penetrating.
Incision — A midline incision is performed because it is rapid and allows for complete visualization and mobilization of intraperitoneal and/or retroperitoneal structures. While the flank and chevron incision are appropriate for elective splenic surgery, we avoid these incisions in managing the injured spleen because entry into the abdomen is slower and exposure is more limited compared with that of the midline approach.
The skin, subcutaneous tissue, and midline fascia (linea alba) are incised, leaving the peritoneum intact. Then, anesthesia personnel are informed and should be prepared for blood loss, which may occur once the tamponade of the closed abdomen is released during the opening of the peritoneum.
Packing — Immediately after opening the peritoneum, the abdomen is packed in all four quadrants. Laparotomy pads are first packed in quadrants where active extravasation has been noted on preoperative imaging studies or where bleeding appears most significant. The left upper quadrant is packed by retracting the abdominal wall away from the spleen and placing laparotomy pads into the space between the diaphragm and spleen, and between the lateral abdominal wall and spleen. Additional packs are placed between the spleen and splenic flexure of the colon, and anterior to the spleen. This method creates a "sandwich," compressing the spleen between the laparotomy pads, which helps tamponade any active bleeding.
In cases where a laparotomy pad count has not been performed prior to packing, and the abdomen is to be closed, a plain radiograph should be taken at the end of the operation to document whether or not any laparotomy pads have been left in place (image 1). For those patients who are managed with an open abdomen approach (damage control laparotomy), a confirmatory radiograph should be obtained when the operating team believes that they have removed all the laparotomy pads that were left in place for hemorrhage control.
Abdominal exploration — To explore the abdomen, the abdominal packs are deliberately removed in reverse order, and active bleeding is controlled as it is encountered before addressing any gastrointestinal contamination. The spleen can remain packed while addressing more urgent injuries, providing the packs adequately control the bleeding. Alternatively, if the spleen is suspected to be the sole or primary source of hemorrhage, it can be addressed first, and the remaining packs can be left in place.
After more life-threatening injuries have been addressed, attention can be directed toward the left-upper quadrant. Adequate inspection of the spleen generally requires full mobilization from its attachments.
Mobilization of the spleen — Splenic mobilization is performed by dividing the spleen's ligamentous attachments to the diaphragm, kidney, stomach, and colon (figure 5). Once mobilization is complete, packs of laparotomy pads are placed behind and lateral to the spleen. During mobilization, bleeding from the spleen can be controlled by manually compressing the splenic vessels in the splenic hilum.
The lateral attachments (ie, splenophrenic and splenorenal ligaments) are divided first. This is best accomplished by placing the left hand up and over the diaphragmatic surface of the spleen, gradually and carefully rotating and elevating it medially while dissecting the plane between the pancreas and kidney (eg, Metzenbaum scissors, cautery, blunt dissection).
The gastrosplenic ligament is divided, and the short gastric vessels contained within it are clamped, divided, and suture ligated. Suture ligation is important in managing the short gastric vessels because postoperative gastric distension can push off a simple tie and lead to postoperative bleeding. Care is also taken not to entrap the gastric wall in the suture, which can result in tissue necrosis and gastric perforation. As an alternative to manually clamping and ligating, the short gastric vessels can also be handled using bipolar vessel sealing technology. The splenocolic ligament is divided to complete splenic mobilization.
Following mobilization, the spleen is inspected, and an intraoperative splenic injury grade determined. (See "Management of splenic injury in the adult trauma patient", section on 'Splenic injury grading'.)
SPLENECTOMY VERSUS SALVAGE — The decision to perform splenectomy versus splenic salvage (ie, splenorrhaphy, partial splenectomy) is made based upon the grade of injury, presence of associated injuries, patient's overall condition, and experience of the surgeon. One decision-making approach is informed by surgeon experience as well as facility resources (figure 6). The small future risk of overwhelming postsplenectomy sepsis needs to be balanced against the more significant risk of recurrent hemorrhage.
