Latrogenic Splenic Injury: Prevention and Treatment

Review Article

Latrogenic splenic injury: Prevention and treatment

Dhananjaya Sharma Incharge GI Surgery Unit, Govt. NSCB Medical College and Allied Hospitals, Jabalpur-482003, India.

How to cite this article: Sharma D. Latrogenic splenic injury: Prevention and treatment. Indian J Surg 2004;66:146-51.

Accidental or iatrogenic splenic injury during other gastrectomy, trans-hiatal oesophagectomy, anti-reflux abdominal operations is neither infrequent nor procedures) 2-9%, splenic flexure mobilization 1.2-8%, inconsequential. Awareness of the hematological and vascular operations (abdominal aortic aneurysm repairs, immunological consequences of splenectomy has led thoracoabdominal aneurysm repair, left renal artery to a significant change in surgical philosophy and has bypass, and reconstruction of the proximal abdominal resulted in with emphasis on splenic preservation. It is aorta and its major branches) 0.5-5%, left nephrectomy well known that accidental splenectomy leads to 1.4-24%, and bariatric surgery 3%.2,3,5,7,8,16-26 Rarely, significantly higher transfusion requirements, spleen gets damaged during drainage of subphrenic significantly longer mean length of hospital stay and abscess, gynecological operations due to traction significantly higher prevalence of infectious during omentectomy, left sided thoracocentesis, complications, regardless of the type of operative percutaneous renal biopsy, percutaneous procedure.1-8 Even more important is the fact that nephrolithotomy and adrenalectomy. An excellent accidental splenectomy is associated with the highest review of various operative procedures leading to mortality among different indications of splenectomy iatrogenic splenic trauma has been recently published.12 (Accidental Splenectomy > external trauma > hematological).9-11 All this makes it mandatory on the ETIOLOGY AND MECHANISM OF INJURY TO part of operating surgeon to ensure that there is no SPLEEN iatrogenic splenic injury. This article is a brief review of etiology, technical tips on how to prevent and treat The spleen is rather firmly attached in the left upper iatrogenic splenic injury. quadrant by eight ligaments or peritoneal reflections:27 1. Gastro-splenic (containing short gastric blood INCIDENCE vessels) 2. Spleno-renal (containing splenic blood vessels) Iatrogenic injury to the spleen is a well known 3. Spleno-phrenic complication of abdominal surgery but the extent of 4. Spleno-colic the problem is often under-estimated; which may be 5. Pre-splenic folds due to failure to report splenic injury on the operation 6. Pancreatico-splenic note or inaccurate recording of the indication for 7. Phrenico-colic splenectomy. Splenectomy for iatrogenic injury may 8. Pancreatico- colic be recorded as being part of a radical cancer procedure (Figure 1) or to facilitate exposure in procedures for benign lesions.12 Not surprisingly, surgeons have been known The spleen may be injured in three ways: Traction, to avoid admitting a splenectomy for iatrogenic application of retractors or directly by the surgeon’s trauma.13 Iatrogenic splenic trauma has been reported instruments.12 as the cause of 9-40% of all splenectomies.4,14-16 Its reported incidence during different surgical procedures Traction is the commonest mechanism of injury. is as follows: gastro-esophageal operations (vagotomy, Excessive manipulation or unnecessary traction on

Address for correspondence: Dr. Sanjay Mahajan, 31/3, US Club, Shimla-171001, India. E-mail: [email protected] Paper Received: July 2003. Paper Accepted: October 2003. Source of Support: Nil.

146 Indian Journal of Surgery 2004 Volume 66 Issue 3 (June) © 2003 Indian Journal of Surgery www.indianjsurg.comSharma D perisplenic peritoneal folds result in tear of splenic capsule and / or pedicle; a fact known courtesy anatomical study of numerous peritoneal attachments of the spleen.28,29 As can be expected, spleen is at a high risk for accidental injury during operations performed in the left hypochondrium and improper/ inadvertent traction during mobilization of stomach, omentum and splenic flexure are commonest surgical mistakes leading to avulsion of peritoneal attachments. The use of retractors can also cause injury to the spleen, either directly or indirectly through excessive traction on the abdominal wall.18 Direct injury to the spleen by the operating surgeon, although possible, is rarely reported.

