Table of Contents
The spleen is highly vascular, is the largest secondary lymphoid organ, and is the most commonly injured organ in the setting of blunt abdominal trauma. Patients may present asymptomatically or with abdominal pain, nausea and vomiting, or signs of hemodynamic instability. Although many splenic injuries caused by blunt abdominal trauma may be managed conservatively, free intra-abdominal fluid with hemodynamic instability warrant surgical management in the form of exploratory laparotomy and splenectomy.
In this video report, we demonstrate the management of a patient who was assaulted, sustaining blunt abdominal trauma and a hemodynamically significant grade IV splenic laceration. Here, we perform an exploratory laparotomy and splenectomy.
Blunt trauma; laparotomy; splenectomy; FAST.
The abdomen is commonly affected in trauma. Blunt abdominal trauma may cause significant bleeding or visceral perforation, requiring surgical intervention. All trauma patients are initially systematically evaluated with the primary survey,1 which encompasses a series of elements outlined by the mnemonic ABCDE. A is for airway stabilization, B is for breathing, C is for circulation, D is for disability evaluation typically with the GCS (Glasgow Coma Score), and E is for exposure/environment. After the primary survey and resuscitation are initiated, rapid evaluation with particular emphasis on identifying significant intra-abdominal bleeding or perforation is performed. The presence of free intra-abdominal fluid or air is diagnosed by Focused Assessment with Sonography in Trauma (FAST) exam, CT, or historically, DPL (diagnostic peritoneal lavage).1 An exploratory laparotomy may be performed to systematically identify and repair intra-abdominal injuries. Indications for exploratory laparotomy in the setting of blunt abdominal trauma include peritonitis, hemodynamic instability with free intra-abdominal fluid, or high-grade organ injury.1 In an effective exploration for blunt abdominal trauma, damage control principles are followed, and management of immediately life-threatening injuries are prioritized.2 Depending on the condition of the patient, injuries may be temporized in the operating room with plans for definitive treatment after adequate resuscitation in the ICU.
The spleen, which is typically located in the left upper quadrant, is one of the most commonly injured organs in blunt abdominal trauma, occurring in a quarter of blunt abdominal trauma cases3 and in 2.7% of all traumatic injuries.4 As a highly vascular structure, blunt trauma injuries may be hemodynamically significant. Splenic injuries in trauma are commonly diagnosed after the primary survey and initial resuscitation on imaging, typically CT scans. A pertinent lab finding may be low hematocrit, which is associated blood transfusion in trauma.5 The majority of traumatic splenic injuries can be conservatively managed with resuscitation guided by close monitoring of hemodynamics and hematocrit levels and occasionally angiography with coil embolization.1,3,4 However, operative intervention in the form of splenectomy to stop intra-abdominal bleeding is indicated for high-grade splenic injuries and hemodynamic instability.1,2,4,6
The presentation of patients with splenic injuries associated with blunt abdominal trauma may vary depending on the severity of the injury.1 Patients may present with various symptoms ranging from asymptomatic to hemodynamic instability or peritonitis with significant intra-abdominal hemorrhage. The patient is monitored for signs of shock with a particular emphasis on tachycardia, hypotension, and the response to resuscitation with crystalloid fluid or blood products. Other symptoms with which these patients may present are abdominal pain, referred left shoulder pain (Kehr’s sign), flank bruising, or nausea and vomiting. In the setting of splenic injuries from blunt trauma, it is important to identify any other concomitant injuries and systematically evaluate the trauma patient.1,2
This patient was a female who presented to an outside hospital after being reportedly assaulted and incurring blunt abdominal trauma. The CT from the outside hospital showed a splenic laceration, and she was transiently responsive to resuscitation with systolic blood pressures over 120 on transfer to the acute care surgery service at the University of Chicago. A repeat CT performed on arrival demonstrated a grade IV splenic laceration, a grade I or II liver laceration, and significant hemoperitoneum with hemodynamic instability, prompting exploration in the OR.
The FAST exam is an adjunct to the primary survey.1,7 Using an ultrasound probe, any abnormal presence of fluid (or rarely air) is identified in the perihepatic space (Morrison’s pouch), perisplenic space, pelvis, or pericardium. There may be multiple reasons for fluid to be seen on the FAST exam in various patients. However, in the setting of trauma, free intra-abdominal fluid, especially in a hemodynamically compromised patient, is presumed to be blood and managed as such (typically with an exploration). The FAST exam is a screening tool, and a negative FAST exam does not rule out an intra-abdominal process or the need for exploration.1,7 One variation on the FAST exam is the extended FAST (EFAST) exam, which also includes evaluation of the lungs to identify pneumothorax.1
CT scan is a helpful adjunct after the primary survey if the trauma patient is hemodynamically stable. CT is a rapid imaging modality that provides more specific anatomic detail as compared to the FAST exam. In the case of splenic injuries, the grading of splenic injury may be performed via CT imaging to guide management. Secondary traumatic injuries are also better delineated on CT scans.1
In this particular trauma case, the patient was transiently responsive to resuscitation en route and required a repeat CT scan. She was found to have a grade IV (high-grade) splenic laceration in addition to a grade I/II (low-grade) liver injury and hemoperitoneum.
