SURGERY.ppt.SPLEEN INJURY HAS MADE EASY IN SLIDES

SPLEEN INJURY : SURGERY

1. SPLEEN INJURY BY: IVANA MARIYAM DEVASIA M2162P

2. INTRODUCTION The spleen is a solid organ which is the largest lymphoid organ in the body and is situated in the left hypochondrium. There are two anatomical components: ■ the red pulp, consisting of sinuses lined by endothelial macrophages and cords (spaces) ■ the white pulp, which has a structure similar to lymphoid follicles. Blood enters via the splenic artery and is delivered to the red and white pulp. During the flow the blood is 'skimmed', with leucocytes and plasma preferentially passing to white pulp. Some red cells pass rapidly through into the venous system and others are held up in the red pulp.

3. SURGICAL ANATOMY Ovoid/wedge, usually purplish, pulpy mass About size and shape of one's fist MOST VULNERABLE ABDOMINAL ORGAN Located in left upper quadrant or LHC Protected by lower thoracic cage Completely encircled and covered with peritoneum except at hilum

4. The spleen have: • 2 borders: Superior and inferior • 2 surfaces: diaphragmatic and visceral • 2 poles: posterior (medial) and anterior (lateral)

5. ETIOLOGY Blunt Trauma rapid deceleration (motor vehicle crashes) direct blows to the abdomen (domestic violence, or leisure and play activities such as bicycling) Penetrating Trauma Combination of above explosive type injuries warfare and civilian bombing l atrogenic Post Colonoscopy (66 patients in literature with 4.5% mortality rate) Spontaneous Rupture : malaria, infectious mononucleosis : Malaria, infectious mononucleosis

6. TYPES OF INJURY Splenic Hematoma Sub capsular Intra parenchymal • Lacerated wound • Clean incised wound Hilar/vascualr injuries

7. ASSOCIATED INJURIES Fracture Left lower ribs (30%) Left sided hemothorax Left lung and diaphragm injury Left lobe liver injury Tail of pancreas injury Left kidney Left colonic injury Small bowel injury

8. CLASSIFICATION Grade 1 : Hematoma subcapsular, <10% Grade 2 : Laceration < 1cm deep Grade 3 : Hematoma subcapsular, 10-50% , intraparenchymal, <5 cm Grade 4 : Laceration. 1-3 cm deep Grade 5 : Hematoma >50%, ruptured, >5cm Grade 6 : Laceration >3 cm, + trabecular vessels Grade 7 : Laceration segmental or hilar vessel with major devascularization Grade 8 : Laceration. shattered spleen, avulsion

9. CLINICAL PICTURE H/O Trauma • Pain abdomen • Occasional distension and vomiting • In severe bleeding associated with shock, syncope or dizziness • Kher's sign Pain over left shoulder joint • Fixed dullness to percussion on the left, and shifting dullness on the right (Ballance's sign). • Tenderness all over the abdomen with or without guarding and rigidity Bowel sounds are absent Bowel sounds are absent • In severe bleeding associated with shock, syncope or dizziness • Kher's sign : Pain over left shoulder joint • Fixed dullness to percussion on the left, and shifting dullness on the right (Ballance's sign). • Tenderness all over the abdomen with or without guarding and rigidity Bowel sounds are absent

10. DIFFERENTIAL DIAGNOSIS Liver injury • Ruptured ectopic pregnancy • Ruptured abdominal aortic aneurysm • Acute hemorrhagic pancreatitis

11. INVESTIGATIONS FAST (focused abdominal sonar trauma): a) is a rapid, non-invasive, portable USG focusing on pericardial, Hepatic ,splenic, pelvic areas. USG abdomen. : b) Detects 100 ml blood in cavities c) NOT reliable for bowel/ penetrating injuries d) Often needs to be repeated

12. CECT CT is the procedure of choice for diagnosis and estimation of the degree of splenic injury in the hemodynamically normal patient. Contrast blush (intraparenchymal hyperdense contrast collection)suggests active hemorrhage and is associated with failure of nonoperative management in all solid organ injuries.

13. SELECTIVE CELIAC ARTERIOGRAPHY Angiography may be used in patients demonstrating a contrast blush on CT scan to identify and treat a vascular abnormality

14. DPA/DPL Procedure of choice in physiologically unstable patient with blunt abdominal injury (eg. spinal Injury, unconsciousness) "Procedure 1) Infuse 11, normal saine Ringer lactate into peritoneal cavity (via subumbilical lavage cattier) 2) Patient's positionis changed from time to time & side-to-side 3) Fluid aspirated

15. AAST -CT GRADING

16. TREATMENT Nonoperative management Requires ICU monitoring in a dedicated trauma center and immediate ability to convert to operative management should that become necessary Indications Hemodynamic stability Minimal evidence of blood loss, <2 units packed red blood cells as transfusion requirement Absence of active contrast extravasation on CT scan Absence of other indication for laparotomy

17. Length of intensive care unit (ICU) monitoring is generally 24 to 48 hours initially, with serial hematocrit evaluation and continuous hemodynamic monitoring . Blood transfusion is limited to 2 units of packed red blood cells. If the patient has an ongoing transfusion requirement of more than 2 units, operative management should be performed ✔The majority of pediatric splenic trauma is successfully managed nonoperatively. ✓ Recovery recommendations include restricted activity in terms of contact sports, running, or similar stresses for 3 months following injury. Angiography is performed in patients who are hemodynamically normal and have a blush on initial CT scan.

18. TREATMENT Operative management Should be performed in those patients demonstrating peritonitis or hemodynamic instability, those failing nonoperative therapy, and those with gunshot wounds to the abdomen Splenectomy is indicated with significant blood loss (>1000 mL), significant associated injuries, hilar involvement, coagulopathy, or massive splenic disruption Splenic salvage includes splenorrhaphy and partial splenectomy Splenorrhaphy can be performed with absorbable mesh (Dexon)

19. Other strategies include the use of topical hemostatic agents, including Surgicel, Avitene, and topical thrombin, as well as the application of mattress sutures to allow tamponade of hemorrhage. Partial splenectomy may be performed for polar injuries. At least 30% of the spleen must be preserved to maintain function.

20. COMPLICATIONS Atelectasis which should be treated with aggressive pulmonary toileting Delayed bleeding in subcapsular hematoma Subpherenic abscess Pancreatic injury resulting Pancreatic fistula Thrombocytosis if platelets are > 10,00,000 OPSI- Overwhelming Post Splenectomy Infection

21. SUMMARY

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