Types of injuries Figure 1: Peritoneal attachments/reflections of spleen Capsular tears, lacerations, avulsions and subcapsular haematomas are the injuries most frequently encountered; capsular tears being the commonest and Pathology in the spleen the lower pole of the spleen appears to bear the brunt Most of the spleens removed incidentally are grossly in most cases.12 This is not surprising as most injuries and microscopically unremarkable; and the lacerations are caused by traction on peritoneal attachments to result from excessive manipulation rather than any the spleen, which are concentrated at the lower pole.15 pathological changes predisposing to rupture but splenic pathology can increase the risk of iatrogenic RISK FACTORS FOR IATROGENIC SPLENIC trauma. A large spleen will be a predisposing factor as TRAUMA it will come in way of other procedures and is more likely to be damaged inadvertently. Similarly, Previous surgery splenomegaly as a result of portal hypertension is more Understandably, risk of splenic injury is significantly likely to get injured; not only due to its size and higher if the patient has had previous abdominal vascularity but also due to traction/retraction trauma surgery, particularly in the left upper quadrant.16,29-31 to its various extra-anatomical (e.g. to diaphragm, to This increased risk is due to the development of dense retroperitoneum) vascular adhesions. Tendency of adhesions in the left upper quadrant of the abdomen. congestive/infective splenomegaly to rupture with Traction on various structures indirectly causes traction even insignificant trauma is well known. on the splenic capsule, through these adhesions, resulting in splenic injury. Difficult dissection of these Patient characteristics adhesions to obtain exposure and to free structures Obesity, with its attendant inadequate exposure and may also result in direct injury to the spleen.12 non-resilient parietal reflections, leads to increased risk of inadvertent splenic trauma.32 Increased friability of Type of surgical incision the spleen secondary to degenerative vascular disease, As expected, poor exposure with a ‘inadequate’ as well as lack of rib elasticity, leading to over vigorous incision is a contributing factor to splenic injury.3,13 In retraction of the left costal margin, gives rise to the case of a left nephrectomy, the risk of splenic injury increased incidence of iatrogenic splenic injury in is much higher with a transperitoneal compared with elderly patients.29,30,33 an extraperitoneal approach.19 PREVENTION Nature of pathology Splenic injury is more likely if the indication for surgery Constant awareness of the problem and continued is malignant disease of left kidney, with a large growth vigilance based on knowledge of anatomic relationships on the upper pole.19,20 Similarly, mobilization of a is the key to prevention of iatrogenic splenic trauma. densely adhered splenic flexure may give rise to Additionally, good exposure and adequate accidental splenic trauma.17 visualization are the two cornerstones of neat and clean

Indian Journal of Surgery 2004 Volume 66 Issue 3 (June) 147 Iatrogenic splenic injury surgery. Nowhere are these basics more important than of traction in operations in the left hypochondrium is in avoiding inadvertent trauma to spleen. another key to avoid accidental splenic trauma. Medial traction on the lieno-omental and lieno-gastric bands Good exposure by appropriate incision and downward traction on the lieno-colic band should First and foremost prerequisite for good exposure is be avoided at all costs.37 (Figure 4). The use of metal the planning of appropriate surgical incision (remember clips to secure the short gastric vessels during upper the old aphorism you can do it properly if you can see gastrointestinal surgery is a safe way of avoiding undue it properly). An inadequate incision is more likely to traction on the stomach.5 result in traction to various splenic folds leading to capsular or hilar tears.3 Superiority, vis-a-vis, exposure Optimize visualization by large left subcostal and bilateral subcostal approach In an attempt to optimize visualization, while mobilizing with a T-vertical cephalad extension (Mercedes Benz splenic flexure of colon, surgeons have positioned the incision)has been shown over midline incision for left patients in a modified lithotomy position and stood nephrectomy.20,34 In the case of a left nephrectomy, between the legs of the patient.17 Use of fiber-optic using an extraperitoneal approach, where possible, is light cable can optimize illumination of the operation the best way of reducing splenic injury.12 It is crucial to field. The superiority of visualization as obtained at remember the aphorism “Pray before surgery, but laparoscopic surgery is confirmed by significantly lower remember the God will not alter a faulty incision.” incidence of splenic injury during laparoscopic surgery (Arthur H. Keeny) and plan an appropriate incision. A as seen in fundoplication.38,39 ‘re-do’ anti-reflux procedure may be easier and safer via a thoracic approach. Similarly, a thoraco-abdominal Careful use of retractors incision can be planned, instead of a abdominal incision Use of rigid retractors must be avoided in re-operations alone, for a difficult time and consuming left especially in elderly people, or where there is suspicion hypochondrium surgical procedure. “Big surgeons of intrinsic splenic abnormality.18,33 Judicious and gentle make big (correct) incision”, holds true even today in use of self-retaining subcostal and manual retractors the era of modern surgery. goes a long way in avoiding iatrogenic trauma to spleen.5,8 Prophylactic division of the splenoperitoneal folds Early prophylactic division of the splenoperitoneal folds Splenic flexure mobilization40,41 ensures that there is no untoward traction to various Mobilization of the splenic flexure is best performed splenic folds.4,5,15-17,20,35,36 (Figures 2 and 3). by the surgeon operating from the right side of the patient with first assistant standing between the Avoid unnecessary traction near spleen patient’s legs, which maximizes his view and ability to Traction over spleen when required should be assist. A second assistant on the left side of the retracts minimized by the well-known technique of keeping a the wound and the left costal margin. It is for this part large moist pack behind the spleen.32 Exercising of the operation that the incision in the upper part of cautious traction, especially ensuring proper direction wound should be adequate.

