Splenorrhaphy - Diagnostic Aid, Surgical Procedures, and Differential Diagnosis

Introduction:

Splenic injuries, frequently caused by accidents, used to require emergency surgery. Non-operative techniques are now favored since they mitigate dangers such as infections following surgery. Similar to auto accidents, blunt trauma is frequent, but knives can also be harmful. In such conditions, the spleen was removed completely; however, now surgeons are increasingly investigating alternatives, such as splenorrhaphy, to improve results and reduce infection rates. It deviates from previous views that advocated for the whole spleen removal.

What Is Splenorrhaphy?

Splenorrhaphy essentially means stitching up the spleen. In simpler terms, it includes different surgical methods to fix and save the spleen when it is damaged. People also use terms like splenic salvage, splenic preservation, or partial splenectomy to describe this. Partial splenectomy, where only part of the spleen is removed, might be chosen in certain situations to treat a condition or repair an injury. General surgeons need to know and be skilled in various techniques of splenorrhaphy to effectively handle spleen-related issues.

What Are the Diagnostic Aids Used in Splenorrhaphy?

1. Hemoglobinopathy Assessment: Consultation with a hematologist is necessary for individuals suspected or known to have blood disorders. Diagnostic tests include blood smear, bone marrow analysis, complete blood count (CBC), and specific blood studies based on the condition.

2. CT Scanning for Splenic Trauma: Hemodynamically stable patients with potential spleen injuries should undergo computed tomography (CT) Scanning. CT is valuable for planning surgeries, assessing the extent of injuries, and understanding vascular anatomy.

3. Ultrasound (US) Evaluation: US is a noninvasive method for checking spleen conditions like enlargement, cysts, and portal hypertension in selected cases. Particularly useful in children, the US minimizes radiation exposure. Focused abdominal sonography for trauma (FAST) is a screening tool for trauma patients to detect intraperitoneal fluid or blood.

4. Preoperative US for Specific Conditions: Patients with symptomatic biliary colic and hemoglobinopathies should undergo preoperative US to evaluate for conditions like cholelithiasis. Those with cholelithiasis may consider concurrent cholecystectomy.

5. Nonoperative Management Criteria: Applicable to stable patients without additional major injuries, limited blood transfusions, documented splenic injury and grade via CT scan, and absence of active intrasplenic bleeding. Contraindications include hemodynamic instability, associated organ injuries, inability to perform reliable abdominal exams, need for anticoagulation, inability to correct coagulopathy, ongoing blood transfusion requirement, and AAST grade V splenic injury.

6. MRI for Splenic Lesions: Magnetic resonance imaging (MRI) is a recognized method for assessing splenic lesions without ionizing radiation. However, it is not recommended in cases of splenic injury.

What Are the Surgical Procedures and Their Considerations in Splenorrhaphy?

Surgery Preparation:

1. Vaccination: Individuals with known or suspected hemoglobinopathies should be vaccinated against certain pathogens before surgery. Even in cases where surgery calls for a complete splenectomy, vaccinations are essential.

2. Blood Product: Intraoperative preparations should include ordering blood products like red blood cells, platelets, and fresh frozen plasma.

3. Imaging: CT scans are essential for assessing splenic conditions, whether due to injury or cysts. The images aid in surgical planning and understanding the extent of the issue.

Surgical Considerations:

1. Antibiotic Use: All patients should receive preventive antibiotics covering skin flora before the surgical incision. This helps minimize the risk of infection during the procedure.

2. Thrombosis Prevention: Patients, especially those aged 12 and above, should have thrombosis prevention measures like sequential compression devices and appropriate anticoagulation medications.

3. Nasogastric Tube (NGT) Usage: A tube is inserted to decompress the stomach and assist visualization during surgery. Consideration is given to keeping the NGT in place postoperatively to prevent gastric distension.

Surgical Approaches:

1. Open Splenorrhaphy: Recommended for splenic injury cases, employing the human hand as a retractor for effective hemostasis. Provides good exposure and flexibility to switch to splenectomy if needed.

2. Laparoscopic Splenorrhaphy: Suitable for elective cases requiring advanced laparoscopic skills. It should be performed by a surgeon who is experienced in the procedure.

3. Splenectomy Consideration: In adult splenic trauma cases, preoperative splenic artery embolization may be considered for improved nonoperative management. Pediatric cases rarely require embolization, necessitating consultation with a pediatric surgeon.

Patient Positioning:

1. Open Splenorrhaphy Positioning: Patients are supine with arms extended for adequate exposure. For pediatric cases, alternative incisions may be used.

2. Laparoscopic Splenorrhaphy Positioning: Supine positioning with arms tucked, using a beanbag to enhance exposure. Table rotation aids in optimal positioning during the procedure.

Surgical Techniques:

Incision choices depend on the clinical scenario. Trauma patients may require a midline incision for maximal exposure, especially for quick assessments and addressing active bleeding.

1. Midline Incision: A vertical incision from the pubic bone to the xiphoid process, the bottom portion of the sternum, made along the midline of the abdomen. The abdominal organs are visible through this incision.

2. Left Subcostal Incision: An incision made beneath the left rib cage that gives the spleen easy access. This method might be chosen for splenic procedures in particular.

3. Left Lateral Decubitus Incision: An incision was made on the patient's left side when they were resting on their left side in the abdomen. Access to the spleen is made easier by this location.

4. Transverse Incision: A transverse cut across the abdomen, usually just below the ribs. This can be applied alone or with other incisions for specific splenic injuries.

What Is the Differential Diagnosis of Splenorrhaphy?

When it comes to injuries or issues with the spleen, they are often categorized into different grades, from I to IV. However, severe grade V injuries cannot be fixed with splenorrhaphy. Sometimes, injuries to the spleen can happen accidentally during surgery, especially when dealing with the transverse colon, stomach, or during certain laparoscopic procedures in the left upper quadrant of the abdomen. Apart from injuries, other conditions might affect the spleen.

• Hemoglobinopathies are disorders related to the structure or function of hemoglobin (the oxygen-carrying protein in red blood cells).

• Hereditary spherocytosis (HS) is a genetic disorder affecting red blood cells.

• Diseases like thalassemia or sickle cell disease can also impact the spleen.

• Certain types of cysts (fluid-filled sacs) or hamartomas (non-cancerous growths) can develop in the spleen.

Understanding these factors is crucial, especially for doctors and surgeons, to determine the appropriate treatment for spleen-related problems.

Conclusion:

Splenectomy was the immediate treatment for splenic damage in the past. However, new developments in non-operative care, such as splenorrhaphy, show that a more sophisticated approach is possible. Traditionally, the spleen was immediately removed in cases of blunt trauma, which was frequently caused by accidents. However, new knowledge highlights options to protect the spleen and lessen the hazards associated with splenectomy.