Feasibility of Laparoscopic Splenectomy in Stable Blunt Trauma: A Case Series

Emergency laparoscopic splenectomy for a grade-V splenic injury following blunt abdominal trauma: A case report

INTRODUCTION AND IMPORTANCE

The utilization of laparoscopy in severe splenic injuries following blunt abdominal trauma is limited because of difficulties encountered due to ongoing bleeding, chances of missed injury, and lack of experience.

CASE PRESENTATION

We report a young male with polytrauma (head injury, haemothorax, femur fracture, Grade V splenic injury) who underwent a successful laparoscopic splenectomy on day 3 following the failure of conservative management of grade V blunt splenic injury involving the hilum.

CLINICAL DISCUSSION

The utility of laparoscopy in the management of blunt trauma is controversial besides several series have shown acceptable outcomes for both solid organ and visceral injuries in experienced hands. Furthermore, there are several reports describing the utility of the laparoscopic approach for isolated splenic injuries in stable patients.

CONCLUSION

The utility of the laparoscopic approach for this patient was successful without major challenges during the procedure. The key initial step was achieving complete hemostasis as early as possible.

Surgical Repair vs Splenectomy in Patients With Severe Traumatic Spleen Injuries

Importance

The spleen is often removed in laparotomy after traumatic abdominal injury, with little effort made to preserve the spleen.

Objective

To explore the association of surgical management (splenic repair vs splenectomy) with outcomes in patients with traumatic splenic injuries undergoing laparotomy and to determine whether splenic repair is associated with lower mortality compared with splenectomy.

Design, Setting, and Participants

This is a trauma registry-based cohort study using the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2019. Participants included adult patients with severe splenic injuries (Abbreviated Injury Scale [AIS] grades 3-5) undergoing laparotomy after traumatic injury within 6 hours of admission. Data analysis was performed from April to August 2023.

Exposures

Splenic repair vs splenectomy in patients with severe traumatic splenic injury.

Main Outcomes and Measures

The primary outcome was in-hospital mortality. Outcomes were compared using different statistical approaches, including 1:1 exact matching with consecutive conditional logistic regression analysis as the primary analysis and multivariable logistic regression, propensity score matching, and inverse-probability weighting as sensitivity analyses.

Results

A total of 11 247 patients (median [IQR] age, 35 [24-52] years; 8179 men [72.7%]) with a severe traumatic splenic injury undergoing laparotomy were identified. Of these, 10 820 patients (96.2%) underwent splenectomy, and 427 (3.8%) underwent splenic repair. Among patients who underwent an initial splenic salvage procedure, 23 (5.3%) required a splenectomy during the subsequent hospital stay; 400 patients with splenic preservation were matched with 400 patients who underwent splenectomy (matched for age, sex, hypotension, trauma mechanism, AIS spleen grade, and AIS groups [0-2, 3, and 4-5] for head, face, neck, thorax, spine, and lower and upper extremity). Mortality was significantly lower in the splenic repair group vs the splenectomy group (26 patients [6.5%] vs 51 patients [12.8%]). The association of splenic repair with lower mortality was subsequently verified by conditional regression analysis (adjusted odds ratio, 0.4; 95% CI, 0.2-0.9; P = .03). Multivariable logistic regression, propensity score matching, and inverse-probability weighting confirmed this association.

Conclusions and Relevance

In this retrospective cohort study, splenic repair was independently associated with lower mortality compared with splenectomy during laparotomy after traumatic splenic injury. These findings suggest that efforts to preserve the spleen might be indicated in selected cases of severe splenic injuries.