The spleen is the most commonly injured organ in blunt abdominal trauma, occurring in a quarter of blunt abdominal traumas.3 In trauma, the major morbidity and mortality is associated with intra-abdominal hemorrhage and concomitant intra-abdominal injuries.1 The specific mortality after a splenic injury is 5.4%.4
The treatment of splenic injuries is in large part guided by patient condition and the severity of injury. The American Association for the Surgery of Trauma (AAST) grades the severity of splenic injuries on a scale of I to V based on CT imaging.1,8 Many low-grade splenic injuries resolve spontaneously and may be managed conservatively with resuscitation, frequently with crystalloid or blood products.1,3,4,6,9–11 Patients are closely monitored in the ICU with special attention paid to hemodynamics (heart rate and blood pressure) and hematocrit levels. Patients who demonstrate persistent low-volume bleeding may also be assessed with angiography and undergo coil embolization of the splenic vessels.1,3,4,6,9–11 Operative intervention in the form of splenectomy to stop intra-abdominal bleeding is indicated for high-grade splenic injuries and hemodynamic instability.1,3,4,6,9–11
A splenectomy may be performed as part of an exploratory laparotomy for intra-abdominal hemorrhage. An exploratory laparotomy with a large midline incision also allows the surgeon to systematically identify and temporize or repair other concomitant intra-abdominal injuries.1 Damage control principles are followed and management of immediately life-threatening injuries are prioritized.2 Depending on the condition of the patient, injuries may also be temporized in the operating room with plans for definitive treatment after adequate resuscitation in the ICU.1,2
This particular patient was reasonably resuscitated en route and in the operating room to allow splenectomy and complete evaluation of the intra-abdominal contents, including the small bowel without identification of any other significant intra-abdominal injuries requiring operative intervention. Upon conclusion of the exploration and splenectomy, the patient’s abdomen was closed, and she was admitted postoperatively in stable condition.
Elective splenectomies for blood dyscrasias or malignancies are outside the scope of this case. However, given the immunologic function of the spleen, all splenectomy patients are at risk for overwhelming postsplenectomy infection (OPSI).12,13 Thus, all patients undergoing splenectomy are recommended to receive vaccinations against encapsulated bacteria, including Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae.12,13 Immunization is ideally administered either two weeks before the splenectomy (in elective cases) or within 14–28 days postoperatively.12,13 In the trauma setting or in cases of unclear follow-up, vaccines may be administered prior to discharge.12
Here we present a female patient who presented from an outside hospital after a reported assault with blunt abdominal trauma. She was found to have a hemodynamically significant grade IV splenic laceration on a repeat CT, requiring exploration and splenectomy. Upon exploration, she was found to have about 1 L of hemoperitoneum that was evacuated, in large part due to the high-grade splenic laceration. We systematically and expeditiously evaluated the abdomen for other intra-abdominal injuries before proceeding with a splenectomy. After hemostasis and splenectomy, we confirmed there were no other intra-abdominal injuries requiring surgical intervention before abdominal closure. The patient experienced an estimated blood loss of 1.8 L and received 2 units of blood intraoperatively and 2 additional units after abdominal closure. Postoperatively, she was monitored closely with an expected hospital length of stay of about 4 days. The plan also included postsplenectomy vaccines to reduce the risk of OPSI.
The spleen is the most commonly injured organ in blunt abdominal trauma, occurring in a quarter of abdominal trauma cases3 and in 2.7% of all traumatic injuries.4 As in the case detailed above, most splenic injuries are diagnosed on CT imaging, although some may be diagnosed on angiography or exploration.9 The management of the splenic injuries in trauma is guided by patient stability and the severity of the splenic injury, as categorized by the AAST.1,8
Indications for exploratory laparotomy and splenectomy as in the case described include patients who present with hemodynamic instability,2 which is associated with higher grades (IV, V) of splenic injuries, or the 4–5% of patients who fail initial nonoperative therapy (decreasing hematocrit, continued need for transfusion, CT change, tachycardia or hypotension, or persistent abdominal pain).4,6 Other reasons for exploratory laparotomy include associated concomitant intra-abdominal injuries that require surgical intervention.1 Although the patient described in this case also had a low-grade liver laceration, the indication for exploration was primarily related to hemodynamic instability and the high-grade splenic injury.
The majority (75%) of splenic injuries are low-grade (I-III) 4 and are associated with small volume hemoperitoneum.6 With a lower chance of hemodynamically-significant splenic injuries, these injuries are more commonly managed nonoperatively with up to 90% success rates.4 Furthermore, initial nonoperative management, which typically consists of resuscitation and close monitoring of hematocrit, has been noted to be increasingly prioritized over operative intervention since 1997.4,6 This trend has been noted in parallel to the increasing use of angioembolization for splenic injuries of all grades and the increasing recognition of the high risk for, and associated mortality of, OPSI in postsplenectomy patients.6
FLOSEAL - Baxter.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Surgeons ACo. Advanced Trauma Life Support (ATLS) Student Course Manual 2018;10th edition.
