RUPTURED SPLEEN

In tropical countries, enlargement of the spleen due to malaria or visceral leishmaniasis is common. The affected spleen is liable to injury or rupture as a result of trivial trauma. Delayed rupture can occur up to three weeks after the injury.

Diagnostic features of a ruptured spleen include:

Consider conservative management, particularly in children, if the patient is haemodynamically stable and you are able to monitor them closely with bedrest, intravenous fluids, analgesics and nasogastric suction.

If the patient’s condition deteriorates, perform a splenectomy.

Perform a laparotomy if you suspect a ruptured spleen and the patient is hypovolaemic. Repair or remove the spleen.

Technique

::	Place the patient supine on the operating table with a pillow or sandbag under the left lower chest. Open the abdomen through a long midline incision (Figure 6.17). Remove clots from the abdominal cavity to localize the spleen. If bleeding continues, squeeze the splenic vessels between your thumb and fingers (Figure 6.18) or apply intestinal occlusion clamps. Assess the extent of splenic injury and inspect other organs.
Figure6.17
Figure 6.18
::	Make the decision whether to remove or preserve the spleen. If the bleeding has stopped, do not disturb the area. If a small tear is bleeding, try to control it with 0 absorbable mattress sutures. This is particularly advisable in children.
::	To remove the spleen, lift it into the wound and divide the taut spleno-renal ligament with scissors (Figure 6.19). Extend the division to the upper pole of the spleen. Apply a large occlusion clamp to the adjoining gastrosplenic omentum (containing the short gastric vessels) and divide the omentum between large artery forceps (Figures 6.20, 6.21).
Figure 6.19
Figure 6.20
Figure 6.21
::	Ligate the short gastric vessels well away from the gastric wall. Dissect the posterior part of the hilum, identifying the tail of the pancreas and the splenic vessels. Ligate these vessels three times, if possible ligating the artery first, and divide them between the distal pair of ligatures (Figures 6.22, 6.23). Now divide the remaining gastrosplenic omentum between several clamps and, finally, divide the anterior layer of the lienorenal ligament.
Figure 6.22
Figure 6.23
::	If there is excess bleeding, drain the bed of the spleen with a latex drain brought out through a separate stab wound. Remove the drain at 24 hours, if possible. Close the abdomen in layers.