Laparoscopic splenectomy as a definitive management option for high-grade traumatic splenic injury when non operative management is not feasible or failed: a 5-year experience from a level one trauma center with minimally invasive surgery expertise

Technique, indications and outcomes of laparoscopic splenectomy in stable trauma patients have not been well described yet. All hemodynamically non-compromised abdominal trauma patients who underwent splenectomy from 1/2013 to 12/2017 at our Level 1 trauma center were included. Demographic and clinical data were collected and analysed with per-protocol and an intention-to-treat comparison between open vs laparoscopic groups. 49 splenectomies were performed (16 laparoscopic, 33 open). Among the laparoscopic group, 81% were successfully completed laparoscopically. Laparoscopy was associated with a higher incidence of concomitant surgical procedures (p 0.016), longer operative times, but a significantly faster return of bowel function and oral diet without reoperations. No significant differences were demonstrated in morbidity, mortality, length of stay, or long-term complications, although laparoscopic had lower surgical site infection (0 vs 21%).The isolated splenic injury sub-analysis included 25 splenectomies,76% (19) open and 24% (6) laparoscopic and confirmed reduction in post-operative morbidity (40 vs 57%), blood transfusion (0 vs 48%), ICU admission (20 vs 57%) and overall LOS (7 vs 9 days) in the laparoscopic group. Laparoscopic splenectomy is a safe and effective technique for hemodynamically stable patients with splenic trauma and may represent an advantageous alternative to open splenectomy in terms of post-operative recovery and morbidity.

Minimally invasive splenectomy in grade IV splenic trauma: A case report associated with high-grade renal trauma

INTRODUCTION AND IMPORTANCE

In closed abdominal trauma, the spleen is the most frequently injured organ (30-45%). Splenic lesions grades IV-V have higher failure rates with nonoperative management (NOM). The minimally invasive approach is an alternative when NOM fails. This is the first reported case of a patient with splenic and left renal trauma, both grade IV, with combined management, which consisted of a minimally invasive surgical resolution of the splenic trauma and a conservative management of the renal trauma, with a satisfactory recovery of the patient. This contributes to understanding the benefits of minimally invasive surgery in moderate splenic trauma associated with other high-grade injuries.

CASE PRESENTATION

We present a 45-year-old woman with a multiple trauma after a motorbike vs car traffic accident. On physical examination, she was hemodynamically stable, with abdominal guarding and generalized rebound tenderness associated with multiple upper and lower limb fractures. An abdominal CT scan revealed grade IV splenic and left renal trauma, with moderate hemoperitoneum. A minimally invasive laparoscopic approach for hemoperitoneum drainage and splenectomy was performed.

CLINICAL DISCUSSION

There is currently no consensus to define the indications for minimally invasive treatment on splenic trauma. While laparotomy is the standard treatment, it is not without potential severe complications, while laparoscopy providing a treatment option in selected cases with hemodynamic stability.

CONCLUSION

The role of the minimally invasive approach is safe and feasible in selected patients with high-grade splenic lesions and hemodynamic stability, including the association with other organic lesions such as kidney trauma.

Laparoscopic splenectomy after trauma: Who, when and how. A systematic review

Importance:

A deep knowledge of the indication for laparoscopic splenectomy (LS) in trauma case can lead trauma surgeon to offer in a wider number of situations a minimally invasive approach to a common injuries.

Objective:

To present and review the advantages and disadvantages of laparoscopic approach for spleen trauma and to identify patient whose can benefit from a minimally invasive approach versus patient that need open surgery to assess the whole severity of trauma.

Evidence Review:

A systematic review was performed according to the PRISMA statement in order to identify articles reporting LS after trauma. A literature search was performed through MEDLINE (through PubMed), Embase and Google Scholar from January 1990 to December 2018. Studies conducted on animals were not considered. All other laparoscopic procedures for spleen trauma were excluded.

Results:

Nineteen articles were included in this study, reporting 212 LS after trauma. The most study includes blunt trauma patient. All LS were performed in haemodynamically stable patient. Post-operative complications were reported in all articles with a median post-operative morbidity rate of 30 patients (14.01%), including 16 (7.5%) post-operative deaths.

Conclusions and Relevance:

This article reports the feasibility and safety of a minimally invasive approach for common trauma injuries which can help non-advanced laparoscopic skill trauma surgeon to develop the best indication to when to adopt this kind of approach.

Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives

The spleen is one of the organs most commonly injured by blunt abdominal trauma. It plays an important role in immune response to infections, especially those sustained by encapsulated bacteria. Nonoperative management (NOM), comprising clinical and radiological observation with or without angioembolization, is the treatment of choice for traumatic splenic injury in patients who are hemodynamically stable. However, this strategy carries a risk of failure, especially for high-grade injuries. No clear predictors of failure have been identified, but minimally invasive surgery for splenic injury is gaining popularity. Laparoscopic surgery has been proposed as an alternative to open surgery for hemodynamically stable patients who require surgery, such as after failed NOM. We reviewed research articles on laparoscopic surgery for hemodynamically stable patients with splenic trauma to explore the current knowledge about this topic. After presenting an overview of the treatments for splenic trauma and the immunological function of the spleen, we try to identify the future indications for laparoscopic surgery in the era of NOM.

Laparoscopic Splenectomy for Trauma

Background and Objectives:

The use of laparoscopy in the trauma setting is gaining momentum, with more therapeutic procedures being performed. We evaluated the use of laparoscopic splenectomy among trauma patients with data from the National Trauma Database. We compared outcomes for trauma patients undergoing laparoscopic (LS) versus open splenectomy (OS).

Methods:

From the National Trauma Database (2007 to 2015), we identified all patients who underwent a total splenectomy. Patients who had other abdominal operations were excluded. All patients were categorized into 1 of 2 groups: LS or OS. Outcomes of in-hospital mortality, postoperative length of stay, and incidence of major complications between the 2 groups were compared. Bivariate parametric and nonparametric analyses were performed. Patients were then matched on baseline demographic and injury characteristics by using propensity score matching techniques, and we compared differences by using regression analysis.

Results:

A total of 25,408 patients underwent OS and 113 patients underwent LS (0.44%). Patients were significantly different at baseline, with the LS group being less severely injured. Bivariate analysis revealed no difference in length of stay (9 vs 8 days, P = .62), incidence of major complications (10% vs 15%, P = .24), or mortality (6% vs 11%, P = .23). LS was performed in 29.2% of patients beyond 24 hours from presentation compared with 9.5% in the OS (P < .001). Adjusted multivariate analysis showed no overall difference in outcomes.

Conclusion:

LS for trauma is increasingly being used at many centers throughout the United States. The procedure is safe, with outcomes similar to those of OS in selected trauma patients.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

Laparoscopic Splenectomy in Patients With Spleen Injuries

INTRODUCTION

Spleen injury appears in 10% to 30% of abdominal trauma patients. Mortality among the patients in the last 20 years remains high (6% to 7%) and shows no tendency to decline. Nowadays nonoperative management is widely accepted management of patients with low-grade spleen injury, whereas management of patients with high-grade spleen injury (III and higher) is not so obvious. There are 3 methods exist in treatment of such patients: conservative (with or without angioembolization), spleen-preserving operations, and splenectomy. Today laparoscopic splenectomy is not a widely used operation and only few studies reported about successful use of laparoscopic splenectomy in patients with spleen injury.The aim of the study was to determine indications and contraindications for laparoscopic splenectomy in abdominal trauma patients and to analyze results of the operations.

PATIENTS AND METHODS

The study involved 42 patients with spleen injury grade III who were admitted in our institute in the years of 2010 to 2014. The patients were divided in 2 groups. Laparoscopic splenectomy was performed in 23 patients (group I) and "traditional" splenectomy was carried out in 19 patients (group II). There was no difference in the demographic data and trauma severity between the 2 groups. Noninvasive investigations, such as laboratory investigations, serial abdominal ultrasound examinations, x-ray in multiple views, and computed tomography had been performed before the decision about necessity of an operation was made.

RESULTS

Patients after laparoscopic operations had better recovering conditions compared with patients with the same injury after "traditional" splenectomy. Neither surgery-related complications nor mortalities were registered in both groups. Laparoscopic splenectomy was more time-consuming operation than "traditional" splenectomy. We suggest that as experience of laparoscopic splenectomy is gained the operation time will be reduced.

CONCLUSIONS

Laparoscopic splenectomy is a safe feasible operation in patients with spleen injury. The operation is indicated in patients with spleen laceration >3 cm of parenchymal depth with moderate continuing bleeding or expanding hematoma and contraindicated in patients with hemodynamic instability and high bleeding rate (>500 mL/h on serial ultrasound examinations).