- Rotondo MF, Schwab CW, McGonigal MD, et al. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35(3):375-382; discussion 382-373.
- El-Matbouly M, Jabbour G, El-Menyar A, et al. Blunt splenic trauma: assessment, management and outcomes. Surgeon. 2016;14(1):52-58. doi:10.1016/j.surge.2015.08.001.
- Chahine AH, Gilyard S, Hanna TN, et al. Management of splenic trauma in contemporary clinical practice: a National Trauma Data Bank study. Acad Radiol. 2020. doi:10.1016/j.acra.2020.11.010.
- Thorson CM, Van Haren RM, Ryan ML, et al. Admission hematocrit and transfusion requirements after trauma. J Am Coll Surg. 2013;216(1):65-73. doi:10.1016/j.jamcollsurg.2012.09.011.
- Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injury in adults: multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma. 2000;49(2):177-187; discussion 187-179. doi:10.1097/00005373-200008000-00002.
- Dolich MO, McKenney MG, Varela JE, Compton RP, McKenney KL, Cohn SM. 2,576 ultrasounds for blunt abdominal trauma. J Trauma. 2001;50(1):108-112. doi:10.1097/00005373-200101000-00019.
- Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma. 1995;38(3):323-324. doi:10.1097/00005373-199503000-00001.
- Cogbill TH, Moore EE, Jurkovich GJ, et al. Nonoperative management of blunt splenic trauma: a multicenter experience. J Trauma. 1989;29(10):1312-1317. doi:10.1097/00005373-198910000-00002.
- Haan JM, Bochicchio GV, Kramer N, Scalea TM. Nonoperative management of blunt splenic injury: a 5-year experience. J Trauma. 2005;58(3):492-498. doi:10.1097/01.ta.0000154575.49388.74.
- Harbrecht BG, Peitzman AB, Rivera L, et al. Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma. J Trauma. 2001;51(5):887-895. doi:10.1097/00005373-200111000-00010.
- Casciani F, Trudeau MT, Vollmer CM Jr. Perioperative immunization for splenectomy and the surgeon's responsibility: a review. JAMA Surg. 2020;155(11):1068-1077. doi:10.1001/jamasurg.2020.1463.
- Tahir F, Ahmed J, Malik F. Post-splenectomy sepsis: a review of the literature. Cureus. 2020;12(2):e6898. doi:10.7759/cureus.6898.
Cite this article
Chung SK, Suah A, Patel D, Hafez NM, Williams B. Exploratory laparotomy and splenectomy for ruptured spleen following blunt force trauma. J Med Insight. 2023;2023(299.9). doi:10.24296/jomi/299.9.
Table of Contents
- Approach and Exposure
- Release Splenorenal Ligament
- Release Splenocolic Ligament
- Release Splenophrenic Ligament and Control Short Gastrics
- Divide Hilum to Remove Spleen
Hi, I'm Dr. Brian Williams. I'm an associate professor of trauma and acute care surgery at the University of Chicago, and it is - I think it's about four o'clock in the morning on Saturday. We've just finished another trauma case. This one was a splenectomy, another classic trauma case - blunt trauma to the abdomen. Our patient was assaulted and sent to us from another hospital. She had a grade IV splenic laceration on her CT scan and intermittently was hypotensive. We also found a lot of blood on her scan, so that combination of findings pretty much mandated that she get a laparotomy. So blunt trauma, hypotensive, a known splenic injury, as well as blood on her scan. So we brought her to the operating room, did an exploratory laparotomy, which starts with a midline incision, evacuated all the blood that was in the abdomen, packed off where her spleen was, and then did our exploration, found no other injuries, so then we went to work on the spleen. So, taking out the spleen involves taking down three attachments. There's your lateral attachment, which is your splenorenal ligament. Inferiorly, your splenocolic ligament, and superiorly there's a splenophrenic ligament. Now your lateral and superior ligaments are avascular. Your inferior ligament has one or two vessels in those. So you take down those ligaments, and the big thing you want to do is mobilize the spleen from way up in the left upper quadrant to the midline. Once it's in the midline, then you can go to work and control the hilar vessels, control your short gastric vessels, and remove the spleen. Now why is that important? Hilar vessels, of course, you want to control the splenic artery and vein. And your short gastrics are the small vessels that attach the stomach to the spleen, and if you don't control those, when you're done with your operation, you're going to have a lot more bleeding. So, key steps here - mobilize to the midline by taking down the splenorenal, which is lateral; splenophrenic, which is superior; and splenocolic, which is inferior. Get to the midline, control the hilar vessels, control your short gastrics, spleen's in the bucket. Thank you. Dr. Brian Williams, University of Chicago.
