Splenic Injury During Abdominal Surgery William Cioffiro, MD; Clarence J. Schein,
MD; Marvin L. Gliedman,
237 splenectomies performed over a six-year period, 39 necessitated by intraoperative injury. Capsular and hilar tears were predominant. All injuries were recognized at the time they occurred. The incidence of pulmonary complications and wound infections exceeded those for other categories of splenectomy and for these other abdominal operations without splenectomy. Although these complications were not fatal and the mortality was not increased, measures for avoidance of intraoperative splenic injury are indicated. These include knowledge of anatomic relationships and exercising cautious traction in operations on the upper part of the stomach and the splenic flexure of the colon, in reoperation in elderly people, or where there is suspicion of intrinsic splenic abnormality. \s=b\ Of
were
(Arch Surg 111:167-171, 1976)
discussion splenectomy secondary Thegical injury Castleman1
of to sur¬ did not appear in the literature until 1949 when Quan and reported on 70 splenec¬ tomies, 13 of which were performed because of intraopera¬ tive injury to the spleen. The magnitude of the problem has only received emphasis in the past ten years, with sev¬ eral authors documenting the large number of splenec¬ tomies necessitated by iatrogenic trauma.2"4 This study was undertaken to review the Montefiore Hospital and Medical Center experience with iatrogenic first
splenic injury requiring splenectomy, to assess compara¬ tive morbidity and mortality figures, and to discuss fac¬ tors of importance in the prevention and management of this problem. SUBJECTS AND METHODS
During the six-year period of January 1968 through December was performed in 237 patients at Montefiore Hospital and Medical Center. A broad spectrum of these cases is shown in Table 1. Of these 237 splenectomies, 39 (16%) were per¬ formed as a result of surgical injury to the spleen. For the purposes of this study, patients who underwent splenectomy in conjunction with another procedure (for example, to achieve a sat¬ isfactory margin of resection in surgery for gastric or colonie car¬ 1974, splenectomy
cinoma) were
were
classified
as
24 male and 15 female
"elective" and thus excluded. There patients ranging in age from 15 to 88
MD
mean age was 68 years, which is significantly higher than that of the 168 patients undergoing elective splenectomy and the 30 patients undergoing splenectomy for blunt or penetrating
years. The
trauma.
RESULTS Mode of Injury
Table 2 summarizes the various procedures leading to and the type of injury inflicted. Resection of the colon involving mobilization of the splenic flexure resulted in the highest number of injuries (21), followed by gastric procedures with or without vagot¬ omy (15). Avulsion of a portion of the splenic capsule was by far the most common type of injury, occurring in 25 of the 39 patients. Disruption of the splenic hilum occurred in nine patients and an unspecified injury occurred in four patients. Bleeding from the vasa brevia was specifically noted in only one case. In 38 of the 39 cases, traction on the peritoneal or omental attachments of the spleen was the mechanism directly or indirectly responsible for the injury. The one exception was a patient whose injury resulted from direct puncture of the spleen while a stab thoracostomy was being per¬ formed, which eventually led to one of the three deaths in the series. Etiologic factors such as trauma from retrac¬ tors and sharp instruments were not encountered. In all cases, the injury was recognized at the time of the pri¬
iatrogenic splenic injury
mary procedure. In nine of the 39
cases (23%), gross and microscopic ex¬ amination of the resected spleen disclosed one or more ab¬ normalities, with notable splenic enlargement in six of these nine patients. These abnormalities are as follows: splenomegaly with extramedullary hemopoiesis, two; sple¬ nomegaly with congestion, two; splenomegaly with hemosiderosis, one; splenomegaly with leukemic infiltration, one; capsular hyalinization, one; infarction, one; and cap¬ sular erosion and inflammation, one. In the one case in which inflammatory erosion of the capsule was seen, the etiologic factor was thought to be a contiguous, perfo¬ rated, greater curvature gastric ulcer.
Morbidity
Twenty-seven of the 39 patients (71%) undergoing sple¬
Accepted for publication Oct 16, 1975. From the Department of Surgery, Montefiore Hospital and Medical Center, and the Albert Einstein College of Medicine, Bronx, NY. Reprint requests to Montefiore Hospital and Medical Center, 111 E 210th St, Bronx, NY 10467 (Dr Schein).