Splenectomy is a life-saving procedure when bleeding from the spleen is the cause of hemodynamic instability. Splenic salvage was extensively practiced in the 1980s and up to the mid-1990s; however, splenectomy is consistently more commonly used, likely because more lower-grade (I to III) injuries in hemodynamically stable patients are managed nonoperatively. When considering splenic salvage, the surgeon must determine whether the patient can tolerate rebleeding and reoperation for the small, but real, risk of recurrent hemorrhage [3-6]. Splenectomy is often a more appropriate choice for patients with multiple injuries or comorbidities who may not tolerate a significant or recurrent episode of hypotension or a second surgical procedure.
Splenectomy is also more appropriate for patients requiring urgent surgical management of other significant injuries that preclude taking the extra time needed for splenic salvage. In the setting of damage control, delayed splenic salvage can be considered (within 24 to 48 hours) for low-grade splenic injuries, provided that the bleeding is controlled with packing. Splenectomy is the safest option, given that most patients who require damage-control surgery are on the brink of physiologic collapse; are hypothermic, acidotic, coagulopathic; and will likely only poorly tolerate recurrent hemorrhage.
Splenectomy may also be the best option for surgeons whose institutional resources cannot support nonoperative management of splenic injury or who do not have adequate experience with splenic salvage. Lower-grade splenic injuries (I to III) (image 2) are the most conducive to splenic salvage techniques; however, the shift toward nonoperative management with angiographic embolization has decreased the number of patients who would be ideal candidates for operative splenic salvage techniques. As such, individual surgeon experience with splenic salvage has declined [7]. (See "Management of splenic injury in the adult trauma patient", section on 'Splenic embolization'.)
SPLENIC SALVAGE — There are several splenic salvage techniques published in journals and textbooks, though no formal comparisons have been made. The selection of specific techniques, materials, and sutures depend on individual surgeon experience and preference. Observational management, with or without splenic embolization, has made splenic salvage an infrequent procedure in surgical practice. Most adult patients who fail nonoperative management will require a splenectomy.
Splenorrhaphy — Splenorrhaphy refers to the suture repair of the spleen with or without splenic wrapping and is generally supplemented by electrocautery techniques for control of parenchymal hemorrhage.
Intraparenchymal bleeding is controlled first, followed by reapproximation of the splenic tissue and capsule when possible. Hemostasis can be achieved with topical hemostatic agents, electrocautery, or argon beam coagulation [8-10]. The choice depends upon availability and surgeon preference. A mass closure technique using absorbable sutures, with or without supporting pledgets, is used to reapproximate the splenic tissue [11,12]. When reapproximation of the tissue is not feasible, due to tissue friability, a tongue of omentum can be laid into the open defect and sutured into place.
The spleen can be wrapped in an absorbable hemostatic mesh to facilitate tissue approximation and effect tamponade. The use of mesh does not appear to be associated with increased infection rates, even in patients who underwent mesh splenorrhaphy and concomitant bowel repair [13]. Splenic wrapping, however, can be time consuming, particularly in inexperienced hands, and has the potential to cause splenic ischemia if the wrapping is too tight at the hilum, or may allow recurrent hemorrhage if the wrap is too loose. Significant residual bleeding despite repair indicates the need for splenectomy.
Partial splenectomy — Partial splenectomy is a form of splenic salvage and refers to the removal of a portion of the spleen based upon its segmental blood supply. Partial splenectomy leaves behind a raw surface, which may have an unacceptably high risk of recurrent hemorrhage, especially in patients with coagulopathy and those at risk for high venous pressures (eg, portal vein injury, preexisting cirrhosis). Accordingly, partial splenectomy is an infrequently selected technique to manage splenic injury.
The hilar vessels supplying the irreparably damaged portion of spleen are ligated and divided. After the surface of the spleen demarcates into viable and nonviable portions, the nonviable portion is removed using a scalpel or electrocautery. The cut edge of the remaining spleen is managed with the splenorrhaphy techniques discussed above. (See 'Anatomy of the spleen' above.)