So guys we're going to review the FAST exam from this patient with a splenic rupture. And initially looking, right, our depth is a little bit too deep, right? Because we're imaging way past the organ of interest, which is our kidney and our liver, right? And it's a little bright, right? So the gain's a little high. And then we're going to obviously adjust our depth down, as you can tell here, right? Which brings that kidney and liver more into focus. And then in the next view what we do is, we kind of adjust the gain down so now everything's a little bit darker and not over-gained or super bright and white. And you'll see the kidney, you'll see the liver, and in the area that, you know, is known as Morison's pouch, which is the potential space between the two as the kidney is retroperitoneal, and remember that the liver is intraperitoneal. And that, by the way, is like one of those myths you're told in med school, right? That there's a pouch, when really, if you think about it, if this is your peritoneum, the kidney is retroperitoneal, and the liver is intraperitoneal, and it's just the reflection, when the patient's supine, of the kidney that the liver lays on, right? And so when you feel fluid in the belly, in the peritoneum, all you're doing is lifting that and separating your liver from your kidney. You're not really like filling up any space, the space is the peritoneum. But, you know, oftentimes if you just get this view, it's hard to identify that fluid, right? Because I mean it's pretty subtle, right? But if you think about it gravitationally, this is the patient's head, this is the patient's foot, right? This is patient's right side, and this is down and towards the left side. The way that we hold the probe with the indicator towards the head on the patient's right side, then if you take your probe and you rock it down towards the inferior liver tip, which is what we do here, you can see the most gravitationally-dependent area and you'll find the free fluid, right? Because it'll fill up here and then track back in that direction because this is his foot and that his head, right? So, nice picture there. And then you can tell that free fluid really does cause like sharp angles, right? Like that's a pretty acute angle, whereas nothing in your body really has that, everything's kind of rounded. If it's in a vascular structure, it'll be linear, but it won't be triangular or sharp. And if it's in the bladder or if it's in the heart, all those have rounded edges, right? Like none of those chambers come to super acute angles, right? But that's the hallmark of free fluid is it's black, anechoic, and it basically is giving you an acute angle somewhere, right? And then we go over to the pelvis view and immediately we find a ton of anechoic fluid, right? So it should never have this much free fluid in the pelvis, and these sharp corners here - this can't be the bladder, right? The bladder is trigonal, it's got soft rounded edges, it's not that sharp. And as we fan through, that appears to be her uterus and that's her bladder coming back into view. And then if we do a sagittal/longitudinal, where we put the indicator towards the patient's head, we get a great line up. So head, feet, superior, and deep and inferior, and basically we see that there's fluid all the way around the uterus, right? So you got bladder, free fluid, and then uterus. And then there's fluid basically behind the uterus in the rectouterine pouch of Douglas, which is where you would expect it on a female, whereas in the male, you expect it directly behind the bladder. You're not going to see it directly between the bladder and the uterus, you're going to see it around the uterus and mostly posterior. And again, some sharp angles, right? We can talk ourselves into the fact that that kind of becomes a triangle, right? So again, right? Like triangular, right? All free fluid is usually pointy. Black and pointy is free fluid. And this is the left upper quadrant, and we don't get a great view of the spleen. We get a good view of the kidney, right? But the spleen kind of comes in and out, which is not shocking, right? Because if this is her spleen, right about here, right? Then we know that that spleen was ruptured, right? So we knew there was damage to the spleen and it wasn't going to have normal anatomy, right? But you can see right here at the edge between the inferior tip of the spleen and the kidney that you have free black fluid. It's not a lot, which you'd think would be surprising because it's the left upper quadrant, so you think there'd be more. But if you look along the splenic edge here, there are some small amounts of fluid, and you can see, right? Free fluid, sharp angle, black, right? That's the way it goes. And then - I didn't do her subxiphoid view just because she was so peritonitic and tender, so I went ahead and did the parasternal long to evaluate the pericardial space, and there was no fluid, as we should have - a pericardial effusion should layer out back here, right along the posterior inferior edge there, above the descending thoracic aorta. Then we did her lung spaces - we kept the same probe just to keep it fast, decreased the depth, right? To allow us to see that pleural sliding better. And then aided that with an M-mode, right? To get our seashore sign, which is linear on top, grainy on the bottom, so seashore is always good. And if you get the barcode sign, that's bad. But you have to remember if it's barcode on the left and they're intubated, they could be mainstemed, so it doesn't mean they have a pneumothorax. What you really want is a lung point, which we don't see that often, or catch that often here sometimes because we're already putting chest tubes in that quickly when we know that the patient has penetrating trauma, and you know they have a pneumothorax because they're already like leaking blood out of that side. But if you have, basically, a barcode all the way down and then you get strips of each, that means you got the probe right where the lung is inflating like to be in the M-mode and then out of the M-mode, and in the M-mode and out of the M-mode, and that's the most sensitive and specific and has a positive predictive value of 100%, so that's a great sign to find, left or right, because it tells you there's a pneumothorax. And this is the left side - also had lung sliding.
