66.6 Injuries of the spleen

Rupture of a patient’s spleen gives you one of your best chances of saving his life, and is the major indication for splenectomy in a district hospital. Big malarial spleens rupture readily, but big schistosomal spleens do not.

If a patient ruptures his spleen, you will not have time to refer him. To succeed, you will need to make the diagnosis promptly, resuscitate him vigorously, operate immediately, and expose his spleen adequately. Emergency splenectomy can be difficult, especially when his spleen has stuck to his diaphragm by dense vascular adhesions which bleed briskly.

Usually, a patient’s spleen is only torn, but it may be shattered, pulped, or completely avulsed from its pedicle. Symptoms usually develop rapidly, but they may occasionally be delayed for a few hours. Rarely, a haematoma seals off bleeding to begin with, and then suddenly bursts. When this happens, symptoms may be delayed several days or even weeks.

The common mistake is to delay making the diagnosis until too late. Maintain the patient’s blood volume. First, give him saline or Ringer’s lactate. Then, when you have controlled his bleeding splenic pedicle, give him blood (53.2). Operate urgently.

The splenic pedicle is in two parts: (1) A fold of peritoneum, the lienorenal ligament, stretches across from its hilum towards the surface of the kidney. In it run the splenic artery and vein, and often the tail of the pancreas also. (2) A second fold of peritoneum, the gastrosplenic ligament, joins the hilum of the spleen to the greater curvature of the stomach. In it run the short gastric arteries. These two ligaments unite to form the pedicle of the spleen. Between them lies the extreme left edge of the lesser sac. You can compress the vessels in the splenic pedicle between two fingers, and so stop a spleen bleeding.

Controlling bleeding is the main difficulty. It will be easier if you have good exposure. If you find a huge haematoma, tying off the patient’s whole splenic pedicle without first identifying the vessels may be life–saving. But there is a danger that you may tie the tail of his pancreas, or even a fold of his stomach or colon, as you do so. The ligatures are also more likely to slip.

The spleen is not quite the disposable organ that it was once thought to be. The risks of removing it include overwhelming infection, and reduced immunity to malaria, particularly in children. The easiest way of conserving some splenic tissues is to put a few slices under a covering of peritoneum below the left costal margin.

In the following method we advise you to start by opening the gastrosplenic ligament, then tying the splenic artery before rotating the spleen medially, and tying and dividing the vessels in its pedicle individually. In desperation you can start by putting a ligature round the entire splenic pedicle.