Which of the following is not an indication for splenectomy: a. Unipolar apical spleen laceration, b. Total splenic avulsion, c. Grade 4 splenic trauma, d. Massive splenomegaly compressing the left lung, or e. Splenic infarct due to splenic artery stenosis?

Indications for Splenectomy in Trauma and Pathological Conditions

The correct answer is e. Splenic infarct due to splenic artery stenosis is not an indication for splenectomy.

Indications for Splenectomy in Trauma

Splenectomy is indicated in the following traumatic conditions:

• Hemodynamic instability unresponsive to resuscitation with splenic injury of any grade 1
• Failed non-operative management (NOM) with ongoing bleeding or hemodynamic deterioration 1
• Total splenic avulsion, as this represents complete devascularization of the spleen 1
• Grade IV splenic trauma (laceration involving segmental or hilar vessels with >25% devascularization) in centers without angiography/angioembolization (AG/AE) capabilities or intensive monitoring 1
• Unipolar apical spleen laceration with active bleeding that cannot be controlled non-operatively 1

Analysis of the Options

a. Unipolar apical spleen laceration

This is an indication for splenectomy when associated with hemodynamic instability or when non-operative management fails. Isolated laceration with hemodynamic stability may be managed non-operatively, but splenectomy remains an option when bleeding cannot be controlled 1.

b. Total splenic avulsion

This is a definite indication for splenectomy as it represents complete devascularization of the spleen, equivalent to a grade V injury 1.

c. Grade 4 splenic trauma

This is an indication for splenectomy, particularly in centers without AG/AE capabilities or when the patient shows signs of hemodynamic instability 1. Grade IV injuries involve laceration of segmental or hilar vessels producing major devascularization (>25% of spleen) 1.

d. Massive splenomegaly compressing left lung

This is an indication for splenectomy as it can cause respiratory compromise. Massive splenomegaly can lead to mechanical compression of surrounding structures, including the left lung, causing respiratory distress 2.

e. Splenic infarct due to splenic artery stenosis

This is NOT an indication for splenectomy. Splenic infarcts due to arterial stenosis are typically managed conservatively unless they cause complications such as abscess formation, persistent pain, or rupture 1, 3. The spleen has collateral circulation that can maintain viability even with splenic artery stenosis 1.

Management Approach to Splenic Trauma

• Non-operative management (NOM) is the preferred approach for hemodynamically stable patients with splenic injuries of any grade 1
• Angiography and angioembolization (AG/AE) should be considered in hemodynamically stable patients with moderate to severe injuries or evidence of vascular abnormalities on CT scan 1
• Operative management is indicated for hemodynamically unstable patients or those with failed NOM 1

Pitfalls and Caveats

• Delayed splenic rupture can occur days to weeks after initial injury, requiring vigilant monitoring of patients managed non-operatively 1
• Overwhelming post-splenectomy infection (OPSI) is a serious complication following splenectomy, emphasizing the importance of splenic preservation when possible 4, 5
• Patients with severe traumatic brain injury and high-grade splenic injuries may benefit from early splenectomy in centers without immediate AG/AE availability 1
• Laparoscopic splenectomy is not recommended in acute trauma with active bleeding 1

In conclusion, while most splenic injuries and many pathological conditions of the spleen can be managed non-operatively in the appropriate clinical setting, specific indications for splenectomy exist. Splenic infarct due to splenic artery stenosis alone is not one of these indications, as it can typically be managed conservatively 1, 3.