Okay, so our patient here was a woman transferred from an outside Hospital, reportedly was assaulted - stomped on her abdomen. The report from the hospital - that she was hypotensive, CT scan showed a splenic laceration with some blood in her belly - transferred her here, she had systolics over 120, en route and since she arrived here, and her images were suboptimal. So we repeated her CT scan, which confirms a grade IV splenic laceration, as well as grade I/II liver laceration with a belly full of blood. So we are going to do an exploratory laparotomy with a plan to take out her spleen. And we'll see what else we find. Incision. Right by the umbo. All right, so that bleeding from the sub-q is a good sign. Can you get that bleeding controlled first? Bovie and a Poole. We have time, so get all that controlled before we start going down through the sub-q. All right, so her - since she's not crashing, we're looking at the belly full of blood. We're going to get the entire incision opened all along its length first, before we get in, release the tamponade. Before we do that we make sure we notify anesthesia that that is about to happen so they are prepared. You want it all open down to the fascia all the way? Yes. Well you know, she got TXA also, I'm not sure if you knew that. Yeah, she did. Bovie scratch, please. Down here as well. Let's see here - extra. Not too bad, so just go ahead and clean it off that way, with that blunt dissection. Find your midline. All right, see - find your midline by the umbo. I think you've got it deep enough there. All right - we're releasing the tamponade here in a minute. All right, since we know the patient has a belly full of blood, we are methodically getting down to the midline fascia. Before we open up the fascia and release the tamponade, we let anesthesia know so they can be prepared if she dumps her pressure and they need to intervene. Want to do a finger? Are we all the way in or is this fascia? It's in. Okay. You know, sometimes it's okay to go preperitoneal in such cases like this, if they're hypotensive, but she's been okay for a couple of hours. Abdomen is open. So we've just been informed by anesthesia that her pressure's doing okay, her gases okay, So it's important that we maintain ongoing communication on both sides of the curtain during the case. Oh, we got lots of room. Man, look at all that! Get the knife and open that bad boy up. Knife back. Because we're going to be up in here, we definitely need as much room up top as we can. I got your knife for you. Knife is on your tray. Thank you. So we released the tamponade, and her pressure did fine. MAP of 97, systolic's in the 130s. Okay, open up - open down here. All right, we need a bucket here, please. And a Poole sucker. Protecting the bladder down there, Dr. Suah? Yep. Okay. Okay, may we have a bunch of packs, please? Open this up some more for me. Poole sucker. Okay, we're packing the right upper quadrant. Oh, I was going to do the left, is that okay? The left - that's what I meant. Okay. My right, patient's left. One pack in. Two packs - so right now we're packing the left upper quadrant where the busted spleen is to provide some tamponade - three packs in - tamponade to slow down the bleeding. All right, now let's get these clots out. Hold this here, David. Let's just put our hands in here and get all this out. Do you have another large Rich? What's that? Another large Rich? Need to put some down here. Two more packs, please. Don't worry about down there. Okay. On your oral boards - yeah, do all that. Uterus, ovaries - see all that, David? Yep. Uterus, fallopian tube, ovaries? Yep. All right. Laps, please. Before you do that, run your hand over the liver, see if you can feel any cracks in the liver. Do you want to take down falci? Yep. Maybe like a small, posterior... All right, so- don't worry about packing that. Okay. May I have two curved... You're caught on something here. Come out, Ashley. Yeah, she's kind of stuck there. Can we have the Bovie, please? So take those down. So... All right, give us some traction here, Dr. Suah, so we can take that down. Then you guys can get your falciform down, put the retractor in, then we have exposure. So, yes, she had blunt trauma, hypotensive, again a belly full of blood - pack all four quadrants. Then slow down, talk to anesthesia, make your plan of attack. We know it's her spleen. We get in, it's her spleen. We've packed that off, evacuated the rest of the blood, and take down this adhesion. You can give yourself a little bit more. So we want to cut, spread, cut, spread. Just give me one second, please. All right, take down the falciform, put your retractor in. Yes? Metz, please? I got it. Okay. And those 2-0 ties. You usually just pass this behind, and it gives you more length. Okay. Right? As opposed to trying to reach behind there to get that. Pass it behind yourself and then you go through, save yourself some time. Throw your knot and then tie. Yes. Suture scissors, please. Cut on the knot. And another 0 tie, please? That's fine. Back to the Yankauer, please. This has to go into our Bovie bin so we don't burn our patient. Okay, we have the abdomen open, we have our falciform taken down, we're putting in our retractor so we can get some exposure. There you go. We have our spleen packed off. I'll take a folded up blue towel, please. Keep it folded up. Put this up top to pad your pressure points. All right, let's see if we can get some more room here. Bovie, please? Okay, so let's take a pause here, all right? Her vitals have been fine. Her spleen is packed off. She has blunt trauma, so let's go ahead and check for RP hematomas really quick. Okay. Because she's doing all right. So we're digging at zone one, which again, is your periaortic and peri-IVC. So... Pull down the stomach, pull up the liver. Liver up, stomach