Approximately 30 % of patients with splenic injury are treated with primary operative exploration. Typically these patients present with hemodynamic instability and hemoperitoneum. While hemoperitoneum may be readily diagnosed in the trauma bay by focused assessment with sonography for trauma (FAST), the splenic injury as the source of the hemoperitoneum is typically diagnosed in the operating room (OR). Standard techniques of trauma laparotomy described earlier in this book should be followed, with packing of all four quadrants to obtain immediate hemostasis followed by controlled removal with inspection for injury and plans for prompt hemorrhage control as injuries are identified.

Many patients with splenic injury, however, are hemodynamically stable enough for diagnostic work-up to be performed after FAST in the trauma bay. In one review, ultrasound was 62–99 % sensitive for the detection of free intraperitoneal fluid. A large percentage of these patients will have splenic injury. However, up to 25 % of patients with splenic injury may not manifest hemoperitoneum [7]. A negative FAST in a hemodynamically stable patient who has significant mechanism concerning for solid organ injury should undergo further evaluation.

In most trauma centers, that diagnostic modality is multidetector CT imaging. CT provides very high sensitivity and specificity for diagnosing injury to the spleen. At the R Adams Cowley Shock Trauma Center, dual-phase imaging with both arterial phase and portal venous phase demonstrates the best diagnostic performance and can help guide management [8]. However, some patients may have discrete contraindications to intravenous (IV) contrast. While image quality may not be as good and detection of vascular lesions is limited, determination of significant injuries that require close follow-up or intervention can be made with a non-contrast-enhanced CT scan [9]. Once splenic injury is diagnosed, several important radiologic features should be evaluated as they impact treatment and outcomes: grade of injury, which should be based on the American Association for the Surgery of Trauma (AAST) grading system (Table 12.1) [10]; the presence or absence of active extravasation of IV contrast; the presence or absence of pseudoaneurysms; and the degree of hemoperitoneum. While CT does not detect all lesions, it detects lesions requiring treatment rather reliably, especially in high-grade injuries, and is useful for directing the initial care of the injured patient [11].

For the patient who is taken immediately to the operating room with hemodynamic instability, hemorrhage control must be quick. If at laparotomy, the spleen is found to be the cause of hemorrhage, splenectomy is the wisest choice in this patient. Our technique for emergent splenectomy is described:

While standing on the right side of the patient, the surgeon uses his/her right hand to rapidly mobilize the spleen by bluntly dividing the splenorenal and splenophrenic ligaments (Fig. 12.1a, b). The spleen is mobilized medially into the abdominal incision. It is an error to operate on the spleen in the left upper quadrant, as exposure is inadequate. The spleen can be elevated on some lap pads (Fig. 12.1c). If needed, a left medial visceral rotation or “Mattox maneuver” can be rapidly completed almost entirely with blunt dissection if other organs are injured in proximity to the spleen or retroperitoneal hemorrhage is identified in addition to splenic hemorrhage. We generally prefer to approach the spleen from its posterior aspect as it allows the best visualization of the pancreatic tail (Fig. 12.1d).The splenic vascular anatomy is variable. Sometimes, the splenic artery and vein extend onto the hilum. If so, they can be ligated flush with the spleen. Other times, they branch proximal to the hilum. If so, each branch should be ligated separately. The short gastric vessels are then ligated and the spleen is removed. The stomach should be carefully inspected to be sure every short gastric has been ligated.

If the patient is in extremis, a one clamp splenectomy can be performed. An aortic vascular clamp is placed across the hilum and short gastric vessels. Care should be taken with this technique to avoid clamping the stomach. The clamp should be placed distal enough to avoid the tail of the pancreas as well (Fig. 12.2). Scissors are then used to remove the organ. The hilum and short gastric vessels can be controlled separately at this point by either ties or suture ligation. We use a combination of ties on all major vessels followed by additional suture ligature to reinforce the splenic artery and vein. Even if there is minimal concern for pancreatic injury from the rapid splenectomy, a closed suction drain can be left as energy transmitted to the injured spleen could also cause occult injury to the tail of the pancreas.

In a hemodynamically stable patient taken to the OR for laparotomy, if splenic injury is found, splenorrhaphy can be an option. In general, a stable patient with minimal blood loss and low-grade injury (grade 1 or 2) is a candidate for splenorrhaphy. However, if a patient has a severe traumatic brain injury such that recurrent hemorrhage may cause secondary brain injury or if the patient is coagulopathic or has comorbidities that may predispose to bleeding (such as chronic liver disease), splenectomy may be a better choice. We usually prefer splenectomy for higher-grade injuries as repeat laparotomy may be difficult if delayed bleeding occurs.

If splenorrhaphy is chosen, there are many options for surgical technique. Partial splenectomy can be done if the injury is limited to one pole. After mobilizing the spleen, temporary hemostasis may be obtained with finger pressure (Fig. 12.3). The corresponding vascular supply to that pole is ligated and divided. The splenic parenchyma is then cut with a scalpel (Fig. 12.4). The raw edge of the parenchyma is compressed with pledgeted horizontal mattress sutures. O-Vicryl or 2-0 Vicryl suture works well and some of the new bioabsorbable pledgets may reduce infectious risk (Fig. 12.5). Argon beam coagulation or placement of fibrin hemostatic sealant can be added to augment hemostasis. For smaller injuries, direct pledgeted suturing can be used to control bleeding from the spleen (Fig. 12.6). If the capsule of the spleen is torn and peeling off the spleen, but parenchymal damage is limited, either an omental patch or mesh wrap can be used (Fig. 12.7). For mesh, we prefer knitted Vicryl mesh soaked in a fibrin gel sealant. The mesh is wrapped around the area of injury (Fig. 12.8a). The sealant allows the mesh to adhere to the parenchyma and provides some additional hemostatic effect. Vicryl sutures can be used to tighten the mesh to compress the spleen and provide further hemostasis (Fig. 12.8b). The argon bean can be useful to weld the mesh to the spleen in some cases (Fig. 12.9). For very minor injuries, direct suture repair may work (Fig. 12.10).