nectomy for intraoperative injury had one or more postop¬
compared with the elective and complications was 22% and 43%, respectively (Table 3). The mean hospital stay
erative
complications,
as
trauma groups whose incidence of
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Table 1.—Case Material, 1968
Through 1975
Table
3.—Morbidity
and
Compli¬
Mean
Elective splenectomy Splenectomy for trauma Splenectomy for surgical injury Totals
Table
No. of Sex Pa- ,_ _ tients Male Female 168 79 89 21 30 9 39 237
24 124
Hos-
pital Age, Stay, yr Days 44 34
15 113
68
29 12
Type CapPrimary Procedure Left hemicolectomy Subtotal colectomy
Elective splenectomy Splenectomy for trauma Splenectomy for
168 30
Totals
237
surgical injury
sular 9
Hilar 5
Table
No. % 15 2
9 7
27 77
3 20
8 8
39
71 33
Injury Gastrie 1
Elective
Unspecified Total 1
16
resection
Vagotomy, pyloroplasty Vagotomy, pyloroplasty, hiatus herniorrhaphy Subtotal gastrectomy Total gastrectomy
Prolonged fever
Thrombophlebitis Pulmonary embolism Myocardial Infarction
Left-sided stab thora¬
cotomy
Renal failure Hepatic failure Gastrointestinal
Plication duodenal ulcer
Exploratory laparotomy 9
Mortality
No. % 37 22 13 43
4.—Complications of Splenectomy
Pneumonia Atelectasis Pleural effusion Wound Infection Subphrenic abscess
25
cations
27
Vagotomy, gastric
Totals
No. of Patients
2.—Analysis of Iatrogenic Splenic Injury of
Mortality
1
4
bleeding
39
27 days in the surgical injury group, 29 days in the elective group, and 12 days in the trauma group. A detailed list of complications encountered in all postsplenectomy patients is shown in Table 4. Prolonged fever was defined as a rectal temperature greater than 38.3 C of known or unknown cause for three or more consecutive postoperative days. This occurred in 20 (57%) of the surgi¬ cal injuries in notable contrast to splenectomy for other indications. When the splenic injury occurred intraoperatively, the incidence of pleural effusion and wound in¬ fection was also considerably higher than in elective sple¬ nectomy. Several complications traditionally ascribed to splenectomy were encountered infrequently or not at all in this series. For instance, thromboembolic phenomena were seen in only six patients in the elective group; sub¬ phrenic abscess occurred in only eight of the total group of 237 splenectomies. None of these complications were in the surgical injury group, and clinical pancreatitis or a pancreatic fistula did not develop in any patient. Documentation of the morbidity resulting from splenec¬ tomy for surgical injury is seen in Table 5. The 38 abdomi¬ nal procedures leading to splenectomy for iatrogenic in¬ jury were compared with an equal number of randomly selected operations in which the spleen was at risk, but
No. % 9 5 14 8 7
4
4 10 7 5 1
3
2 6 4 3 0.5 0.5 0.5 2
2
1
1 1
Traumatic No. % 3 6
10 20
7 3
23 10
Surgical Injury No. % 20 51 7
18
5 8 6
13 21 15
was
not
damaged or removed. Splenectomy for surgical injury
Table
and Mortality of Abdominal With and Without Splenectomy
5.—Morbidity
tomyt (N 38)
W
%
No.
11
29
1
8 0
21 0
=
Prolonged fever Pneumonia Atelectasis Pleural effusion Wound infection Abdominal abscess
Colec-
Vagot¬ omy* (N 38)
=
Operations Splenec¬ tomy.
(N
=
38§)
%
No. %
4
11
20 7 5
0 4
0 11
8 6
53 18 13 21 16
0
0
11
29
28
72
Thrombophlebitis Pulmonary embolism Gastrointestinal
bleeding Intestinal obstruction Total patients with
complications
19
Total deaths
50 8
Mean age, 59 years; mean hospital stay, 21 days. age, 62 years; mean hospital stay, 25 days. t Mean age, 68 years; mean hospital stay, 27 days. § Fatal splenic Injury secondary to stab thoracotomy excluded. *
t Mean
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I_
Fig 1.—Ligamentous
attachment of
spleen
to
greater curvature of stomach (A) and to splenic flexure (B).
resulted in a higher incidence of total complications and in the more frequent occurrence of the complications com¬ mon to the procedures.
