Splenic salvage using an absorbable mesh: feasibility, reliability and safety

Effects of different kinds of meshes on postoperative adhesion formation in the New Zealand White rabbit

The aim of this study was to compare the effect of different kinds of surgical meshes on postoperative adhesion formation. Forty-two New Zealand White rabbits were studied. The rabbits were grouped into six groups, according to the type of surgical meshes (Prolene, Mersilene, Vypro, polytetraflouroethylene (PTFE), Proceed and control group) implanted into the peritoneum cavity. Thirty days after the operation, the relaparotomies were carried out, and any adhesions observed between the implanted mesh and tissues were evaluated and graded. The mean adhesion degree was 9.2 in the Mersilene mesh group, 9.5 in the Prolene mesh group, 9.7 and in the Vypro mesh group (P > 0.05). The mean adhesion degree was 1 in the control group, 2.75 in the Proceed mesh group and 2.25 in the PTFE mesh group. There was a significant difference in adhesion degree between the control, Proceed and PTFE groups and the Prolene, Mersilene and Vypro mesh groups. The adhesion degree was significantly lower in the Proceed and PTFE mesh groups when comparing them with the Prolene, Mersilene and Vypro meshes.

Utilidad de las mallas reabsorbibles en los traumatismos esplénicos

INTRODUCTION

The spleen is not an essential organ for survival but given its important role in immunologic functions its preservation is justified.

OBJECTIVE

To analyze our experience with absorbable meshes applied to treat splenic injuries.

PATIENTS AND METHOD

We performed an ambispective study. From July 1999 to February 2004, 30 patients were treated for traumatic splenic injuries. Ultrasonography and/or spiral computed tomography scanning was carried out for the initial screening evaluation and grading of splenic injuries. The New Injury Severity Score (NISS) was calculated to quantify the severity of trauma. Operative splenic preservation was performed according to established selection criteria. Splenorrhaphy with prosthetic material was accomplished by means of a bag of polyglycolic acid mesh measuring 18 cm yen 23 cm (Dexon mesh) that was hand tailored and wrapped around the entire surface of the spleen.

RESULTS

Thirty patients with splenic traumatic injuries were treated. The mean age was 36.2 +/- 16.6 years. Twenty-three patients (76.6%) required splenectomy, nonoperative management was achieved in 1 patient (3.3%), and splenorrhaphy with prosthetic material was carried out in 6 patients (20%). Grade III injuries were present in 13 patients (43.3%), grade IV in 13 patients (43.3%), and grade V in 4 patients (13.3%). The mean NISS was 18.9 +/- 9.1. No significant differences were detected between the two groups (splenectomy or mesh splenorrhaphy) in NISS (p=.53) or grade of splenic injuries (p=.69). Morbidity was related to the presence of multiple injuries (p=.002) and was greater in the group with mesh splenorrhaphy (p=.002); however, there were no septic complications in this group. A positive correlation was observed between the length of hospital stay and NISS (p=.01). The length of hospital stay was also significantly associated with the presence of multiple injuries (p=.005) and with morbidity (p=.0002), but was not associated with the type of surgery carried out (p=.17). No complications were observed during follow-up (median of 28 months) in patients who underwent splenic salvage procedures.

CONCLUSIONS

Mesh splenorrhaphy is a suitable therapeutic option for patients with severe trauma, grade IV splenic injuries, or delayed rupture of the spleen. Both morbidity and length of hospital stay were associated with the presence of multiple injuries rather than with the type of surgery carried out. The safety, effectiveness and absence of septic complications related to the use of prosthetic material in splenic trauma salvage surgery were notable.

Splenic preservation: an additional haemostatic measure during mesh splenorrhaphy

BACKGROUND

Various treatment measures have been described in achieving splenic preservation following splenic injury. We describe an additional measure in achieving haemostasis during mesh splenorrhaphy.

METHODS

Oxycel (BD, Franklin Lakes, NJ, USA) (topical haemostatic agent composed of oxidized cellulose) is sutured onto the inside of Dexon (Sherwood, Davis & Geck, St Louis, MO, USA) (polyglycolic acid) mesh.

RESULTS

Two patients with splenic lacerations were operated on from July 2002 to February 2003 using this technique and both patients did not experience postoperative abdominal complications and were clinically well at follow up 1-2 months later.

CONCLUSIONS

In our experience this technique made the Dexon mesh bulkier and easier to secure as well as more haemostatic.

An experimental study of the adhesive potential of different meshes

OBJECTIVE

To assess the adhesive potential and incidence of incisional hernia with three meshes.

DESIGN

Open experimental study.

SETTING

Surgical Research Laboratory, Turkey.

ANIMALS

75 Wistar albino rats

INTERVENTIONS

Abdominal walls were excised, and defects closed primarily or with polyglactin 910, polypropylene, or dura mater. Adhesions were graded and hydroxyproline concentrations measured on days 14 and 180. On day 180, the incidence of incisional hernia, and the grades of inflammation and fibrosis were also recorded.