down. It's a little hard with this retractor. Get a little suction. I don't see anything obvious. Yep, don't see anything there. Okay, let's go inframesocolic. That was... Ooh, this is beautiful anatomy here. Look at this, this is nice. Nothing there, keep moving - big Rich. Wow, her kidney is like... Floating. Right there. Yep, keep moving - big Rich. So zone two. Nothing, right? Negative. All right, just go around clockwise. Zone three - left zone three. This will be your iliacs. So zone two would be your left kidney. Zone three would be your left iliacs. Nothing? Nope. All right, Dr. Suah, you take this. Keep going all the way around. Right zone three - nothing? All right, so that's just a quick look for retroperitoneal hematomas, okay? Don't see any. No. We're going to run the bowel real quick, to make sure we're not missing any holes. Again, we'll do this multiple times before we close, but just a quick pass through now looking for anything obvious. So start at the ligament of Treitz, the suspensory ligament of the duodenum. So colon - transverse colon goes up and onto the chest, all the way down to the base of the mesocolon. Then start running the bowel. Two person procedure, we fan out the bowel, milking the lumen all along the way, and examining both sides of the mesentery all the way down to its base, looking for holes, vascular injury, hematomas, contusions, anything not normal. That's a good job working together, keeping it fanned out the entire way, flipping both sides, yep. And they're flipping, flipping - yep. It should be like, a 10-cm segment - flip. So it's flip, move - flip, move - flip, move. Now if she were dumping her pressure or hemorrhaging, we'd get that spleen out right away, but we clearly have time to do this first. You just go with what's handed to you. But you would not be faulted for just getting the spleen out and then doing this. Right, right, right. All right, now at the terminal ileum - so what are we going to find here, David? The appendix. The appendix is there. The fold of...? Treves, fold of Treves. Fat pad of Treves, or the fold of Treves. Fold of trees? Treves: T-R-E-V-E-S. All right, now we're working our way up the ascending colon. It's nice and glossy for us. She's got very pretty anatomy. Yes, she does. How lucky are we? Okay. Big Rich, please? Uterus. Do we want a malleable...? That's okay, if we pull this up, and push this back…
All right, so we've done our initial exploration, know the spleen's busted. On CT scan, there's some liver lacerations, which we don't feel so they're not really clinically significant. We checked for RP hematomas, nothing there. We've run the bowel, nothing there. So now our plan of attack is to get this spleen out. So, the spleen has three attachments. Laterally you have your splenorenal - spleen to kidney, those are avascular. Inferiorly you have your splenocolic - you may have one or two small vessels in there. And superiorly you have you're - So, splenocolic is spleen to colon. And superiorly you have your splenophrenic, which is to your diaphragm. That's avascular. So you can pretty much take a paw laterally with impunity, superiorly - inferiorly you have to make sure to control the vessels. And when we get to the hilum, we also have to worry about the gastrosplenic, which is where your short gastrics is. But for now we need to mobilize those three attachments. Superiorly, laterally, and inferiorly, that way we can mobilize the spleen to the midline, get to the hilum, control the hilum - that comes out, short gastrics, spleen's in the bucket. All right, so your goal is to get this spleen sitting right there because right now it's way back there where it's not doing you any good. So, David, you know what your job is going to be? Tell me. Come around on this side. Grab a big Rich. Go up on top of Harry here, and give him some exposure. Can I have that bucket? Yep. Dr. Suah, how many of these have you done? None, this is my first. Okay, Harry - this is going to be a... This is just all clot coming from the spleen here. So here- you're going to be pulling up here. If you ever need to take a rest, let me know, okay? Because this part that you're doing does get tiring. Okay, up there? If you want switch with him, let me know, Harry. I can see better here. Okay. Okay, we've got, so far, out about, I don't know, 500 cc of clot? She's doing good, she's doing good up here. Okay. Don't, don't, don't let that... Let me get a feel here and see what you got. Okay. Yeah, that's going to fall apart in your hand, seriously. So you can feel where it's attached, right? Mm hmm. So when you get those mobilized - so your left hand is going to be over the spleen, holding - pulling it towards your midline. Your right hand's going to be doing the work, okay? Okay. All right, so get your left hand. Okay. With the Bovie or do you want...? Get a Metz. Okay, Metz please.
Thank you. What you don't want to do is bring up the kidney, okay? Okay. And - yep. Does she, do you want her to...? She may go to the floor. Yep, see the white line there? Yes. Careful with my glove. Okay. All right, so that's - the kidney's down - you feel - I'm going to hold this here while you feel that the kidney's down. Okay. Okay, so you don't want to bring up the kidney, so - we have mobilized the lateral attachment, that's your splenorenal, avascular, make sure we're leaving the kidney down.
Now we can do these inferior attachments, splenocolic. See that? Do you have her TA ready? TA or GIA? Actually, GIA, sorry. Can you open that GIA? Do you want a 60 or 80? Let's uh, 60. GIA 60, please. A little bit, little bit... Can we have a...? DeBakey, please. Do you want me to put a right angle on it? I'll get it. Can we have a right angle, please? Okay. 2-0 tie on a pass. That's too much. Yep. Tie that. I'll hold that. Okay, get your spleen again, left hand.