Mortality Three of the 39 patients (8%) who underwent splenec¬ tomy for operative trauma died (Table 3). One death, as
mentioned previously, resulted from severe hemorrhage and irreversible shock in a 43-year-old man whose spleen was punctured during an attempted left-sided stab thoracostomy and removed six hours after the accident. Another death was that of an 82-year-old woman who un¬ derwent a left-sided hemicolectomy for bleeding diverticulosis. Bleeding reoccurred in the postoperative period followed by a saddle embolus and fatal cardiac arrest. The third patient, an 82-year-old woman on whom plication of a perforated duodenal ulcer, a cholecystectomy, and a sple¬ nectomy were performed, experienced fatal refractory pulmonary edema and cardiac arrest 24 hours postopera¬
tively. In only the first of these three patients, could death be attributed directly to the splenic injury and subsequent splenectomy. It can be seen in Table 3 that mortality is virtually the same in splenectomy for any indication. Table 5 shows a nearly identical mortality figure for pro¬ cedures leading to splenectomy for surgical injury when compared with abdominal operations in which no splenec¬ tomy was required. COMMENT The
importance of splenectomy for surgical injury in
morbidity and mortality has been discussed ex¬ tensively.2'3·58 Evidence in the literature and from our ex¬ perience refutes the conclusion drawn by Rich et al4 that splenectomy necessitated by operative trauma is a proce¬ dure without serious sequelae. The postoperative courses of our 38 patients who underwent either vagotomy or coIonic resection involving the splenic flexure were appre¬ ciably smoother than those of an equal number of patients in whom splenectomy had to be added to the procedure. While 71% of patients undergoing incidental splenectomy in this series had one or more postoperative complications, none of these complications had fatal results. The high in¬ cidence of pulmonary complications observed did not al¬ ways prolong hospital stay. Mortality in the surgical injury group, however, was not increased when compared with splenectomy for other indi¬ cations or with vagotomies and colectomies without sple¬ nectomy. Only one major series has documented a consid¬ erably higher morality.7 Further, splenectomy per se could be implicated directly in only one of the three deaths in the surgical injury group. The studies of Rich et al4 and Brown and associates5 also concluded that mortality, in most instances, could not be directly attributed to the splenectomy itself. A majority of the operative deaths tend to occur following complex procedures in elderly pa¬ tients who have many associated medical problems.9 Trauma to the spleen during abdominal operations is usually preventable.1 Thorough familiarity with the anat¬ omy of the spleen and its attachments, attention to estab¬ lished principles of technique and exposure, and recogni¬ tion of those patients especially susceptible to splenic terms of
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Fig 2.—Left, If area of fundus is mobilized without preparatory di¬ vision and ligation of short gastric vessels, then traction avulses a broad area of upper pole of spleen. This is area of vulnerability in surgery of upper part of stomach and diaphragmatic hiatus.
Right, Mobilization of splenic flexure by caudal traction avulses lower pole of splenic capsule, which is avoidable if lienocolic ligament is divided in advance.
injury6 should lessen the incidence of this event (Fig 1). Vigorous traction of the stomach downward and to the right in the performance of gastrectomy or vagus section or strong downward traction on the splenic colon and its attached omentum (Fig 2) produced the largest number of splenic injuries in this series. Lord and Gourevitch10 dem¬ onstrated a peritoneal band attaching the greater omen¬ tum to the lower pole and hilum of the spleen in a large series of autopsy specimens; it is likely that this anatomic arrangement accounts for the susceptibility of the lower pole of the spleen to avulsion injury in gastric and colonie surgery. Wangensteen and Kelly11 recommended partial mobilization of the stomach prior to vagotomy as a way of lessening the danger of traction injury. Adequate incision, good anesthesia, and proper expo¬ sure are cited by most authors as essential for the pre¬ vention of splenic injuries.5-6 Palpation of the spleen during routine abdominal explorations should be done carefully with these anatomic features in mind. The fol¬ lowing are the mechanisms of injury and the number of incidents from the present study: traction on splenic fix¬ ture, 20; traction on stomach, 14; exploration of left upper
quadrant, three; retraction of left costal margin, one; puncture with thoracostomy tube, one. Reoperation on the left upper quadrant in elderly pa¬ tients or in patients with abnormal splenic appearance seems to be an important factor predisposing the spleen to iatrogenic injury.2 The mean age of the surgical injury group was considerably higher than that of the elective or trauma groups. Devlin and associates2 hypothesized that increased friability of the spleen secondary to degenera¬ tive vascular disease, as well as lack of rib elasticity lead¬ ing to overvigorous retraction of the left costal margin, may account for the increased incidence of accidental splenic injury in elderly patients. Nine of the 39 spleens injured intraoperatively in this series were found to have
abnormalities
on pathologic examination. These findings truly important, however, in terms of increased susceptibility to injury. None of the entities reported were predisposed to spontaneous splenic rupture and, there¬ fore, any assumption that these spleens were at greater risk of sustaining intraoperative trauma does not seem justified.1213 Most surgeons advocate splenectomy as the only safe
are
not
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and reliable treatment for all types of splenic injuries. Re¬ ports such as that of Eraklis and associates14 that em¬ phasizes the risk of overwhelming postsplenectomy sepsis, especially in children, have led to investigations that sug¬ gested other methods of dealing with splenic trauma un¬ der certain conditions. Bodon and Verzosa15 advocated the use of absorbable gelatin sponge packing for small, super¬ ficial, single capsular tears in easily accessible areas of the spleen; they report three cases in which this was done suc¬ cessfully. Morgenstern16 described a technique for partial splenectomy in patients with myeloproliferative disorders in whom preservation of splenic tissue was an important consideration. Suture ligatures were used for control of surface bleeding points, followed by the application of cyanoacrylate monomer for additional hemostasis. The au¬ thor points out, however, that this method might not be universally applicable since these diseased spleens had an
unusually firm consistency and were thus better able to hold sutures. Repair of injuries to normal spleens has also been reported. Mishalany17 repaired a hilar laceration in an 8-year-old boy using atraumatic chromic catgut. By se¬ rial splenic scans and arteriograms, Mishalany was able to demonstrate complete healing in eight of ten pediatrie pa¬ tients. Orda and associates18 performed subtotal resec¬ tions of spleens and livers in rats, covering the visceral wound with a peritoneal patch held in place with cyanoacrylate monomer with uniformly good hemostasis. Microcrystalline collagen applied to the cut splenic surface had had one successful trial after extensive laboratory experi¬ ence in dogs.19 Several spleens that were bleeding due to avulsion of lower pole vessels or capsular denudation were successfully treated by gelatin sponges and electric cau¬ terization. A small drain was left to rapidly identify post¬ operative bleeding.
