Etiologically, splenic rupture can be divided into two categories: traumatic and spontaneous (idiopathic). Traumatic splenic rupture can be subdivided into open, closed, and medically induced. Among closed abdominal injuries, splenic rupture accounts for the first of all visceral injuries. In case of violent or crushing injury to the left quadrant, one must be highly alert to the possibility of spleen rupture.
I. Diagnosis
1.Clinical manifestations
(1) Symptoms.
① Abdominal pain: sudden onset left upper abdominal pain, which may be accompanied by radiating pain in the left shoulder and, in severe cases, a feeling of urgency.
(2) Shock: Mildly, it only shows pale face, cold sweat or accelerated pulse rate, and when bleeding is obvious, there may be signs of shock such as irritability and blood pressure drop.
(2) Signs: left upper abdominal pressure, muscle tension and very obvious rebound pain and other peritoneal irritation may appear, and even positive abdominal mobile turbid sounds may appear.
2.Auxiliary examination
When there is clinical suspicion of splenic rupture, abdominal puncture should be performed first, and the diagnosis can be confirmed if non-coagulated blood is drawn. However, in some atypical cases, especially in cases of compound injury or spontaneous splenic rupture, the diagnosis is often easily missed.
(1) CT examination: it is of great value for the diagnosis of traumatic splenic rupture and the grasp of surgical indications. If the subperitoneal hematoma does not exceed 50% of the surface area, or the depth of the splenic parenchymal laceration does not exceed 3 cm, the possibility of successful conservative treatment is quite high.
(2) Ultrasonography is also useful for diagnosis.
(3) X-ray examination reveals elevation of the left diaphragm and restriction of movement; sometimes a fracture of the left rib is seen.
(4) Diagnostic lavage: If repeated puncture does not yield positive results, lavage of the abdominal cavity is feasible. A plastic tube with lateral holes can be placed into the abdominal cavity and 500~1000 ml of sterile saline is slowly injected, then the intra-abdominal irrigation fluid is siphoned out, and the collected fluid is observed with the naked eye or microscope.
(5) Dynamic observation of red blood cell count and pressure volume.
(6) Laparoscopy may be considered to further exclude splenic rupture, especially in cases of compound injury or when the patient is in a comatose state.
(7) Selective splenic arteriography.
(7) Selective splenic arteriography, sometimes used in conjunction with embolization to stop bleeding.
Treatment options
Once the diagnosis of splenic rupture is established, in principle, surgical treatment should be performed, especially for patients who are already in shock when they come to the hospital, and they should be sent to the operating room for resuscitation after emergency treatment. However, as the importance of the spleen in anti-infection immune function is gradually recognized and the successful experience and satisfactory results of spleen-preserving treatment increase, appropriate treatment measures should be selected for different patients while taking into account the urgency of emergency treatment.
1. Open splenic rupture
In the vast majority of patients, dissection should be preferred, and if intraoperative hemodynamic instability or other organ injuries are combined, splenectomy and autologous splenic tissue implantation should be performed if necessary; if the situation is good, splenoprotection can be tried. For individual left upper abdominal puncture injury, if hemodynamically stable and confirmed by CT as simple splenic injury, conservative treatment can be tried under close observation.
2.Closed splenic rupture
When the conditions of close observation and the ability to transit surgery at any time are available, the following cases can be treated conservatively.
(1) Hemodynamic stability can be achieved with rehydration of <2500ml.
(2) Tolerable pain limited to the left upper abdomen.
(3) Absence or mild and limited peritoneal irritation.
(4) CT shows a hematoma encapsulated in the spleen and not exceeding 50% of the surface area, with a rupture depth of the splenic parenchyma not exceeding 3 cm.
(5) Laboratory indicators showing that the bleeding has tended to stop.
(6) No blood transfusion is required or the amount of blood transfusion is limited to 1~2 units.
(7) Age not more than 55 years.
During the course of conservative treatment, CT should be reviewed, and if the hematoma tends to increase, selective splenic artery embolization is feasible to stop the hemorrhage if available; otherwise, dissection is performed.
III. Surgical methods
According to the different types of splenic rupture, the following surgical methods are usually used.
1. Splenic repair
As long as the anatomical and physiological conditions allow, it can be applied from inadvertent splenic peritoneal avulsion injury caused during surgery to subperitoneal hematoma or shallow splenic parenchymal rupture without involvement of the splenic hilum. Fibrin adhesive, argon electrocoagulation, or laser coagulation can be used to stop the hemorrhage, and the addition of absorbable hemostatic gauze is often effective; when suturing, it is recommended that both the incoming and outgoing stitches pass through the greater omentum with the tip and be used for caulking. After surgery, the spleen is placed in situ for 20 hours for observation, and generally no drainage is placed.
2.Partial splenectomy
The indications for partial splenectomy are
(1) limited irregular rupture of the spleen.
(2) rupture of the spleen with blood leakage even after repair.
(3) Interruption of the blood supply to the ruptured part of the spleen, resulting in inactivation of the splenic tissue. According to recent studies on splenic vascular grading, segmental upper, middle, lower, or subtotal (75%) splenectomy can be performed. However, it should be emphasized that the residual spleen must have a good blood supply and not less than 25%; because of the long operation time and more bleeding, it should be performed only when the patient is stable and the operator is skilled.
3. Autologous splenic tissue implantation after total splenectomy
The indications for total splenectomy are
(1) Comminuted splenic rupture with severed splenic hilum.
(2) Those with life-threatening compound or open injuries that need to end the operation as soon as possible.
(3) Combined gastrointestinal injuries with significant abdominal contamination
(4) Pathological splenic rupture.
(5) Those who have tried various splenic preservation surgeries and failed to achieve effective hemostasis.
(6) Elderly patients. The parasplenium will develop compensatory hypertrophy after total splenectomy, so it should be preserved as much as possible. The value of autologous spleen tissue implantation has been more affirmed in children. 4cm×4cm×0.3cm slices of splenic tissue can be cut, rinsed and placed in the omental capsule, and marked with silver clips.
4.Other
Ligation of the splenic artery or selective splenic artery branches is sometimes useful for hemostasis of a traumatized spleen, but should not be applied when there is.
(1) the spleen shows significant ischemia after blocking the splenic artery
(2) In cases where the spleen has been extensively freed and the collateral circulation has been completely cut off.
(3) Spleen trauma combined with serious injury to other organs.
(4) Patients in unstable condition.