SPLENECTOMY — Splenectomy removes the entire spleen. Following mobilization, the splenic artery and vein at the hilum are isolated. Each vessel is, ideally, individually ligated and divided to prevent the potential development of an arteriovenous fistula.
Care is taken during the isolation and ligation of the hilar vessels to identify and avoid injury to the tail of the pancreas, which is adjacent to the splenic hilum.
Once the spleen is removed, the splenic bed is examined for bleeding. Because the region of the splenic bed is deep in the left upper quadrant, bleeding may not be easily visualized. One useful technique is to roll up a laparotomy pad, place it into the left upper quadrant, and slowly roll it toward the divided hilar vessels. Blood that appears on the pad indicates the location requiring further hemostasis.
The greater curvature of the stomach is reexamined to ensure control of the divided short gastric vessels. If there is any concern that a tie is encroaching on the gastric wall, that area of gastric wall can be inverted with sutures placed in a Lembert fashion.
We do not routinely use drains unless there is concern for another injury that might benefit from closed drainage (eg, known or suspected pancreatic injury, renal collecting system injury). (See 'Postsplenectomy sepsis' below.)
Replantation of splenic tissue — If splenectomy for injury is deemed necessary, heterotopic autotransplantation of splenic tissue into omental pockets may provide some splenic function, although this has not been proven conclusively [14-17]. One study that compared the computed volume of splenic tissue identified using scintigraphy with red blood cell pit counts found that 20 to 30 cm3 of implanted tissue was sufficient to provide return of some splenic function [18]. However, the degree of clinical immunologic protection offered by this splenic tissue is unclear [17,19].
Deliberate autotransplantation of splenic tissue into omental pockets is a relatively simple procedure but requires a patient without severe concomitant injury who is hemodynamically stable and without acidosis, hypothermia, or coagulopathy. These conditions are rarely met, and thus, heterotopic autotransplantation is generally not performed in the setting of acute injury [20,21]. Autotransplantation, termed splenosis, is discussed below. (See 'Splenosis' below.)
LAPAROSCOPIC APPROACH — Open exploration remains the standard of care for surgical intervention. While the laparoscopic approach has been described in case reports and small case series [22-32], a laparoscopic approach to manage splenic injury should only be considered in select cases. As an example, a low-grade injury found during diagnostic laparoscopy for penetrating trauma with minimal-to-no hemorrhage in a hemodynamically stable patient may be amenable to laparoscopic repair or, if needed, laparoscopic splenectomy.
The laparoscopic approach is hampered by inadequate visualization due to ongoing hemorrhage and potential hypotension (ie, decreased venous return from pneumoperitoneum). Due to the general success of nonoperative management strategies, surgical intervention is more typically performed in patients who are hemodynamically unstable. Under these circumstances, laparoscopic exploration is contraindicated due to the potential for further hemodynamic compromise.
POSTOPERATIVE CARE — Much of the postoperative course following surgical management for splenic injury is dictated by the presence of associated injuries. In particular, the decision to leave an indwelling nasogastric tube is informed by the presence of concomitant gastrointestinal tract injuries (particularly proximal injuries), placement of packing materials, or gastrointestinal discontinuity. Elective procedures for splenectomy (eg, hematologic disease, resection of distal pancreatic malignancy) often forego nasogastric drainage without untoward consequence.
Serial hematocrits and platelet counts are obtained following splenic repair or splenorrhaphy to monitor for postoperative bleeding and thrombocytosis (see 'Thrombocytosis' below). There is no optimal regimen; however, we check the hematocrit every eight hours for the first 24 hours. Patients who have undergone splenic repair should be monitored similarly to those who are undergoing nonoperative management. (See "Management of splenic injury in the adult trauma patient", section on 'Nonoperative management'.)
