Exploratory Laparotomy and Splenectomy for Ruptured Spleen Following Blunt Force Trauma

Abstract

The spleen is highly vascular, is the largest secondary lymphoid organ, and is the most commonly injured organ in the setting of blunt abdominal trauma. Patients may present asymptomatically or with abdominal pain, nausea and vomiting, or signs of hemodynamic instability. Although many splenic injuries caused by blunt abdominal trauma may be managed conservatively, free intra-abdominal fluid with hemodynamic instability warrant surgical management in the form of exploratory laparotomy and splenectomy.

In this video report, we demonstrate the management of a patient who was assaulted, sustaining blunt abdominal trauma and a hemodynamically significant grade IV splenic laceration. Here, we perform an exploratory laparotomy and splenectomy. 

Keywords

Blunt trauma; laparotomy; splenectomy; FAST.

Case Overview

Background

The abdomen is commonly affected in trauma. Blunt abdominal trauma may cause significant bleeding or visceral perforation, requiring surgical intervention. All trauma patients are initially systematically evaluated with the primary survey,¹ which encompasses a series of elements outlined by the mnemonic ABCDE. A is for airway stabilization, B is for breathing, C is for circulation, D is for disability evaluation typically with the GCS (Glasgow Coma Score), and E is for exposure/environment. After the primary survey and resuscitation are initiated, rapid evaluation with particular emphasis on identifying significant intra-abdominal bleeding or perforation is performed. The presence of free intra-abdominal fluid or air is diagnosed by Focused Assessment with Sonography in Trauma (FAST) exam, CT, or historically, DPL (diagnostic peritoneal lavage).¹ An exploratory laparotomy may be performed to systematically identify and repair intra-abdominal injuries. Indications for exploratory laparotomy in the setting of blunt abdominal trauma include peritonitis, hemodynamic instability with free intra-abdominal fluid, or high-grade organ injury.¹ In an effective exploration for blunt abdominal trauma, damage control principles are followed, and management of immediately life-threatening injuries are prioritized.² Depending on the condition of the patient, injuries may be temporized in the operating room with plans for definitive treatment after adequate resuscitation in the ICU. 

The spleen, which is typically located in the left upper quadrant, is one of the most commonly injured organs in blunt abdominal trauma, occurring in a quarter of blunt abdominal trauma cases³ and in 2.7% of all traumatic injuries.⁴ As a highly vascular structure, blunt trauma injuries may be hemodynamically significant. Splenic injuries in trauma are commonly diagnosed after the primary survey and initial resuscitation on imaging, typically CT scans. A pertinent lab finding may be low hematocrit, which is associated blood transfusion in trauma.⁵ The majority of traumatic splenic injuries can be conservatively managed with resuscitation guided by close monitoring of hemodynamics and hematocrit levels and occasionally angiography with coil embolization.^1,3,4 However, operative intervention in the form of splenectomy to stop intra-abdominal bleeding is indicated for high-grade splenic injuries and hemodynamic instability.^1,2,4,6

Focused History and Physical Exam of the Patient

The presentation of patients with splenic injuries associated with blunt abdominal trauma may vary depending on the severity of the injury.¹ Patients may present with various symptoms ranging from asymptomatic to hemodynamic instability or peritonitis with significant intra-abdominal hemorrhage. The patient is monitored for signs of shock with a particular emphasis on tachycardia, hypotension, and the response to resuscitation with crystalloid fluid or blood products. Other symptoms with which these patients may present are abdominal pain, referred left shoulder pain (Kehr’s sign), flank bruising, or nausea and vomiting. In the setting of splenic injuries from blunt trauma, it is important to identify any other concomitant injuries and systematically evaluate the trauma patient.^1,2

This patient was a female who presented to an outside hospital after being reportedly assaulted and incurring blunt abdominal trauma. The CT from the outside hospital showed a splenic laceration, and she was transiently responsive to resuscitation with systolic blood pressures over 120 on transfer to the acute care surgery service at the University of Chicago. A repeat CT performed on arrival demonstrated a grade IV splenic laceration, a grade I or II liver laceration, and significant hemoperitoneum with hemodynamic instability, prompting exploration in the OR. 

Imaging

The FAST exam is an adjunct to the primary survey.^1,7 Using an ultrasound probe, any abnormal presence of fluid (or rarely air) is identified in the perihepatic space (Morrison’s pouch), perisplenic space, pelvis, or pericardium. There may be multiple reasons for fluid to be seen on the FAST exam in various patients. However, in the setting of trauma, free intra-abdominal fluid, especially in a hemodynamically compromised patient, is presumed to be blood and managed as such (typically with an exploration). The FAST exam is a screening tool, and a negative FAST exam does not rule out an intra-abdominal process or the need for exploration.^1,7 One variation on the FAST exam is the extended FAST (EFAST) exam, which also includes evaluation of the lungs to identify pneumothorax.¹ 

CT scan is a helpful adjunct after the primary survey if the trauma patient is hemodynamically stable. CT is a rapid imaging modality that provides more specific anatomic detail as compared to the FAST exam. In the case of splenic injuries, the grading of splenic injury may be performed via CT imaging to guide management. Secondary traumatic injuries are also better delineated on CT scans.¹ 

In this particular trauma case, the patient was transiently responsive to resuscitation en route and required a repeat CT scan. She was found to have a grade IV (high-grade) splenic laceration in addition to a grade I/II (low-grade) liver injury and hemoperitoneum. 

