Management of Blunt Trauma to the Spleen (Part 2)

Spleen is the most frequently-injured solid organ in blunt abdominal trauma. Considering its important role in providing immunity and preventing infection by a variety of mechanisms, every attempt should be made 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, and admission in the intensive care unit for high-grade splenic injury and in the ward for milder types with close monitoring. About two-thirds of the patients would respond to non-operative management. In most patients, the failure of non-operative measures usually occurs 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 such as splenorrhaphy or partial splenectomy should be tried. In cases of total splenectomy, auto-transplantation, preferably in the omental pouch, may lead to the 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, the patients should also be protected by vaccination and daily antibiotic for certain period of time. The essential steps for the prevention of overwhelming infection after total splenectomy are not only immunization and administration of daily antibiotic for up to 5 years of age or one year in older children, but also 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.