Patients who have had upper abdominal surgery are at a higher-than-average risk for pulmonary complications due to pain associated with the abdominal incision and splinting. Therefore, deep breathing exercises, incentive spirometry, or positive expiratory pressure devices should be instituted to address the potential for significant atelectasis. (See "Strategies to reduce postoperative pulmonary complications in adults", section on 'Postoperative strategies'.)
POSTOPERATIVE ISSUES — Patients who are discharged with staples, sutures, or drains in place should follow up with their surgeon within one to two weeks. Some patients require a more prolonged hospitalization and recovery from multiple associated injuries. These patients should be monitored by their surgeon for postoperative complications. (See 'Surgical outcomes and complications' below.)
Thrombocytosis — The platelet count should be monitored in patients who have developed thrombocytosis in the postoperative period. A modest secondary reactive thrombocytosis following injury without splenectomy occurs in approximately 20 percent of patients and is due to increases in circulating thrombopoietin, interleukin-6, and other inflammatory mediators [33,34].
Following splenectomy, reactive thrombocytosis occurs in 75 to 82 percent of patients [35]. The platelet count commonly increases 30 to 100 percent following splenectomy, usually peaking between 7 and 20 days postoperatively, and then falling to normal levels over weeks to months, but sometimes over years [35]. Counts exceeding 1,000,000/microL are not uncommon following splenectomy. In a retrospective review of patients with splenic trauma, the platelet count initially increased in all patients with thrombocytosis (platelet count >500 x 109/L, >500,000/microL), occurring in 41 percent (64 of 156). Thrombocytosis was more likely following splenectomy compared with spleen-preserving strategies (odds ratio [OR] 7.58, 95% CI 2.26-25.45), independent of length of stay, injury grade, injury severity score, age, and transfusion [36]. Extreme thrombocytosis (platelet count >1000 x 109/L, >1,000,000/microL) was more likely following splenectomy compared with spleen-preserving strategies (OR 10.39, 95% CI 3.59-30.07), independent of length of stay.
Thrombocytosis may cause platelet aggregation, which may lead to vessel thrombosis that is not reliably predictable. Thrombocytosis alone is not usually sufficient to lead to clinically significant thrombosis. While most patients with secondary thrombocytosis do not require specific therapy, postoperative patients at high risk for venous thrombosis (eg, thrombophilia, cancer) who have concomitant thrombocytosis may be treated with antiplatelet therapy (eg, aspirin). Data are lacking on whether aspirin therapy yields a significant outcome benefit, and for which patient population. Therapy may be instituted when the platelet count exceeds 1,000,000/microL, if not contraindicated (eg, cerebral trauma). When extreme thrombocytosis (platelet count >1,000,000/microL) is coupled with evidence of venous or arterial thrombosis, additional treatment may be required to treat symptoms. The management of patients with thrombophilia and acute thrombosis is discussed in detail elsewhere. (See "Approach to the patient with thrombocytosis".)
Thromboprophylaxis — The incidence of venous thromboembolism following splenectomy for trauma is estimated to be approximately 10 percent [36-38], which is similar to reported rates for isolated splenectomy for other indications [39].
Venous thromboembolism prophylaxis can be initiated within 24 hours after splenectomy unless contraindicated by other associated injuries [37,40].
Immunizations — Following splenectomy, the patient should be immunized against encapsulated organisms. Following splenorrhaphy or partial splenectomy, the need to immunize is unclear. Issues pertaining to immunization and timing are reviewed elsewhere. (See "Management of splenic injury in the adult trauma patient", section on 'Immunocompetence after splenic injury'.)
Postsplenectomy identification — The patient should have identification (eg, bracelet, necklace, wallet card) to notify future health care providers of prior splenectomy, in the event the patient is unable to do so.