Okay, so now it's your superior attachments that are holding you up here. Okay. Just let me feel here before we start going blindly back there. Let me feel here. So you're going to take your left hand. You're going to have to pull up to your right hand, snipping away with your Metz, every now and then make sure you're feeling for the hilum because you can feel the vessels in there. You don't want to get to the vessels, okay? And once those superior attachments come down, we can work our way towards the hilum and get that controlled. Yeah, the vessels are right there - right there, okay? Here? So you want to get... You are tethered up here - where there's this band right here that you need to get. Hang on one second, make sure those aren't the short gastrics that we're getting into, which are right there. Might as well go ahead and get those taken care of right now. Okay, do you want me to use the - a LigaSure or just tie them off? Tie them off, so right angle, right angle. Can I have a right angle, please? Ashley, pull that out. Okay. Just get me a hemostat. Times two. Okay, don't get the gastric wall. Okay. Cheat towards the spleen. Okay? Metz, please. Metz. Tie on a pass. Get this off the shadow there, so I'm not caught in your knot. So very important to control the short gastrics. If these are missed, they bleed. A lot. That's a re-operation. Cut yourself. There's usually two or three, so we got to find the other one in there. Okay, let's try to get this... Do you want me to tie this one? It's the specimen side, it's coming out, so... All right, so we still... Pull up there, David. This is stomach right here, right? Yep, so cheat towards the spleen, yep. Take down that attachment. Bovie that. DeBakey, please. Right angle. Good, got it. Tie on a pass to Dr. Suah. Cut yourself. So we're just controlling the superior vasculature here. Right here. This looks pretty good, almost got it. Can we have a dry lap? Thanks Danny. Don't worry about that. Right angle. Really can't be too safe. Another right angle. Metz. And 2-0 ties on a pass, please. Do my right hand first, that's the important one. Scissors. Two knots here is fine, it's coming out. Okay. DeBakey. Suction. DeBakey. Can we have another right angle, please? I'm not worried about the spleen side, I just want to make we got the... Staying side? Staying side. Metz. 2-0 tie, please. So we're just making sure we're getting all the vessels controlled that lead to the spleen. The spleen is a very vascular organ, lots of blood. Okay, trash, instruments, lap pads - back towards the feet. So take your left hand. See what you got there? Oh, yeah. Okay, don't pull, don't tug too hard.
So let's get a right angle, please. Because there's not much left here. Do you want me to 0 tie it, or... Go ahead and take the specimen off first. I'll take a 2-0 stick tie. A 2-0 stick? Yep. Can I have a 2-0 on a V-20? A 2-0 silk on a V-20. Specimen's coming. And I have a specimen coming. Do you want to go take a look at that, David? A look at the spleen? Yep. Yeah. Before it gets passed off? Y'all may want to get a picture of the spleen, over there. So, some people say you should divide out the two vessels separately because if you take them together it's a chance of AV fistula, it's not been borne out by data. I just take them and get them controlled and we're done. Okay. So... Here's your tie. You want to do it here? DeBakey, please. And I want to go around, right? Yeah. All right, I'm going to cut the needle and then I want to do another tie below that one. Needle coming back - it's free. Needle back. Spleen is out. All right, let's suck up the rest of this blood. Big Rich, please. Got our bucket? All right, toss a couple packs up in there now, just for now. All right, two packs in the splenic fossa. We'll see the spleen before it goes - is it already gone? No, it's here. So yeah, see? This definitely would have been a problem in a couple days. The splenic capsule is torn. It's like ruptured.
So Dr. Suah, we're going to make sure we got everything controlled in the splenic fossa. So you're going to take the burrito. Burrito, please? Going to be way out laterally, you're going to roll this back towards yourself, you're going to have the Bovie tip in your right hand. Long Bovie tip. Now as you're rolling it back, you see something, you zap it. Okay. Don't zap the bowel, though, okay? Okay. And just kind of roll it back - zap, zap, zap - roll. We're going to have to come up all the way over the remnant of the splenic hilum, down the greater curvature of the stomach, make sure we've got the short gastrics. We're going to do this several times, okay? A couple times. So now we're just confirming we have hemostasis where we took out our spleen. These look pretty dry. Famous last words. I know. Famous last words, you're just jinxing us. Be careful, make sure we're not... That's not bowel there, so - or stomach. Is it pancreas? That's pancreas. So you're checking the fossa, you're checking the hilum, you're checking where you took down all your ligaments, so splenocolic, phrenic, and splenorenal ligament. Taking a good look at the greater curvature of the stomach, make sure you got your short gastrics controlled. You miss those, they start bleeding - mmh. Back to the OR. All right, so what we've done so far - we'll talk about that in a minute, here. Let's make sure we got the bleeding under... Looks pretty dry. All right. Here's what you're going to do, okay? Harry, you're going to come over here. You're all going to do your exploration, irrigate, then I'm going to take a look, okay?
