Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
The Abdomen
Laparotomy and Abdominal Trauma
Labarotomy
Abdominal trauma
Acute Abdominal Conditions
Assessment and diagnosis
Intestinal obstruction
Peritonitis
Stomac and duodenum
Gallbladder
Appendix
Abdominal Wall Hernia
Groin hernia
Surgical repair of inguinal hernia
Surgical repair of femoral hernia
Surgical treatment of strangulated groin hernia
Surgical repair of umbilical and para-umbilical hernia
Surgical repair of epigastric hernia
Incisional hernia
Urinary Tract and Perineum
The urinary bladder
The male urethra
The perineum
Abdominal Trauma
 


> RUPTURED SPLEEN
> LACERATION OF THE LIVER
> SMALL INTESTINE
> COLON
> RETROPERITONEUM
> RUPTURE OF THE BLADDER
> MANAGEMENT OF RUPTURED
> BLADDER


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:

:: History of trauma with pain in the left upper abdomen (often referred to the shoulder)
:: Nausea and vomiting
:: Signs of hypovolaemia
:: Abdominal tenderness and rigidity and a diffuse palpable mass
:: Chest X-ray showing left lower rib fractures and a shadow in the upper left quadrant displacing the gastric air bubble medially.

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.
Figure 6.17
Figure6.17
Figure 6.18
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 6.19
Figure 6.20
Figure 6.20
Figure 6.21
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 6.22
Figure 6.23
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.

 

> RUPTURED SPLEEN
> LACERATION OF THE LIVER
> SMALL INTESTINE
> COLON
> RETROPERITONEUM
> RUPTURE OF THE BLADDER
> MANAGEMENT OF RUPTURED
> BLADDER



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  Kep Points  
Splenectomy is the treatment for severe injuries to the spleen, but consider preserving the spleen if bleeding is not profuse


The spleen has blood supplied from the splenic artery and the short gastric arteries


 
Vaccination with pneumovax and prophylactic antibiotics are indicated due to the immune deficiency occurring in splenectomized patients.