Splenosis — Splenosis consists of transplanted splenic tissue, which, if spontaneous, can be located anywhere within the abdomen or pelvis. The nodules associated with splenosis contain functioning splenic tissue and are usually multiple, with each measuring a few millimeters to a few centimeters in diameter [16]. The presence of splenosis may provide a critical mass of splenic tissue to confer some degree of splenic immunocompetence to the individual, but splenosis may not provide full protection against infection due to small size or poor vascularization [17,19]. (See "Management of splenic injury in the adult trauma patient", section on 'Immunocompetence after splenic injury' and "Splenomegaly and other splenic disorders in adults", section on 'Splenosis'.)
Splenosis as a consequence of splenic injury is a common benign condition that requires no specific therapy but may mimic malignancy or endometriosis on diagnostic studies. The nodules can be grossly distinguished from accessory spleens by the absence of a hilum, capsule, and trabeculae, and location that is often not in association with the splenopancreatic or gastrosplenic ligaments [16].
SURGICAL OUTCOMES AND COMPLICATIONS — Morbidity and mortality in multitrauma patients are highly dependent upon the nature and severity of other injuries and medical comorbidities. The mortality rate for patients undergoing surgery for isolated splenic injury is also dependent on the grade of injury, as well as the presence or absence of shock. Mortality can be as high as 22 percent for grade V injury [41,42].
Patients undergoing splenic salvage or splenectomy are at risk for the commonly reported complications of patients undergoing other abdominal procedures (eg, surgical site infection, ileus, urinary tract infection). Pulmonary complications are the most common complications following splenic surgery after injury, with atelectasis found in 38 percent, pneumonia in 9 percent, and pleural effusion in 6 percent of patients in one retrospective study [43]. (See 'Postoperative care' above.)
Postoperative bleeding — Common sources of bleeding following splenectomy include the raw edges of the divided splenic attachments and short gastric or hilar vessel remnants. Bleeding that requires reoperation after isolated splenectomy is rare but has been reported to occur in 1.6 percent of patients in one series and may involve hemorrhage from surrounding structures (eg, pancreatic tail) [44].
Gastric perforation — Gastric perforation is uncommon (case reports only) but can result from necrosis of the gastric wall from the effects of the initial trauma, or ligation of the short gastric vessels where gastric wall tissue is incorporated into the suture ligature. (See 'Splenectomy' above.)
Vascular thrombosis — Thrombosis occurs in approximately 5 percent of patients following splenectomy [45,46]. Thrombosis of any vein can occur, but the portal, mesenteric, and splenic veins appear to be affected more often [47]. Thrombocytosis may increase the risk for venous or arterial thrombosis following splenectomy, though the relationship between thrombocytosis and thrombosis remains unclear. The relative contributions of immobility, thrombogenic fluid administration, other injuries, repeat operation, recurrent hypotension, and other factors may contribute more to thrombotic complications than thrombocytosis. (See 'Thrombocytosis' above.)
Pancreatic fistula — Pancreatic fistula develops in approximately 1.5 percent of patients following splenectomy, due to injury of the tail of the pancreas, either from the initial trauma or due to splenic hilar dissection [43]. (See 'Mobilization of the spleen' above.)
Any patient who develops left upper quadrant pain, fever, and leukocytosis after splenectomy should be imaged with ultrasound or computed tomography (CT) scan to identify any left upper quadrant fluid collections. The diagnosis of pancreatic fistula can be made by guided percutaneous fluid sampling, demonstrating amylase-rich fluid indicative of a pancreatic leak. Cultures of the fluid should also be sent to rule out an abscess, which is more common than a pancreatic leak.
In addition to percutaneous drainage of pancreatic fluid, endoscopic management (endoscopic retrograde cholangiopancreatography [ERCP] with stenting) can be used to promote internal drainage of pancreatic secretions, which reduces flow through the fistula tract.
Perioperative infection — Following splenectomy, the patient is at a small but increased risk for postoperative infection [48,49]. Splenic preservation in patients with blunt splenic injury by operative or nonoperative management has been reported to lead to lower early infection rates (in adults) compared with splenectomy. As an example, one prospective study reported that adult patients managed with observation, splenic repair, and splenectomy had postoperative infection rates of 5, 15, and 49 percent, respectively [48]. It is unclear whether the determining factor was the preservation of splenic tissue, or a reflection of injury severity allowing observation or requiring splenectomy. Pneumonia was the most common postoperative infection in all three groups, but not all infections were due to encapsulated organisms.