Laparoscopic splenectomy for spontaneous rupture of the spleen

Laparoscopic splenectomy is a gold standard for management of planned benign splenic pathologies. Spontaneous rupture of the spleen (SRS) leading to acute abdomen occurs in only 1% of all splenic ruptures. Laparoscopic splenectomy in traumatic and atraumatic rupture due to intra-splenic pathology is reported. We present the first reported case of laparoscopic splenectomy in a 23-year-old male who presented with hemoperitoneum due to idiopathic or SRS. The procedure was safely accomplished with slight modified technique and minimum usage of advanced gadgets.

Literature review of non-operative management of patients with blunt splenic injury: impact of splenic artery embolization

Splenic injuries constitute the most common injuries accompanying blunt abdominal traumas. Non-operative treatment is currently the standard for treating hemodynamically stable patients with blunt splenic injuries. The introduction of splenic angiography has increased the possibility of non-operative treatment for patients who, in the past, would have qualified for surgery. This cohort includes mainly patients with severe splenic injuries and with active bleeding. The results have indicated that applying splenic angioembolization reduces the frequency of non-operative treatment failure, especially in severe splenic injuries; however, it is still necessary to perform prospective, randomized clinical investigations.

Preliminary Experience of Sandwich Repair Technique

Background. Laparoscopic splenectomy has been used safely for patients with blunt splenic trauma and failed nonoperative management. Reports of using laparoscopic splenorraphy for spleen salvage were fewer and mainly limited to lower grades of injuries. No study has focused on the role of laparoscopic splenorraphy in the treatment of patients with high grades of splenic injuries. Methods. Medical records of 15 patients with high grades of splenic injuries that required an operation for failed nonoperative management were retrospectively reviewed. They underwent a new technique of sandwich repair laparoscopically for spleen salvage by 3 surgeons who had adequate training in laparoscopy for trauma. Preoperative parameters, sandwich repair technique, perioperative parameters, and postoperative outcomes were evaluated. Results. Fourteen of the 15 (93.3%) patients underwent the technique successfully with 1 patient converting to laparotomy. The median (interquartile range) time to reach hemostasis was 30.0 (26.0-40.0) minutes, and the median overall operation time was 135.0 (120.0-165.0) minutes. Median blood loss amount was 1300.0 (750.0-2300.0) mL. The median length of hospital stay was 8.0 (7.0-11.0) days, and the intensive care unit stay was 2.0 (0.0-4.0) days. No mortality was noted. No rebleeding, total splenic infarction, or intra-abdominal abscess was noted during 3-month follow-up after the operation. Conclusions. The preliminary results show that laparoscopic splenorraphy by the “sandwich repair technique” is feasible and safe for patients with high-grade splenic injuries.

Laparoscopic splenectomy: experience of a single center in a series of 300 cases

BACKGROUND

Laparoscopic splenectomy (LS) has gradually become the technique of choice for surgical removal of the spleen. The aim of this study was to evaluate the efficacy of LS in a large cohort of patients from a single center.

METHODS

From March 1992 to June 2010, 300 patients underwent LS at our hospital for predominantly hematologic disorders. The first 92 cases were performed using an anterior approach, whereas in the remaining 208 cases a lateral approach with a four-trocar technique was used. Patient demographics, diagnosis, and outcomes were reviewed.

RESULTS

Spleen volume was similar between the anterior (350 ml) and the lateral (370 ml) approaches. The lateral approach was associated with shorter operative time (60 vs. 80 min), less blood loss (30 vs. 110 ml), and no conversion (0 vs. 2.2 %) compared to the anterior approach. Reoperations were required in three patients (1.0 %) because of bleeding, subphrenic abscess, and intestinal ischemia. Postoperative complications were significantly fewer for the lateral (4.8 %) than for the anterior (31.5 %) approach and the hospital stay was shorter (3.1 vs. 5.2 days) and there was less postoperative pain. Splenectomy for hematologic malignancies resulted in a higher morbidity rate, more postoperative pain, and longer hospital stay. Overall mortality rate was 0.3 %. No late complications were observed during the 1-5-year follow-up.