References 1.
Quan S, Castleman B: Splenic vein thrombosis following transthoracic
gastrectomy and incidental splenectomy. N Engl J Med 240:835-837,1949. 2. Devlin HB, Evans DS, Birkhead JS: The incidence and morbidity of
accidental injury to the spleen occurring during abdominal surgery. Br J Surg 56:446-448, 1969. 3. Olson WR, Beaudoin DE: Surgical injury to the spleen. Surg Gynecol Obstet 130:57-62, 1970. 4. Rich NM, Lindner HH, Mathewson C: Splenectomy incidental to iatrogenic trauma. Am J Surg 110:209-217, 1965. 5. Brown MJ, Woodward B, Mehnert JH: Surgical trauma to the spleen. Am Surg 29:710-712, 1963. 6. Lieberman RC, Welch CS: A study of 248 instances of traumatic rupture of the spleen. Surg Gynecol Obstet 127:961-965, 1968. 7. Peck DA, Jackson FC: Splenectomy after surgical trauma. Arch Surg 89:54-64, 1963. 8. Roy M, Geller JS: Increased morbidity of accidental splenectomy. Gynecol Obstet 139:392-394, 1974. 9. Zollinger RM, Stewart WR, Williams RD: Indications for splenectomy. Postgrad Med 27:148-157, 1960. 10. Lord MD, Gourevitch A: The peritoneal anatomy of the spleen with special reference to the operation of partial gastrectomy. Br J Surg 52:202\x=req-\
204, 1965.
11. Wangensteen SL, Kelly JM: Gastric mobilization prior to vagotomy to lessen splenic trauma. Surg Gynecol Obstet 127:603-605, 1968. 12. Hardy JD, Yelverton RL: "Spontaneous rupture" of the spleen: One mechanism. Arch Surg 87:468-470, 1963. 13. Calamel BM, Cleveland HC, Waddell WR: Ruptured spleen. Surg Clin North Am 43:445-455, 1963. 14. Eraklis AJ, Kevy SV, Diamond LK, et al: Hazard of overwhelming infection after splenectomy. N Engl J Med 276:1225-1229, 1967. 15. Bodon GR, Verzosa ES: Incidental splenic injury: Is splenectomy always necessary. Am J Surg 113:303-304, 1967. 16. Morgenstern L, Cahn F, Weinstein J: Subtotal splenectomy in myelofibrosis. Surgery 60:336-339, 1966. 17. Mishalany H: Repair of the ruptured spleen. J Pediatr Surg 9:175\x=req-\ 178, 1974. 18. Orda R, Wiznitzer T, Goldberg G, et al: Repair of hepatic and splenic
injury by autoplastic peritoneal patches and butyl-2-cyanoacrylate monomer: An experimental study. J Surg Res 17:365-374, 1974. 19. Morgenstern L: Microcrystalline collagen used in experimental splenic injury. Arch Surg 109:44-47, 1974.