Natural History

The spleen is the most commonly injured organ in blunt abdominal trauma, occurring in a quarter of blunt abdominal traumas.³ In trauma, the major morbidity and mortality is associated with intra-abdominal hemorrhage and concomitant intra-abdominal injuries.¹ The specific mortality after a splenic injury is 5.4%.⁴

Options and Rationale for Treatment

The treatment of splenic injuries is in large part guided by patient condition and the severity of injury. The American Association for the Surgery of Trauma (AAST) grades the severity of splenic injuries on a scale of I to V based on CT imaging.^1,8 Many low-grade splenic injuries resolve spontaneously and may be managed conservatively with resuscitation, frequently with crystalloid or blood products.^{1,3,4,6,9–11} Patients are closely monitored in the ICU with special attention paid to hemodynamics (heart rate and blood pressure) and hematocrit levels. Patients who demonstrate persistent low-volume bleeding may also be assessed with angiography and undergo coil embolization of the splenic vessels.^{1,3,4,6,9–11} Operative intervention in the form of splenectomy to stop intra-abdominal bleeding is indicated for high-grade splenic injuries and hemodynamic instability.^{1,3,4,6,9–11}

A splenectomy may be performed as part of an exploratory laparotomy for intra-abdominal hemorrhage. An exploratory laparotomy with a large midline incision also allows the surgeon to systematically identify and temporize or repair other concomitant intra-abdominal injuries.¹ Damage control principles are followed and management of immediately life-threatening injuries are prioritized.² Depending on the condition of the patient, injuries may also be temporized in the operating room with plans for definitive treatment after adequate resuscitation in the ICU.^1,2

This particular patient was reasonably resuscitated en route and in the operating room to allow splenectomy and complete evaluation of the intra-abdominal contents, including the small bowel without identification of any other significant intra-abdominal injuries requiring operative intervention. Upon conclusion of the exploration and splenectomy, the patient’s abdomen was closed, and she was admitted postoperatively in stable condition.

Special Considerations

Elective splenectomies for blood dyscrasias or malignancies are outside the scope of this case. However, given the immunologic function of the spleen, all splenectomy patients are at risk for overwhelming postsplenectomy infection (OPSI).^12,13 Thus, all patients undergoing splenectomy are recommended to receive vaccinations against encapsulated bacteria, including Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae.^12,13 Immunization is ideally administered either two weeks before the splenectomy (in elective cases) or within 14–28 days postoperatively.^12,13 In the trauma setting or in cases of unclear follow-up, vaccines may be administered prior to discharge.¹²

Discussion

Here we present a female patient who presented from an outside hospital after a reported assault with blunt abdominal trauma. She was found to have a hemodynamically significant grade IV splenic laceration on a repeat CT, requiring exploration and splenectomy. Upon exploration, she was found to have about 1 L of hemoperitoneum that was evacuated, in large part due to the high-grade splenic laceration. We systematically and expeditiously evaluated the abdomen for other intra-abdominal injuries before proceeding with a splenectomy. After hemostasis and splenectomy, we confirmed there were no other intra-abdominal injuries requiring surgical intervention before abdominal closure. The patient experienced an estimated blood loss of 1.8 L and received 2 units of blood intraoperatively and 2 additional units after abdominal closure. Postoperatively, she was monitored closely with an expected hospital length of stay of about 4 days. The plan also included postsplenectomy vaccines to reduce the risk of OPSI. 

The spleen is the most commonly injured organ in blunt abdominal trauma, occurring in a quarter of abdominal trauma cases³ and in 2.7% of all traumatic injuries.⁴ As in the case detailed above, most splenic injuries are diagnosed on CT imaging, although some may be diagnosed on angiography or exploration.⁹ The management of the splenic injuries in trauma is guided by patient stability and the severity of the splenic injury, as categorized by the AAST.^1,8 

Indications for exploratory laparotomy and splenectomy as in the case described include patients who present with hemodynamic instability,² which is associated with higher grades (IV, V) of splenic injuries, or the 4–5% of patients who fail initial nonoperative therapy (decreasing hematocrit, continued need for transfusion, CT change, tachycardia or hypotension, or persistent abdominal pain).^4,6 Other reasons for exploratory laparotomy include associated concomitant intra-abdominal injuries that require surgical intervention.¹ Although the patient described in this case also had a low-grade liver laceration, the indication for exploration was primarily related to hemodynamic instability and the high-grade splenic injury. 

The majority (75%) of splenic injuries are low-grade (I-III) ⁴ and are associated with small volume hemoperitoneum.⁶ With a lower chance of hemodynamically-significant splenic injuries, these injuries are more commonly managed nonoperatively with up to 90% success rates.⁴ Furthermore, initial nonoperative management, which typically consists of resuscitation and close monitoring of hematocrit, has been noted to be increasingly prioritized over operative intervention since 1997.^4,6 This trend has been noted in parallel to the increasing use of angioembolization for splenic injuries of all grades and the increasing recognition of the high risk for, and associated mortality of, OPSI in postsplenectomy patients.⁶

Equipment

FLOSEAL - Baxter.

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.