CONCLUSIONS

LS using the lateral approach with the placement of four trocars can be considered the procedure of choice for both benign and malignant diseases affecting the spleen. Extensive experience and technical standardization help to avoid surgical pitfalls, providing an adequate control of hemostasis, the excision of accessory spleens (AS), and the avoidance of parenchymal rupture.

To study the incidence of organ damage and post-operative care in patients of blunt abdominal trauma with haemoperitoneum managed by laparoscopy

BACKGROUND:

Laparoscopy is safe and effective in the management of blunt trauma abdomen (BTA) with haemoperitoneum, with all benefits of minimal access surgery.

AIMS:

To study the incidence of organ damage and post-operative care in patients of blunt abdominal trauma with haemoperitoneum, managed by a new modality of treatment — laparoscopy.

MATERIALS AND METHODS:

Prospectively collected data on laparoscopy performed in patients with blunt abdominal injury, between the years 2004 to 2006, were analysed. Under general anaesthesia pneumoperitoneum was created. A 10 mm umbilical port, right-sided port in the anterior axillary line (5 mm / 10 mm), left-sided port in the anterior axillary line (5 mm / 10 mm) and an extra port were made according to the organ injury, and laparoscopy was performed and managed according to the organ injury.

RESULT:

Twenty-five patients had laparoscopy for blunt trauma abdomen with haemoperitoneum. Liver followed by the spleen were the most common sites of injuries. The overall failure rate was 4%. Post-operative stay and complications were much less. Laparoscopy reduced the number of negative laparotomies, with a limitation that it could not be performed in haemodynamically unstable patients.

CONCLUSION:

The liver and spleen are the most common organs involved in patients with blunt abdominal trauma with haemoperitoneum. Laparoscopy is safe and efficient in patients with blunt trauma abdomen with haemoperitoneum, with fast recovery and low hospital stay.

Laparoscopic splenectomy in a case of blunt abdominal trauma

Splenic rupture is a frequent consequence of blunt abdominal trauma. Removal of the spleen (splenectomy) or alternative conservative procedures (splenorrhaphy, partial splenectomy and haemostatic collagen application) are surgical treatment options. Splenectomy was first described in 1910 by Sutherland. Laparoscopic splenectomy was first described in 1991 by Delaitre and Maignien. Since then significant improvements in instrumentation and technology such as harmonic scalpel, endovascular staplers have increased its ease of performance. Laparoscopic splenectomy for a ruptured spleen has been reported only in a few cases, in which a hand-assisted technique was used. We present the first reported case from India (to the best of our knowledge) of a successful removal of a ruptured spleen by means of a totally laparoscopic technique.

Open partial splenectomy for trauma using GIA-Stapler and FloSeal matrix haemostatic agent

A ruptured spleen caused by blunt abdominal injury is often treated by splenectomy. In view of the gravity of the 'postsplenectomy syndrome,' a conservative approach has been increasingly used. We present the case of a 29-year-old man with a Grade III splenic lesion for a blunt abdominal trauma after a car accident. We performed a partial splenectomy of the upper pole using GIA-Stapler. A supplemental haemostasis of the stapled line was successfully achieved by the application of FloSeal matrix haemostatic agent. The splenic remnant was fixed into the left-upper quadrant using human fibrin glue.

Splenic rupture as a complication of colonoscopy: report of a case

Colonoscopy is a common procedure with the rare complication of a splenic injury. The proposed mechanism of injury is excessive splenocolic ligament traction. The diagnosis is made by computed tomography and the treatment is determined by the patient's stability. Here we report a case of splenic injury during colonoscopy with failure to manage conservatively. A review of the literature and suggested guidelines are also provided.

Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries

Use of laparoscopy in penetrating trauma has been well established; however, its application in blunt trauma is evolving. The authors hypothesized that laparoscopy is safe and feasible as a diagnostic and therapeutic modality in both the patients with penetrating and blunt trauma. Trauma registry data and medical records of consecutive patients who underwent laparoscopy for abdominal trauma were reviewed. Over a 4-year period, 43 patients (18 blunt trauma / 25 penetrating trauma) underwent a diagnostic laparoscopy. Conversion to laparotomy occurred in 9 (50%) blunt trauma and 9 (36%) penetrating trauma patients. Diagnostic laparoscopy was negative in 33% of blunt trauma and 52% of penetrating trauma patients. Sensitivity/specificity of laparoscopy in patients with blunt and penetrating trauma was 92%/100% and 90%/100%, respectively. Overall, laparotomy was avoided in 25 (58%) patients. Use of laparoscopy in selected patients with blunt and penetrating abdominal trauma is safe, minimizes nontherapeutic laparotomies, and allows for minimal invasive management of selected intra-abdominal injuries.

Laparoscopic splenectomy for blunt trauma: a safe operation following embolization

BACKGROUND

Embolization of the injured spleen from blunt trauma reduces the risk of continued or delayed hemorrhage in patients being treated with nonoperative management (NOM). Splenectomy is required in some patients following embolization due to continued bleeding or infarction with abscess formation. Laparoscopic splenectomy for blunt trauma can be done safely in patients following embolization.

METHODS

A retrospective chart review was conducted on patients undergoing splenectomy following embolization due to blunt trauma at two level I trauma centers. Minimally invasive techniques were compared to laparotomy for operative time, operative blood loss, and postoperative length of stay.

RESULTS

Eleven of 46 patients required splenectomy following embolization, eight for continued bleeding and three for abscess formation. Four of these patients had their spleens removed laparoscopically, three for continued bleeding and one for abscess formation. Patients undergoing laparoscopic splenectomy for continued bleeding had slightly longer operative times, more blood loss but shorter postoperative stay than those undergoing laparotomy. (96 versus 76 min, 500 versus 300 cc, and 4.0 versus 7.0 days, respectively). Laparoscopic removal of the abscessed spleen took 270 min compared to 55 and 90 min for the open procedures but the postoperative hospital stay was only 6 days compared to 10 and 13 days. There were no serious complications in any patients.

CONCLUSION

Laparoscopic removal of the spleen following embolization for blunt trauma is safe and should be considered in patients that have persistent bleeding or are at risk for delayed bleeding, as well as patients in whom complications of infarction and abscess formation develop.

Laparoscopic Splenectomy in an Adipose Elderly Patient With Symptomatic Non-Hodgkin Lymphoma-related Splenomegaly and Traumatic Central Splenic Hematoma

During recent years, laparoscopic splenectomy has shown to be a safe and effective surgical approach in patients with hematologic disorders requiring spleen removal. Especially in cases with splenomegaly, the laparoscopic approach results in a shorter hospital stay and faster recovery of the patients. Due to the increasing experience in laparoscopy, this approach also is emerging to be a therapeutic option in patients with blunt abdominal trauma with splenic rupture or hematoma. We report the case of an 80-year-old female patient who underwent laparoscopic splenectomy for symptomatic splenomegaly due to non-hodgkin Lymphoma in combination with stable traumatic splenic hematoma after blunt abdominal trauma.

Laparoscopic splenectomy: present status and future perspective

Laparoscopic splenectomy has become widely accepted as the approach of choice for the surgical treatment of benign and malignant hematologic diseases. Advances in technology have led to better outcomes for the procedure, and have allowed surgeons to apply the technique to disease processes that were at one time felt to be contraindications to laparoscopic splenectomy. However, challenges still remain. There is a steep learning curve associated with the procedure. The development of cost-effective laparoscopic simulators to target the skills required for laparoscopic splenectomy and other laparoscopic procedures is essential. The advent of devices which isolate and seal the large blood vessels that surround the spleen have reduced intra-operative bleeding and minimized conversions to open splenectomy. Improvements in optics and instrumentation, as well as robotic technology, will continue to define the frontier of minimally invasive surgery, and further facilitate the acceptance of laparoscopic splenectomy for the treatment of benign and malignant hematologic diseases.