Editorial Comment
ever-increasing
number of indications for splenec¬ to the need of a special effort to avoid injury of the spleen, especially during up¬ per-abdominal procedures on the colon or stomach. Fabri and others have likewise emphasized the hazards associ¬ ated with iatrogenic splenic -injury and subsequent splenectomy. While the patient can lose his spleen without undue concern, the addition of splenectomy to other procedures is associated with an increase in complications. As soon as the abdomen is opened, the area of the spleen should be inspected for the presence of any ligamentous attachments, regardless of how small, to the margins of the spleen. Some of the attachments can be divided before undue
There is
an
tomy. The authors have properly called attention
traction tears the splenic capsule. The increase of complications as reported by the authors sug¬ gests that in addition to prophylaxis against splenic injury, the surgeon might consider additional time to utilize local methods, including suturing to control the bleeding, especially when associ¬ ated with small tears of the capsule. This study clearly indicates that iatrogenic splenic injury leading to splenectomy is associated with an increase in complications and length of hospitalization. Their message should alert surgeons to take increased precautions to avoid splenic injury. Robert M. Zollinger, MD Columbus, Ohio
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MD; Marvin L. Gliedman,
237 splenectomies performed over a six-year period, 39 necessitated by intraoperative injury. Capsular and hilar tears were predominant. All injuries were recognized at the time they occurred. The incidence of pulmonary complications and wound infections exceeded those for other categories of splenectomy and for these other abdominal operations without splenectomy. Although these complications were not fatal and the mortality was not increased, measures for avoidance of intraoperative splenic injury are indicated. These include knowledge of anatomic relationships and exercising cautious traction in operations on the upper part of the stomach and the splenic flexure of the colon, in reoperation in elderly people, or where there is suspicion of intrinsic splenic abnormality. \s=b\ Of
were
(Arch Surg 111:167-171, 1976)
discussion splenectomy secondary Thegical injury Castleman1
of to sur¬ did not appear in the literature until 1949 when Quan and reported on 70 splenec¬ tomies, 13 of which were performed because of intraopera¬ tive injury to the spleen. The magnitude of the problem has only received emphasis in the past ten years, with sev¬ eral authors documenting the large number of splenec¬ tomies necessitated by iatrogenic trauma.2"4 This study was undertaken to review the Montefiore Hospital and Medical Center experience with iatrogenic first
splenic injury requiring splenectomy, to assess compara¬ tive morbidity and mortality figures, and to discuss fac¬ tors of importance in the prevention and management of this problem. SUBJECTS AND METHODS
During the six-year period of January 1968 through December was performed in 237 patients at Montefiore Hospital and Medical Center. A broad spectrum of these cases is shown in Table 1. Of these 237 splenectomies, 39 (16%) were per¬ formed as a result of surgical injury to the spleen. For the purposes of this study, patients who underwent splenectomy in conjunction with another procedure (for example, to achieve a sat¬ isfactory margin of resection in surgery for gastric or colonie car¬ 1974, splenectomy
cinoma) were
were
classified
as
24 male and 15 female
"elective" and thus excluded. There patients ranging in age from 15 to 88
MD
mean age was 68 years, which is significantly higher than that of the 168 patients undergoing elective splenectomy and the 30 patients undergoing splenectomy for blunt or penetrating
years. The
trauma.
RESULTS Mode of Injury
Table 2 summarizes the various procedures leading to and the type of injury inflicted. Resection of the colon involving mobilization of the splenic flexure resulted in the highest number of injuries (21), followed by gastric procedures with or without vagot¬ omy (15). Avulsion of a portion of the splenic capsule was by far the most common type of injury, occurring in 25 of the 39 patients. Disruption of the splenic hilum occurred in nine patients and an unspecified injury occurred in four patients. Bleeding from the vasa brevia was specifically noted in only one case. In 38 of the 39 cases, traction on the peritoneal or omental attachments of the spleen was the mechanism directly or indirectly responsible for the injury. The one exception was a patient whose injury resulted from direct puncture of the spleen while a stab thoracostomy was being per¬ formed, which eventually led to one of the three deaths in the series. Etiologic factors such as trauma from retrac¬ tors and sharp instruments were not encountered. In all cases, the injury was recognized at the time of the pri¬
iatrogenic splenic injury
mary procedure. In nine of the 39
cases (23%), gross and microscopic ex¬ amination of the resected spleen disclosed one or more ab¬ normalities, with notable splenic enlargement in six of these nine patients. These abnormalities are as follows: splenomegaly with extramedullary hemopoiesis, two; sple¬ nomegaly with congestion, two; splenomegaly with hemosiderosis, one; splenomegaly with leukemic infiltration, one; capsular hyalinization, one; infarction, one; and cap¬ sular erosion and inflammation, one. In the one case in which inflammatory erosion of the capsule was seen, the etiologic factor was thought to be a contiguous, perfo¬ rated, greater curvature gastric ulcer.
Morbidity
Twenty-seven of the 39 patients (71%) undergoing sple¬
Accepted for publication Oct 16, 1975. From the Department of Surgery, Montefiore Hospital and Medical Center, and the Albert Einstein College of Medicine, Bronx, NY. Reprint requests to Montefiore Hospital and Medical Center, 111 E 210th St, Bronx, NY 10467 (Dr Schein).