RESULTS

The polyglactin 910 group had a higher adhesion grading than the control and dura mater groups on day 14, whereas the polypropylene group had higher adhesion grading than controls. Both polypropylene and polyglactin 910 groups had significantly higher concentration of hydroxyproline than the control and dura mater groups. On day 180, the polypropylene group had a higher adhesion grading than the controls. There were no differences in hydroxyproline concentrations, incidence of hernias, or grading of fibrosis levels among the groups.

CONCLUSION

Polyglactin 910 induced more fibrotic adhesions in the early postoperative period whereas polypropylene did in both the early and late postoperative periods.

10 year experience of splenic injury: an increasing place for conservative management after blunt trauma

It has been suggested that over 30 per cent of splenic injuries are suitable for conservative management by non-operative treatment and splenorrhaphy; splenic conservation avoids the risk of overwhelming post-splenectomy infection. In this study, injuries of the spleen have been retrospectively analysed for a 10 year period. In the first 5 years the spleen was conserved in only 6/45 (15 per cent) of patients with blunt injury (three non-operative, three splenorrhaphy). In the second 5 years of the study, the spleen was conserved in significantly more patients with blunt trauma, 25 of 61 (41 per cent). This change has been a result of increased non-operative management which has been successful in the majority of cases (20/22). This has been associated with the increased use of abdominal ultrasound. The rate of splenorrhaphy has not changed significantly, five patients compared with three in the previous 5 years. Non-operative management may be increasingly appropriate as less severe splenic injuries are being detected with an increased use of ultrasound. Splenic injury is not a mandatory indication for laparotomy; non-operative management of splenic injuries should be considered in selected patients who are haemodynamically stable and can be closely monitored.

Current concepts in splenic trauma

Despite its protected location inside the rib cage, the spleen remains the most commonly injured organ after blunt abdominal trauma. The clinical decision-making process of splenic injury management continues to evolve due to improvements in surgical technique and noninvasive assessment. Splenic preservation techniques and splenic injury grading systems using computerized tomography were developed due to an increased understanding of the spleen's importance in the body's immunological defense system and awareness of the spleen's resiliency after injury. The concept of splenic salvage using splenorrhaphy and nonoperative management was initially applied to the pediatric population during the 1970s, with great success. Application of splenic salvage to hemodynamically stable adult patients with known or unknown splenic injury has demonstrated that adults can be less predictable in their clinical course. Despite the rigorous attention splenic trauma has received, it remains a controversial subject in the surgical and the radiological literature.

A new option for splenic preservation in normal sized spleen based on preserved histology and phagocytic function of the upper pole using upper short gastric vessels

Despite the recognized desirability of splenic salvage, forced splenectomy remains the rule in many operative situations, including trauma and pancreatic cancer. An anatomic study was conducted to assess whether the upper short gastric arteries provide sufficient collateral circulation to the spleen that the upper pole could remain viable even when the hilum is resected and the splenic artery and vein no longer intact. The anatomy of the upper short gastric vessels was studied in 59 human spleens and 18 albino rat spleens. Fifty-four human specimens (92%) and 18 (100%) of the rat spleens showed at least 1 upper short gastric artery and 1 vein connecting the fundus of the stomach with the interior of the upper pole of the spleen with no connection to the major hilar vessels. Lower two-thirds splenectomy, which included excision of the hilum of the spleen after ligation of both the splenic artery and vein, was performed on 14 of the 18 rats. The remaining 4 rats served as control animals. The upper pole of the spleen was preserved solely on the upper short gastric vessels that pass directly between the stomach and the interior of the spleen. Structure and macrophage function in the residual splenic tissue was shown to be preserved at 1 hour and 2 weeks postoperatively, based on results of the India ink technique for demonstrating phagocytic function and on results of regular histologic examination. Preservation was attributed to the fact that blood supply for the residual splenic tissue after splenic mass reduction remained adequate through the upper short gastric vessels. Splenic mass reduction is essential to improve perfusion to the residual splenic tissue if excision of the splenic hilum or ligation of the main splenic vessels becomes an operative necessity.

Use of polyglycolic acid mesh with a new double pursestring technique in renal trauma: an experimental study

Repair of major kidney lacerations with conventional techniques is extremely difficult and 'through and through' suturing is associated with further loss of viable tissue because it promotes scarring. In this study, we investigate the haemostatic and viable parenchyma salvaging effect of an alternative, new wrapping technique in an experimental renal trauma model. This resulted in immediate haemostasis in all 25 animals, while the same injury caused excessive haemorrhage with 50 per cent mortality in eight untreated controls. This technique differs from other wrapping methods because no additional suturing for the application of PAM or haemostasis is required. It is an easy, rapid procedure which decreases the operating time and may allow successful repair in major lacerations of the kidney.