Giancarlo Basili, MD, Dario Pietrasanta, MD, Federico Filidei, MD, Nicola Romano, MD, Aurelio Costa, MD. Pontedera General Hospital, General Surgery Department
Introduction: The incidence of splenic injury in blunt abdominal trauma has been reported as high as 25% in literature. The management has undergone major changes over the past from nearly mandatory laparotomy with splenectomy, to an increase in non-operative management, with every effort made to preserve the spleen. Close observation has become an accepted treatment of stable splenic injuries from blunt trauma. High grade splenic injury (grade III and higher AAST) tend to have a higher transfusion requirement and increased morbidity and mortality. The role of laparoscopy in blunt trauma has yet to be clearly defined, yet laparoscopic exploration in trauma has been attempted and cited as an acceptable option in literature.
Case Report: A 12-year-old girl suffered from grade III and IV splenic injury (AAST) after a fall from a bicycle. She was hemodynamically stable. Contrast-CT showed a laceration of the lower pole of the spleen with contrast extravasation and hemoperitoneum. An emergency laparoscopic partial splenectomy was carried out. During laparoscopic exploration, a large laceration with devascularisation at the lower pole of the spleen was discovered. Parenchyma dissection was carried out using ultrasonic shears and endo-GIA. The operative time was 120 min, the estimated blood loss was 100 ml. The postoperative course was uneventful.
Discussion: Nonoperative management (NOM) has become the standard of care for solid organ injury in the hemodynamically stable child, with success rates greater than 90%. Failure rates for NOM are very variable, ranging from 10% to 40%. Patients with severe (grade III or higher) splenic injuries have higher failure rates, along with transfusion requirement and increased morbididy and mortality. Contrast extravasation on CT evaluation is associated with negative outcomes in children with blunt splenic injuries, determining a failure of NOM and the need for surgical intervention. With better understanding of immunologic function of the spleen and the potential threat of severe post-splenectomy infections, surgeons began to perform parenchyma-sparing procedures. In the case described, laparoscopic partial splenectomy was required considering the active bleeding and the location of the laceration. Emergency laparoscopy was demonstrated to be and effective diagnostic and therapeutic modality in the management of blunt abdominal injuries in hemodynamically stable child.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86225
Program Number: V049
Presentation Session: Solid Organ Videos Session
Presentation Type: Video
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