All right, start from the very beginning. Just opened the belly. So for trauma laparotomies, you can never run the bowel too many times. And I say that with some facetiousness. Of course, if they're acidotic, hypothermic, coagulopathic, we don't want to spend too much time in the OR. They should to get to the ICU to get resuscitated. But the point I'm trying to make is you want to be sure that you run everything enough times that you're convinced you have no missed injuries. I'll take one more lap. Do we need to do an x-ray, or did we count beforehand? We did count. We did count? So we're good? We're about to count. I mean, so - we don't need an x-ray then? If the counts are okay? Okay. If the count's okay. Hopefully - I mean - I think we'll be all right. We don't have to do a mandatory x-ray, I mean. No. Yeah. Okay. Yeah, two, just like last time. Yeah. All right, my turn? Yep. All right, one last time. Okay. Okay, let's run the bowel - you and I. Let me get on your side, so I can show you how you can run somebody through this quickly. So you have your trainee find the ligament of Treitz. So they're going to be proximal to you already, right? So you have them stay there and you're going to guide this along - that's what... Let's run the bowel. And they need to just keep up with you, right? So, my left hand will be handing it to your left hand, as I move along. Wow, look at this. This is nice. This is nice. All right, terminal ileum, appendix, cecum. Big Rich, please. I don't think we need it on this side. Or actually, don't worry about that. I know, it's like already mobilized. All right, that's all good. Liver one more time. The diaphragm is fine. Man. I know. Man, too bad we can't do a sigmoid colon, this... I know, she's so floppy. She must be terrible with her colonoscopies... I know, she'd be like... It's so long, and redundant, all floppy. When she's an old lady, it'll be really hard. All right, big Rich, please. And a couple burritos to me. Whoop, is it down? You got it. This is pancreas. Put your finger there, David. That rubbery thing is the pancreas. Uh huh. And the tail of the pancreas kisses the spleen. So we took the spleen out, that's what we have left. Another burrito, please. Short gastric tied off there. There are usually two or three - we've got two. I don't see any other vessels out there hanging. I'm going to get that in a second, I want to make sure the greater curvature's okay, before I let that go. Yeah, there's something here, see it? We can maybe put another tie around it. Yeah, let's switch sides so we can do that. Okay, can we have a right angle, please? Get this guy. So what we're going to do is take... I see it. Let's do those separately. Okay, because it's right here, yeah. Yeah. It's coming out of this... Yeah. Yep. Okay, can I have the 2-0 tie, please? 2-0 tie? Mm hmm. Scissors. I got that tie to her. So just stop, see what you're doing now? You should pass your instrument to the tip not your finger, especially when you're deep in a hole like that. Okay. Oh, like this? Yep, and then pull the tip down. Yes, exactly. How'd that feel? Good. Can I have a dry lap, please? Is this pancreas here? I think so. That's pancreas. That was still - that was a little oozy earlier. We'll get some of that slurry, that... Yeah, Surgicel or something? The Surgiflo stuff... Oh, Surgicel. Floseal? Whatever you guys call it here. Do we have Floseal, Allely? Long DeBakey. Just make sure we got it. Bovie? This, or...? No, I was just taking a look here. Take this off or...? Nope. Just leave it? Going to leave that exactly where it is. Okay. Put the lap pad on there. You can relax, David. Harry, you want to do it? I can show you. So it's right here. Yep. All of it? I guess, should I just push it in, or...? Just leave it there and then just let it fall back into his fossa. Okay. Do you have that thing? Yeah, I'm looking at bowel. All right, let it drop. Do you have the thing? Nice. All right. I have one more drop. Don't worry about it. Put everything into anatomical position. Okay. Make sure the bowel's not twisted up. This is cecum. Omentum down.
All right, so we had blunt trauma to the abdomen, due to assault, transferred from an outside hospital, reportedly hypotensive at the outside hospital with a splenic injury. She arrived here normotensive. We confirmed the splenic injury on a repeat CT scan because her images from the outside hospital were not adequate for us to make a clinical decision about what to do with her. Brought her up to the OR, midline incision, evacuated about a liter of blood and clot, did a splenectomy, found no other injuries, and now we're about to close. Some clinical pearls about doing a splenectomy - There are three attachments. You have your lateral attachment, which is the splenorenal ligament, that is avascular. Your inferior attachment is your splenocolic, you may have one or two vessels there. And your superior is the splenophrenic, which is avascular. So those are the three attachments you need to mobilize to get the spleen to the midline. That is imperative to do because the spleen sits way up in the left upper quadrant. You cannot operate deep in that hole. So mobilize it to the midline. Once you've done that, you do two things: that is control the hilum, which is your vasculature to the spleen and then control your short gastrics, which are the gastrosplenic ligament. There's two to three vessels there. Once you've done that, spleen comes out. Confirm hemostasis, put everything back into anatomical position, and close. Thank you for joining us for this splenectomy.
All right, good time for a debrief, we all ready? Actual procedure performed: exploratory laparotomy and a splenectomy. Need for OR full x-ray: no. Wound classification: II. Incision closure: deep and superficial layers. Specimen: spleen - has it been labeled? Yes? It's labeled Dr., it's over there. EBL is 1.2 - let's say 1.8 L. 1.2 in the bucket and 500-600 of blood and clot additional. 1.8? 1.8 L. 1.8 L. Okay. And received two units of blood, two more coming. Yes. 250 of the abdomen and 1.5 of crystalloid. And urine is? About 100. About 100, okay, I'll take that. Antibiotics, Doctor? Antibiotics post-op - no, but she will need splenectomy vaccines at some point. Post-op Foley - Foley's coming out. VTE: doesn't need any. Oh, okay. No VTE? Yeah, get her up walking. Okay. I continued the other guy's peri-op... That's fine. VTE prophylaxis - keep it going. Foley comes out, OG tube comes out. Wound care: going to have a dressing. Recovery: PACU. Anything else, recovery? No. ID band present? Anticipated date of discharge? Let's say - four days. Four days, okay. Surgeon: Williams. Okay, any issues? No issues. No issues, okay.