nectomy for intraoperative injury had one or more postop¬
compared with the elective and complications was 22% and 43%, respectively (Table 3). The mean hospital stay
erative
complications,
as
trauma groups whose incidence of
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Table 1.—Case Material, 1968
Through 1975
Table
3.—Morbidity
and
Compli¬
Mean
Elective splenectomy Splenectomy for trauma Splenectomy for surgical injury Totals
Table
No. of Sex Pa- ,_ _ tients Male Female 168 79 89 21 30 9 39 237
24 124
Hos-
pital Age, Stay, yr Days 44 34
15 113
68
29 12
Type CapPrimary Procedure Left hemicolectomy Subtotal colectomy
Elective splenectomy Splenectomy for trauma Splenectomy for
168 30
Totals
237
surgical injury
sular 9
Hilar 5
Table
No. % 15 2
9 7
27 77
3 20
8 8
39
71 33
Injury Gastrie 1
Elective
Unspecified Total 1
16
resection
Vagotomy, pyloroplasty Vagotomy, pyloroplasty, hiatus herniorrhaphy Subtotal gastrectomy Total gastrectomy
Prolonged fever
Thrombophlebitis Pulmonary embolism Myocardial Infarction
Left-sided stab thora¬
cotomy
Renal failure Hepatic failure Gastrointestinal
Plication duodenal ulcer
Exploratory laparotomy 9
Mortality
No. % 37 22 13 43
4.—Complications of Splenectomy
Pneumonia Atelectasis Pleural effusion Wound Infection Subphrenic abscess
25
cations
27
Vagotomy, gastric
Totals
No. of Patients
2.—Analysis of Iatrogenic Splenic Injury of
Mortality
1
4
bleeding
39
27 days in the surgical injury group, 29 days in the elective group, and 12 days in the trauma group. A detailed list of complications encountered in all postsplenectomy patients is shown in Table 4. Prolonged fever was defined as a rectal temperature greater than 38.3 C of known or unknown cause for three or more consecutive postoperative days. This occurred in 20 (57%) of the surgi¬ cal injuries in notable contrast to splenectomy for other indications. When the splenic injury occurred intraoperatively, the incidence of pleural effusion and wound in¬ fection was also considerably higher than in elective sple¬ nectomy. Several complications traditionally ascribed to splenectomy were encountered infrequently or not at all in this series. For instance, thromboembolic phenomena were seen in only six patients in the elective group; sub¬ phrenic abscess occurred in only eight of the total group of 237 splenectomies. None of these complications were in the surgical injury group, and clinical pancreatitis or a pancreatic fistula did not develop in any patient. Documentation of the morbidity resulting from splenec¬ tomy for surgical injury is seen in Table 5. The 38 abdomi¬ nal procedures leading to splenectomy for iatrogenic in¬ jury were compared with an equal number of randomly selected operations in which the spleen was at risk, but
No. % 9 5 14 8 7
4
4 10 7 5 1
3
2 6 4 3 0.5 0.5 0.5 2
2
1
1 1
Traumatic No. % 3 6
10 20
7 3
23 10
Surgical Injury No. % 20 51 7
18
5 8 6
13 21 15
was
not
damaged or removed. Splenectomy for surgical injury
Table
and Mortality of Abdominal With and Without Splenectomy
5.—Morbidity
tomyt (N 38)
W
%
No.
11
29
1
8 0
21 0
=
Prolonged fever Pneumonia Atelectasis Pleural effusion Wound infection Abdominal abscess
Colec-
Vagot¬ omy* (N 38)
=
Operations Splenec¬ tomy.
(N
=
38§)
%
No. %
4
11
20 7 5
0 4
0 11
8 6
53 18 13 21 16
0
0
11
29
28
72
Thrombophlebitis Pulmonary embolism Gastrointestinal
bleeding Intestinal obstruction Total patients with
complications
19
Total deaths
50 8
Mean age, 59 years; mean hospital stay, 21 days. age, 62 years; mean hospital stay, 25 days. t Mean age, 68 years; mean hospital stay, 27 days. § Fatal splenic Injury secondary to stab thoracotomy excluded. *
t Mean
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I_
Fig 1.—Ligamentous
attachment of
spleen
to
greater curvature of stomach (A) and to splenic flexure (B).
resulted in a higher incidence of total complications and in the more frequent occurrence of the complications com¬ mon to the procedures.