Figure 2: Prophylactic division of the splenoperitoneal folds Figure 3: Prophylactic division of the splenoperitoneal folds

Figure 4: Correct and wrong direction of applying traction Figure 5: Dissection and delivery of the spleen from its around the spleen subdiaphragmatic position by antero-medial retraction of spleen and division of lieno-renal and phrenico-lineal ligaments The first three steps in the mobilization are: 1. Release of omental adhesions to the anterior border splenic injuries during various procedures like of spleen. laparoscopic nephrectomy, fundoplication, 2. Release of omental adhesions to the left paracolic adrenalectomy etc.43-46 The reasons are same as in gutter at the level of lower pole of spleen. conventional surgery e.g. traction injuries of splenic 3. Division of peritoneum between the colon and the ligaments and adhesions and very rarely direct trocar lower border of spleen. injuries. Rarely, even a simple diagnostic laparoscopy and induction of pneumoperitoneum can result in These three manoeuvres release the spleen and tearing away of delicate peritoneal reflections or small effectively prevent traction injury to splenic capsule. adhesions on the splenic capsule leading to sudden rupture and hemorrhage.47 But, by and large, superior It is important not to pull down on the descending visualization obtained at laparoscopic surgery should colon because this can result in splenic injury; instead also result in a decrease in the incidence of iatrogenic the thrust of dissection is upwards towards the splenic splenic injuries. Another advantage is that an flexure. One must remember that the spleno-colic experienced laparoscopic surgeon can identify and ligament is often quite thick and may require division repair the injury intra-operatively, laparoscopically, between clamps and transfixing suture ligation. Corman minimizing patient morbidity postoperatively.48 suggests putting only one clamp on the splenic side to avoid tearing the splenic capsule; and dividing the TREATMENT OF IATROGENIC SPLENIC spleno-colic ligament on the flexure side.42 If the splenic TRAUMA flexure is difficult to expose, it is helpful to enter the lesser sac in the midline and approach the spleno-colic An unexplained pool of blood in the left ligament from both the sides: along the left transverse hypochondrium should alert the surgeon to the colon from within the lesser sac and along the possibility of iatrogenic splenic trauma. Immediate descending colon in the retroperitoneum. dissection and delivery of the spleen from its subdiaphragmatic position is the first step, thus Constant awareness of the continued prevalence of this avoiding further iatrogenic injuries, which can readily operative complication and the mechanisms by which occur in such an emergency situation.49,50 (Figures 5 it is produced has enabled surgeons to lessen its and 6). The hilus is then clamped with a non-crushing frequency and potential sequelae.16 vascular or intestinal clamp, which avoids blood loss during the examination of severity of trauma. Good Laparoscopic surgery and iatrogenic splenic injuries visualization of the trauma site can be obtained by Laparoscopic surgery, with all of its modern complete removal of clot by gentle irrigation. The technology, is no panacea and has its share of iatrogenic methods used for the repair are well known and depend

Indian Journal of Surgery 2004 Volume 66 Issue 3 (June) 149 Iatrogenic splenic injury

Table 1: Grade of injury based protocol [20]

Grade I Haemostatic agents alone (Fibrin glue, resorbable collagen platelets, resorbable gauze) Grade II Haemostatic agents, or splenorrhaphy/ omentoplasty or mesh enclosure Grade III Splenorrhaphy/mesh enclosure Grade IV Anatomic splenic resection, ligation of main/ polar segmental arteries, subtotal splenectomy Grade V Intra-omental auto transplantation/Splenectomy

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