management of blunt trauma to the spleen (part 1)

spleen is the most frequent solid organ to be injured in blunt abdominal trauma. considering its important role in providing immunity and preventing infection by a variety of mechanisms, every attempt should be made, if possible, to salvage the traumatized spleen at any age particularly in children. after primary resuscitation, mandatory requirements for non-operative management include absence of homodynamic instability, lack of associated major organ injury, admission in the intensive care unit for high-grade splenic injury and in the ward for milder types with close monitoring. about two third of the patients would respond to non-operative management. in most patients, failure of non-operative measures usually occur within 12 hours of management. determinant role of abdominal sonography or computed tomography, and in selected cases, diagnostic peritoneal lavage, for appropriate decision cannot be overemphasized. however, the high status of clinical judgment would not be replaced by any paraclinical investigations. when operation is unavoidable, if possible, spleen saving procedures (splenorrhaphy or partial splenectomy) should be tried. in case of total splenectomy, auto-transplantation, preferably in the omental pouch, may lead to return of immunity, at least partially, to prevent or reduce the chance of subsequent infection. although total splenectomy with autograft is immunologically superior to total splenectomy-only procedure, these patients should also be protected by vaccination and daily antibiotic for certain period of time. the essential steps for prevention of overwhelming infection after total splenectomy are not only immunization and administration of daily antibiotic (up to 5 years of age or one year in older children), but include education and information about this dangerous complication. when non-operative management is successful, the duration of activity restriction (in weeks) is almost equal to the grade of splenic injury plus 2.