Mortality Three of the 39 patients (8%) who underwent splenec¬ tomy for operative trauma died (Table 3). One death, as
mentioned previously, resulted from severe hemorrhage and irreversible shock in a 43-year-old man whose spleen was punctured during an attempted left-sided stab thoracostomy and removed six hours after the accident. Another death was that of an 82-year-old woman who un¬ derwent a left-sided hemicolectomy for bleeding diverticulosis. Bleeding reoccurred in the postoperative period followed by a saddle embolus and fatal cardiac arrest. The third patient, an 82-year-old woman on whom plication of a perforated duodenal ulcer, a cholecystectomy, and a sple¬ nectomy were performed, experienced fatal refractory pulmonary edema and cardiac arrest 24 hours postopera¬
tively. In only the first of these three patients, could death be attributed directly to the splenic injury and subsequent splenectomy. It can be seen in Table 3 that mortality is virtually the same in splenectomy for any indication. Table 5 shows a nearly identical mortality figure for pro¬ cedures leading to splenectomy for surgical injury when compared with abdominal operations in which no splenec¬ tomy was required. COMMENT The
importance of splenectomy for surgical injury in
morbidity and mortality has been discussed ex¬ tensively.2'3·58 Evidence in the literature and from our ex¬ perience refutes the conclusion drawn by Rich et al4 that splenectomy necessitated by operative trauma is a proce¬ dure without serious sequelae. The postoperative courses of our 38 patients who underwent either vagotomy or coIonic resection involving the splenic flexure were appre¬ ciably smoother than those of an equal number of patients in whom splenectomy had to be added to the procedure. While 71% of patients undergoing incidental splenectomy in this series had one or more postoperative complications, none of these complications had fatal results. The high in¬ cidence of pulmonary complications observed did not al¬ ways prolong hospital stay. Mortality in the surgical injury group, however, was not increased when compared with splenectomy for other indi¬ cations or with vagotomies and colectomies without sple¬ nectomy. Only one major series has documented a consid¬ erably higher morality.7 Further, splenectomy per se could be implicated directly in only one of the three deaths in the surgical injury group. The studies of Rich et al4 and Brown and associates5 also concluded that mortality, in most instances, could not be directly attributed to the splenectomy itself. A majority of the operative deaths tend to occur following complex procedures in elderly pa¬ tients who have many associated medical problems.9 Trauma to the spleen during abdominal operations is usually preventable.1 Thorough familiarity with the anat¬ omy of the spleen and its attachments, attention to estab¬ lished principles of technique and exposure, and recogni¬ tion of those patients especially susceptible to splenic terms of
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Fig 2.—Left, If area of fundus is mobilized without preparatory di¬ vision and ligation of short gastric vessels, then traction avulses a broad area of upper pole of spleen. This is area of vulnerability in surgery of upper part of stomach and diaphragmatic hiatus.
Right, Mobilization of splenic flexure by caudal traction avulses lower pole of splenic capsule, which is avoidable if lienocolic ligament is divided in advance.
injury6 should lessen the incidence of this event (Fig 1). Vigorous traction of the stomach downward and to the right in the performance of gastrectomy or vagus section or strong downward traction on the splenic colon and its attached omentum (Fig 2) produced the largest number of splenic injuries in this series. Lord and Gourevitch10 dem¬ onstrated a peritoneal band attaching the greater omen¬ tum to the lower pole and hilum of the spleen in a large series of autopsy specimens; it is likely that this anatomic arrangement accounts for the susceptibility of the lower pole of the spleen to avulsion injury in gastric and colonie surgery. Wangensteen and Kelly11 recommended partial mobilization of the stomach prior to vagotomy as a way of lessening the danger of traction injury. Adequate incision, good anesthesia, and proper expo¬ sure are cited by most authors as essential for the pre¬ vention of splenic injuries.5-6 Palpation of the spleen during routine abdominal explorations should be done carefully with these anatomic features in mind. The fol¬ lowing are the mechanisms of injury and the number of incidents from the present study: traction on splenic fix¬ ture, 20; traction on stomach, 14; exploration of left upper
quadrant, three; retraction of left costal margin, one; puncture with thoracostomy tube, one. Reoperation on the left upper quadrant in elderly pa¬ tients or in patients with abnormal splenic appearance seems to be an important factor predisposing the spleen to iatrogenic injury.2 The mean age of the surgical injury group was considerably higher than that of the elective or trauma groups. Devlin and associates2 hypothesized that increased friability of the spleen secondary to degenera¬ tive vascular disease, as well as lack of rib elasticity lead¬ ing to overvigorous retraction of the left costal margin, may account for the increased incidence of accidental splenic injury in elderly patients. Nine of the 39 spleens injured intraoperatively in this series were found to have
abnormalities
on pathologic examination. These findings truly important, however, in terms of increased susceptibility to injury. None of the entities reported were predisposed to spontaneous splenic rupture and, there¬ fore, any assumption that these spleens were at greater risk of sustaining intraoperative trauma does not seem justified.1213 Most surgeons advocate splenectomy as the only safe
are
not
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and reliable treatment for all types of splenic injuries. Re¬ ports such as that of Eraklis and associates14 that em¬ phasizes the risk of overwhelming postsplenectomy sepsis, especially in children, have led to investigations that sug¬ gested other methods of dealing with splenic trauma un¬ der certain conditions. Bodon and Verzosa15 advocated the use of absorbable gelatin sponge packing for small, super¬ ficial, single capsular tears in easily accessible areas of the spleen; they report three cases in which this was done suc¬ cessfully. Morgenstern16 described a technique for partial splenectomy in patients with myeloproliferative disorders in whom preservation of splenic tissue was an important consideration. Suture ligatures were used for control of surface bleeding points, followed by the application of cyanoacrylate monomer for additional hemostasis. The au¬ thor points out, however, that this method might not be universally applicable since these diseased spleens had an
unusually firm consistency and were thus better able to hold sutures. Repair of injuries to normal spleens has also been reported. Mishalany17 repaired a hilar laceration in an 8-year-old boy using atraumatic chromic catgut. By se¬ rial splenic scans and arteriograms, Mishalany was able to demonstrate complete healing in eight of ten pediatrie pa¬ tients. Orda and associates18 performed subtotal resec¬ tions of spleens and livers in rats, covering the visceral wound with a peritoneal patch held in place with cyanoacrylate monomer with uniformly good hemostasis. Microcrystalline collagen applied to the cut splenic surface had had one successful trial after extensive laboratory experi¬ ence in dogs.19 Several spleens that were bleeding due to avulsion of lower pole vessels or capsular denudation were successfully treated by gelatin sponges and electric cau¬ terization. A small drain was left to rapidly identify post¬ operative bleeding.