Intra-abdominal abscess complicates splenectomy in 3 to 13 percent of patients and is associated with concomitant intestinal tract injuries and the presence of splenic bed drains [50].
Postsplenectomy sepsis — Postsplenectomy sepsis is a fulminant and rapidly fatal illness due to encapsulated pathogens [48,49]. The incidence of postsplenectomy sepsis associated with splenic injury appears to be lower than that for splenectomy performed for other indications. Autotransplantation of splenic tissue at the time of the injury (ie, splenosis) may provide a critical mass of splenic tissue to confer some degree of splenic immunocompetence to the patient, although this is not reliably established [51]. An alternate explanation is that splenectomy for trauma is more commonly performed in otherwise healthier (notwithstanding their traumatic injuries) individuals who have fewer medical comorbidities as compared with those undergoing splenectomy for other reasons. (See "Clinical features, evaluation, and management of fever in patients with impaired splenic function".)
Risk for malignancy — A few studies have suggested that there is possibly an increased risk for malignancy following splenectomy (traumatic or nontraumatic), but in others, the association with malignancy following traumatic splenectomy has not been found [52-54]. A large population-based cohort study that sought to determine the risk of malignancy among patients undergoing splenectomy for traumatic (n = 2295) compared with nontraumatic (n = 2603) indications identified some differences [55]. Traumatic splenectomy had a significantly increased risk for malignancy compared with controls (hazard ratio 1.28, 95% CI 1.06-1.60), but the identified risk was slightly lower than that of patients undergoing splenectomy for nontraumatic reasons. In subgroup analysis, among those with traumatic splenectomy, the increased risk compared with controls was significant among men, those younger than 45, and those with comorbidities. (See "Elective (diagnostic or therapeutic) splenectomy", section on 'Cancer'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Traumatic abdominal and non-genitourinary retroperitoneal injury".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Splenectomy (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Emergent surgical exploration of the abdomen is indicated for hemodynamically unstable trauma patients who have 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 'Indications for exploration' above.)
●Exploratory laparotomy for trauma consists of initial control of hemorrhage by abdominal cavity packing, followed by systematic inspection of all intraperitoneal structures, followed by exploration of the retroperitoneum, as needed, depending upon the zone of retroperitoneal injury. Active bleeding is managed prior to addressing gastrointestinal injury. The spleen may remain packed to address more urgent injuries, provided the packs adequately control bleeding. (See 'Exploratory laparotomy' above.)
●Indications for surgical exploration in the hemodynamically stable trauma patient with splenic injury include a contraindication to nonoperative management, evidence of another intra-abdominal injury requiring surgery, and failure of nonoperative management. (See 'Indications for exploration' above.)
●Open surgical techniques to manage splenic injury include partial or total splenectomy or splenorrhaphy (ie, splenic repair). The choice of technique depends upon the extent of splenic injury, the presence of associated injuries, medical comorbidities, the experience of the surgeon, as well as the hemodynamic stability of the patient. (See 'Splenectomy versus salvage' above.)
●For hemodynamically unstable patients with ongoing bleeding from splenic injury, splenectomy is a necessary, life-saving procedure. For patients requiring urgent surgical management of other significant injuries, splenectomy is more appropriate than splenic salvage because of its expediency. (See 'Splenectomy' above.)
●For patients who have failed nonoperative management, including splenic embolization, we suggest splenectomy over operative splenic salvage (Grade 2C).
●For splenic injury, we suggest an open approach via conventional laparotomy over a laparoscopic approach (Grade 2C). The role of laparoscopy in the management of the injured spleen is not yet defined. (See 'Laparoscopic approach' above.)
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