What are the steps for performing a splenectomy during trauma exploration?

Steps for Performing a Splenectomy During Trauma Exploration

Splenectomy should be performed in patients with hemodynamic instability, failure of non-operative management, or associated injuries requiring laparotomy such as peritonitis, bowel evisceration, or impalement. 1

Indications for Splenectomy

• Hemodynamic instability unresponsive to resuscitation
• Failed non-operative management with angioembolization
• Significant drop in hematocrit levels or continuous transfusion requirements
• Associated injuries requiring laparotomy (peritonitis, hollow organ injuries)
• Severe splenic injuries (grade IV-V) in centers without intensive monitoring capabilities or rapid angioembolization
• Concomitant severe traumatic brain injury where hypotension must be avoided 1, 2

Preoperative Considerations

• Ensure adequate large-bore IV access and blood products availability
• Optimize hemodynamics with fluid resuscitation and blood products as needed
• Consider rapid sequence intubation for airway protection
• Position patient supine with arms extended
• Prepare and drape from nipples to mid-thighs

Surgical Steps for Splenectomy

1. Initial Access and Exploration

   • Perform a midline laparotomy from xiphoid to umbilicus or beyond as needed
   • Evacuate hemoperitoneum and perform rapid assessment of all abdominal organs
   • Pack all four quadrants to identify major sources of bleeding
   • Control ongoing hemorrhage with direct pressure or vascular clamps

2. Exposure of the Spleen

   • Mobilize the left colon medially to expose the retroperitoneum
   • Retract the stomach medially to expose the splenic hilum
   • Divide the lateral peritoneal attachments (splenocolic and splenophrenic ligaments)

3. Vascular Control

   • Identify and ligate the splenic artery and vein at the hilum first to minimize blood loss
   • Double ligate the splenic vessels with non-absorbable sutures or vascular staples
   • Alternative approach: identify and ligate splenic vessels at the superior border of the pancreas before mobilization in cases of massive bleeding

4. Complete Mobilization

   • Divide the short gastric vessels between ligatures or using energy devices
   • Divide the remaining ligamentous attachments (splenorenal ligament)
   • Carefully separate the tail of the pancreas from the splenic hilum to avoid pancreatic injury

5. Removal and Hemostasis

   • Remove the spleen and inspect the splenic bed for bleeding
   • Achieve meticulous hemostasis in the splenic bed
   • Consider placement of topical hemostatic agents if diffuse oozing persists
   • Inspect the tail of the pancreas for injury

6. Closure

   • Place a closed suction drain if there is concern for pancreatic injury
   • Perform a final inspection for hemostasis
   • Close the abdomen in standard fashion

Post-Splenectomy Management

• ICU admission with continuous monitoring for at least 24-48 hours
• Serial hemoglobin/hematocrit checks every 6 hours
• Strict bed rest for 48-72 hours initially
• Thromboprophylaxis with mechanical methods initially, followed by LMWH when bleeding risk has decreased 2
• Vaccination against encapsulated bacteria (S. pneumoniae, H. influenzae, N. meningitidis) 14 days after splenectomy 2

Special Considerations

• Partial splenic preservation is debated and generally not recommended in trauma settings 1
• Laparoscopic splenectomy is not recommended in acute trauma with active bleeding 1, 2
• The reported overall hospital mortality of splenectomy in trauma is approximately 2% 1
• Postoperative bleeding after splenectomy occurs in 1.6-3% of cases, with a mortality rate of about 20% 1

Common Pitfalls to Avoid

• Failure to control the splenic artery early, leading to excessive blood loss
• Injury to the tail of the pancreas during hilar dissection
• Inadequate mobilization leading to difficult access and poor visualization
• Missed associated injuries due to focus on splenic trauma
• Delayed recognition of postoperative bleeding requiring reoperation

By following these systematic steps, surgeons can efficiently perform splenectomy during trauma exploration while minimizing complications and optimizing patient outcomes.