V Naraynsingh, D Maharaj, M Ramdass
gauze packing, medicine, planned reoperation, splenic trauma, surgery
V Naraynsingh, D Maharaj, M Ramdass. Gauze Packing And Planned Reoperation For Splenic Trauma In The Presence Of Coagulopathy. The Internet Journal of Surgery. 2000 Volume 2 Number 2.
Although gauze packing and planned reoperation has been documented for the treatment of liver
trauma, it has not been described for the management of the ruptured spleen.
We document a single case of a grade I splenic injury, which occurred during an emergency subtotal colectomy for a massive lower
gastrointestinal bleed. The options of suturing and packing with absorbable mesh failed in the presence of a severe coagulopathy
and it became necessary to perform perisplenic packing with large gauze swabs with planned reoperation resulting in a favourable
outcome and splenic conservation.
Splenectomy remains the standard treatment for uncontrollable splenic haemorrhage 1 with many techniques of splenic conservation recommended, including suturing, wrapping with mesh and oxidized cellulose, partial splenectomy as well as splenectomy and reimplantation of tissue 2,3,4,5,6. However none of these is appropriate in severe coagulopathy, since any suturing causes bleeding and splenic mobilisation leaves a raw retroperitoneal surface that is likely to continue oozing.
A 50-year old man developed sudden, massive rectal bleeding. He transiently responded to fluid resuscitation, and was subsequently transfused with whole blood, fresh frozen plasma (FFP) and cryoprecipitate. Colonoscopy and arteriography failed to demonstrate a specific site of haemorrhage. Since he was hemodynamically unstable and had developed a coagulopathy due to the massive haemorrhage, an emergency laparotomy was undertaken to perform a subtotal colectomy. At surgery, there was widespread diverticulosis throughout the colon with some surrounding adhesions. In mobilising the splenic flexure, a 1 cm splenic laceration occurred, which began to bleed steadily. At this point an attempt was made at suturing with 3.0 chromic catgut, then light packing with an absorbable mesh. Both procedures failed and the attempt at suturing actually made the bleeding worse. The spleen was then packed with abdominal gauze swabs and the subtotal colectomy successfully completed.
On removal of the gauze, the spleen was noted to be persistently oozing with much surrounding blood. Digital pressure for 10 minutes stopped the ooze only during compression, but resumed immediately on release. The patient’s hemoglobin was now 2g/dl and he was oozing from many sites; it was decided that mobilisation of the spleen and splenectomy could cause further uncontrollable oozing. Four large laparotomy swabs were then packed tightly around the spleen to produce compression of the capsular tear. The abdomen was closed and the patient managed in the high dependency unit. He was resuscitated with 5 units of whole blood, FFP and cryoprecipitate postoperatively and a
The spleen is the abdominal organ most commonly injured by blunt trauma. Injuries vary from a small subcapsular tear to hilar devascularization or a shattered spleen, but are rarely fatal with good medical care 1.
Approximately 20% of splenic injuries are iatrogenic in abdominal procedures 2 and immediate splenectomy is indicated in patients with severe multiple injuries, splenic avulsion, fragmentation, rupture, extensive hilar injuries, failure of hemostasis, peritoneal contamination from gastrointestinal injury or rupture of a diseased spleen 1.
This is reported in many series such as hepatic trauma with a pre-existing coagulopathy in
A search of the literature reveals minimal information on splenic packing as an option when all else fails in the presence of a coagulopathy. However, packing with oxidized cellulose, mesh or omentum have been the trends as seen by the work on successful packing with oxidized cellulose or omentum in 27 out of 37 cases in a series of 127 cases by
The mesh was applied in such a fashion to act as a matrix to promote clotting and is advocated for those with bleeding from a large surface area, from deep parenchymal injuries or those extending into the hilum 4. However, this requires splenic mobilisation, which can produce oozing in the midst of coagulopathy. Splenorrhaphy is also a possibility as seen as a viable option for the injured spleen with a grade I or II injury as seen in a series by
We document this case of a grade I splenic injury, which occurred during an emergency subtotal colectomy for a massive lower gastrointestinal bleed with a pre-existing coagulopathy. The options of suturing and packing with absorbable mesh failed and the spleen was pressure packed with 4 large laparotomy gauze swabs to achieve hemostasis. A planned re-operation was undertaken 2 days later when the coagulopathy was corrected.
This case illustrates a relatively well-documented technique for liver trauma applied successfully to splenic injury in the presence of coagulopathy for control of life-threatening haemorrhage in splenic trauma since the options of using absorbable mesh, oxidized cellulose, omentum, splenorraphy or even splenectomy (due to a raw oozing area) may fail in circumstances where the surface area injured is large and a coagulopathy exits.
We hope our fellow surgeons who may find themselves in such situations consider of this option and use it more liberally in the hope of reducing mortality and morbidity rates by the avoidance of splenectomy in cases of severe coagulopathy where other techniques may be hazardous.
Dr. MJ Ramdass
100 East Drive,
Trinidad, West Indies.
Fax: (868) 663-9064