References 1.
Quan S, Castleman B: Splenic vein thrombosis following transthoracic
gastrectomy and incidental splenectomy. N Engl J Med 240:835-837,1949. 2. Devlin HB, Evans DS, Birkhead JS: The incidence and morbidity of
accidental injury to the spleen occurring during abdominal surgery. Br J Surg 56:446-448, 1969. 3. Olson WR, Beaudoin DE: Surgical injury to the spleen. Surg Gynecol Obstet 130:57-62, 1970. 4. Rich NM, Lindner HH, Mathewson C: Splenectomy incidental to iatrogenic trauma. Am J Surg 110:209-217, 1965. 5. Brown MJ, Woodward B, Mehnert JH: Surgical trauma to the spleen. Am Surg 29:710-712, 1963. 6. Lieberman RC, Welch CS: A study of 248 instances of traumatic rupture of the spleen. Surg Gynecol Obstet 127:961-965, 1968. 7. Peck DA, Jackson FC: Splenectomy after surgical trauma. Arch Surg 89:54-64, 1963. 8. Roy M, Geller JS: Increased morbidity of accidental splenectomy. Gynecol Obstet 139:392-394, 1974. 9. Zollinger RM, Stewart WR, Williams RD: Indications for splenectomy. Postgrad Med 27:148-157, 1960. 10. Lord MD, Gourevitch A: The peritoneal anatomy of the spleen with special reference to the operation of partial gastrectomy. Br J Surg 52:202\x=req-\
204, 1965.
11. Wangensteen SL, Kelly JM: Gastric mobilization prior to vagotomy to lessen splenic trauma. Surg Gynecol Obstet 127:603-605, 1968. 12. Hardy JD, Yelverton RL: "Spontaneous rupture" of the spleen: One mechanism. Arch Surg 87:468-470, 1963. 13. Calamel BM, Cleveland HC, Waddell WR: Ruptured spleen. Surg Clin North Am 43:445-455, 1963. 14. Eraklis AJ, Kevy SV, Diamond LK, et al: Hazard of overwhelming infection after splenectomy. N Engl J Med 276:1225-1229, 1967. 15. Bodon GR, Verzosa ES: Incidental splenic injury: Is splenectomy always necessary. Am J Surg 113:303-304, 1967. 16. Morgenstern L, Cahn F, Weinstein J: Subtotal splenectomy in myelofibrosis. Surgery 60:336-339, 1966. 17. Mishalany H: Repair of the ruptured spleen. J Pediatr Surg 9:175\x=req-\ 178, 1974. 18. Orda R, Wiznitzer T, Goldberg G, et al: Repair of hepatic and splenic
injury by autoplastic peritoneal patches and butyl-2-cyanoacrylate monomer: An experimental study. J Surg Res 17:365-374, 1974. 19. Morgenstern L: Microcrystalline collagen used in experimental splenic injury. Arch Surg 109:44-47, 1974.
Editorial Comment
ever-increasing
number of indications for splenec¬ to the need of a special effort to avoid injury of the spleen, especially during up¬ per-abdominal procedures on the colon or stomach. Fabri and others have likewise emphasized the hazards associ¬ ated with iatrogenic splenic -injury and subsequent splenectomy. While the patient can lose his spleen without undue concern, the addition of splenectomy to other procedures is associated with an increase in complications. As soon as the abdomen is opened, the area of the spleen should be inspected for the presence of any ligamentous attachments, regardless of how small, to the margins of the spleen. Some of the attachments can be divided before undue
There is
an
tomy. The authors have properly called attention
traction tears the splenic capsule. The increase of complications as reported by the authors sug¬ gests that in addition to prophylaxis against splenic injury, the surgeon might consider additional time to utilize local methods, including suturing to control the bleeding, especially when associ¬ ated with small tears of the capsule. This study clearly indicates that iatrogenic splenic injury leading to splenectomy is associated with an increase in complications and length of hospitalization. Their message should alert surgeons to take increased precautions to avoid splenic injury. Robert M. Zollinger, MD Columbus, Ohio
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