bubble_chart Overview

The spleen is a highly vascularized and fragile solid organ. It is fixed in the upper left abdomen by ligaments connected to its capsule. Despite being protected by the lower chest wall, abdominal wall, and diaphragm, external trauma can easily cause it to rupture, leading to internal bleeding. Based on different disease causes, splenic rupture is divided into two main categories: ① Traumatic rupture, which accounts for the vast majority of cases, always has a clear history of trauma. The site of rupture is often on the convex outer surface of the spleen but can also occur at the inner hilum, depending mainly on the direction and location of the traumatic force. ② Spontaneous rupture, which is extremely rare and primarily occurs in pathologically enlarged spleens. Upon careful review of medical history, most cases still have certain triggers, such as severe coughing, sneezing, or sudden changes in body position.

bubble_chart Clinical Manifestations

The clinical manifestations of splenic rupture are characterized by internal bleeding and irritation of the peritoneum caused by blood, often closely related to the amount and speed of bleeding. Rapid and massive bleeding quickly leads to hypovolemic shock, presenting a critical condition; slow and minor bleeding causes mild symptoms, with no obvious signs other than grade I pain in the left upper abdomen, making diagnosis difficult. Over time, as bleeding continues, pre-shock symptoms appear, followed by shock. Due to peritoneal irritation by blood, abdominal pain initially occurs in the left upper abdomen and gradually spreads to the entire abdomen, though it remains most pronounced in the left upper quadrant, accompanied by tenderness, rebound tenderness, and muscle guarding. Sometimes, blood irritates the left diaphragm, causing referred pain to the left shoulder, which worsens with deep breathing—this is known as Kehr's sign. Laboratory tests reveal progressive decreases in red blood cells, hemoglobin, and hematocrit, indicating internal hemorrhage.

bubble_chart Diagnosis

The diagnosis of traumatic splenic rupture mainly relies on: ① history of {|###|}injury{|###|}; ② clinical manifestations of internal hemorrhage; ③ non-coagulating blood obtained through diagnostic abdominal puncture, etc. Cases with subcapsular laceration and subcapsular hematoma present atypical clinical symptoms, negative abdominal puncture results, and difficulty in immediate diagnosis. In recent years, for cases with diagnostic challenges and stable conditions, methods such as peritoneal lavage, B-mode ultrasound, radionuclide scanning, CT, or selective abdominal {|###|}stirred pulse{|###|} angiography have been employed to aid in definitive diagnosis.

(1) Peritoneal Lavage This is an invasive examination that cannot specifically localize the injured organ nor indicate the extent of the injury. It also carries a small risk of false-positive or false-negative results. Findings must be analyzed in conjunction with clinical and other examination results.

(2) B-mode Ultrasound This is a non-invasive and commonly used method that can visualize a ruptured spleen, larger subcapsular hematomas, and intra-abdominal hemorrhage.

(3) CT Examination It clearly displays the morphology of the spleen and offers high accuracy in diagnosing parenchymal lacerations or subcapsular hematomas.

(4) Radionuclide Scanning Techniques such as ^99mTc sulfur colloid scanning or γ scintigraphy can safely diagnose splenic injury.

(5) Selective Abdominal {|###|}Stirred Pulse{|###|} Angiography This is an invasive and relatively complex procedure with certain risks. However, it provides high diagnostic accuracy for splenic rupture by visualizing damaged vessels and parenchymal injury sites. It is only used for stable closed injuries where other methods fail to confirm the diagnosis.

It must be emphasized that splenic rupture is often accompanied by injuries to other organs, such as the liver, kidneys, pancreas, stomach, or intestines. Care must be taken not to overlook these conditions during diagnosis and treatment.

bubble_chart Treatment Measures

Since the 1960s, with advances in immunology, it has been recognized that the spleen is the largest lymphoid organ in the body and an important component of the human immune system, playing a significant role in both humoral and cellular immunity. The spleen is a vital organ for producing opsonins, tuftsin, and properdin, and it effectively filters and clears pathogens that invade the bloodstream. After splenectomy, the integrity of the human immune system is compromised, inevitably reducing resistance to pathogens and increasing the risk of severe infections. Previously, total splenectomy was considered the primary treatment for splenic rupture, and many textbooks advocated it as the standard procedure regardless of the extent of the injury. However, as reports of overwhelming postsplenectomy infection (OPSI), primarily in children, have increased, this traditional approach has been challenged. Additionally, based on the spleen's anatomical structure and existing hemostatic measures, partial splenectomy can now be performed safely. Although the current principle for managing splenic rupture remains surgical intervention, the choice of procedure—whether to preserve the spleen partially or entirely—should be tailored to the severity of the injury and available conditions. The following surgical options can be selected based on the specific circumstances of the injury:

(1) **Splenic Repair** Applicable to capsular tears or linear parenchymal lacerations. Minor injuries can be managed with adhesive hemostasis, but if ineffective, repair is recommended. The key surgical steps involve fully mobilizing the spleen to bring it out of the incision, controlling splenic pedicle blood flow with atraumatic clamps or manual compression, and suturing active bleeding points with 1-0 chromic catgut or 3-0 silk sutures before repairing the laceration. Post-repair oozing can be controlled with hot saline gauze compression or topical hemostatic agents until bleeding ceases completely.

(2) **Partial Splenectomy** Suitable when simple repair fails to achieve hemostasis or when damaged splenic tissue is nonviable, provided that over half of the parenchyma can be preserved. The procedure should be performed after mobilizing the spleen and controlling the pedicle. All nonviable tissue is excised, bleeding points are individually ligated or sutured, and the cut surface is treated with hemostatic agents and hot saline gauze compression until hemostasis is achieved. Finally, the area is covered with a pedicled omental flap.

(3) **Total Splenectomy** Indicated for severe splenic fragmentation or pedicle avulsion where repair or partial resection is not feasible.

Appropriate preoperative preparation is critical for managing patients with shock. Administering adequate blood or fluids enhances tolerance to anesthesia and surgery. If blood pressure and pulse do not improve after rapid transfusion of 600–800 mL of blood, ongoing active bleeding is likely, necessitating emergency laparotomy with rapid pressurized transfusion to control the splenic pedicle. Once active bleeding is controlled, hemodynamic stability improves, facilitating further surgical management. In cases of limited blood supply, intraperitoneal blood can be collected, filtered, and reinfused to replenish volume.