Videolaparoscopic treatment of spleen injuries

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Splenectomy is very frequently used to manage splenic lesions. Nevertheless, spleen-injured patients who have undergone splenectomy are exposed to hyposplenism. Authors report two patients with splenic lesions treated by conservative surgery (with
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  Surg Endosc (1994) 8:910-912 Surgical ndoscopy © Spfinger-Verlag New York Inc. 1994 Videolaparoscopic treatment of spleen injuries Report of two cases A. Tricarico 1 A. Tartaglia 1 F. Taddeo 1 R. Sessa 2 E. Sessa 2 S. Mineili 3 1Department of Emergency Surgery, Cardarelli Hospital, Naples, Italy 2Department of Surgical Endoscopy, Cardarelli Hospital, Naples, Italy 3Department of Radiology, Cardarelli Hospital, Naples, Italy Received: 11 January 1993/Accepted: 25 October 1993 Abstract. Splenectomy is very frequently used to manage splenic lesions. Nevertheless, spleen-injured patients who have undergone splenectomy are ex- posed to hyposplenism. Authors report two patients with splenic lesions treated by conservative surgery (with fibrin glue) using the videolaparoscopic method. In both cases the preservation of the spleen was achieved. The conservative treatment allows one to avoid the risk of hyposplenism and the videolaparoscopy pro- vides the possibility to treat the patient with minimal surgical stress. Key words: Peritoneoscopy -- Spleen injuries -- Bio- logic glue -- Conservative surgery The most frequent complication of abdominal trauma is spleen injury [6]. Usually the patient only shows a splenic lesion (30--70% of the cases), but rarely, other intraabdominal injuries can be present [2]. Splenectomy is the most frequently used method to manage spleen lesions; nevertheless, after the first ob- servations of infective accidents following splenec- tomy [8, 12, 15], conservative surgery has been con- sidered for safe treatment of patients with splenic trauma. Such a kind of therapy allows one to avoid the risk of postsplenectomy hyposplenism. The recent large diffusion of coelioscopic surgery for the treatment of several abdominal diseases [4, 7, 18] suggests that a mini-invasive surgical approach might be suitable in performing a conservative ther- Correspondence to F. Taddeo, via D. Fontana, 200, 80131, Naples, Italy apy. Although the successes of the laparoscopic tech- nique have been seen mainly in the field of elective surgery (biliary lithiasis, inguinal hernia, appendicitis, etc.), it can be used for emergency surgical proce- dures. The conservative surgical therapy of splenic le- sions by coelioscopic method offers the advantages of spleen preservation and the minimal surgical stress that characterizes the laparoscopic approach. We report here on two spleen-injured patients who underwent conservative treatment by videolaparo- scopic surgery. Patients and methods Case report A 42-year-old woman, multiply injured owing to a serious car acci- dent (in which the driver died), was admitted at the Emergency Department showing hemorrhagic shock in hemodynamic compen- sation. The patient also had a head injury. The X-ray examination demonstrated multiple costal fractures and absence of pleuroparen- chymal lesions. The abdominal ultrasonography showed an echo- genic area located in the medial side of the spleen. Laboratory test results indicated anemia and leucocytosis. Case report 2 A 26-year-old man with multiple trauma and head injury was admit- ted at the Emergency Department presenting coma status (third de- gree). Radiology proved multiple fractures of limbs. Ultrasound scanning showed multiple capsular hematomas of spleen and a cap- suloparenchymal lesion located in the inferior polus. Laboratory tests showed anemia and leucocytosis. Technique For both patients videolaparoscopic reatment was considered. The procedure required the introduction of a 10-mm rocar in the  k t Fig. 1. Sites of portals for the conservative treatment of spleen in- jury umbilical region, receiving the camera (25 ° angle of view), two 5-mm trocars in the left hypochondrium, receiving the suction/irrigation tube and the Duploject system, and a 10-ram trocar in the right flank, receiving the atraumatic grasping forcep (Fig. 1). Both patients presented a hemoperitoneum with presence of blood in right and left parietocholic grooves, the rectouterine or rectovescical pouch, and the perihepatic area. In case 1, after careful removal of the epiploon which coated the spleen, the medial side of the spleen was washed and a linear cap- suloparenchymal lesion (from anterosuperior margin to hilus) was found. In case 2, after removal of a big clot coating the whole splenic surface, a triangular-shaped capsuloparenchymal lesion involving the superior polus, other capsular lesions on the anterior margin, and a large capsular lesion of the splenic inferior polus were found. In both cases, the estimation of the injuries, after the aspiration of hemoperitoneum and the washing of lesions and cavity, suggested a conservative treatment using fibrin glue (Tissucol) [3, 9, 14] and omentoplasty. The Tissucol was applied by a duploject catheter. Later, the cleansing of peritoneal cavity and recesses was per- formed and a double tubular drain in the rectovescical or Douglas pouch and perisplenic area was inserted. Both patients received intraoperative antibiotic prophylaxis. Results The postoperative follow-up of patient 1 showed the resolution of the clinical picture, with disappearance of the hemorrhagic shock. The ultrasonographic scan- ning on second, fifth, and seventh days confirmed the restoration of the lesions. Blood exams returned to normal levels. The restoration of the spleen lesions was also proved by scintigraphy performed 1 month later. Patient 2 also presented resolution of the hemor- rhagic shock and restoration of splenic lesions, con- firmed by ultrasonography. Nevertheless, the patient Table 1. Functions of the spleen 911 Hematocatheresis Culling effect Pitting function Reticulocyte molding Hematopoiesis (compensatory in adult age) Immunologic function Phagocytosis Synthesis of opsonins --specific opsonins IgG and mainly IgM --aspecific opsonins tuftsin (enhancing phagocytosis) properdin (activating the alternate pathway of complement) Production of T and B lymphocytes Maturation of B cells Platelet, ferrum, factor VIII reservoir Granulocyte storage Others Hormonal action Antitumoral function died on the 10th postoperative day, owing to the se- vere head injury. Discussion The spleen has unique and vital functions (Table 1): • Hematocatheresis • Hematopoiesis • Immunologic function • Platelet, ferrum, factor VIII reservoir • Granulocyte storage • Hormonal action • Antitumoral function [2, 5, 6] The ab~sence of splenic tissue due to splenectomy exposes the patient to a condition of hyposplenism with a real risk for the development of: • OPSI (overwhelming postsplenectomy infection): due to a lowering of the immunologic surveillance (mainly in children); this condition occurs less often in patients who have undergone splenectomy for trauma than in those who are affected by other dis- eases needing such treatment because of the vicar- ious function of the uninjured extrasplenic reticulo- endothelial system and the born-again spleen or splenosis. • Thrombocytosis: due to disappearance of the culling effect and responsible for thromboembolic obstruc- tion of mesenteric and portal vein [1] and cerebral and coronary vasa. • Reduction of erythrocyte deformability. A conservative therapy for splenic lesions (nonop- erative treatment, partial splenectomy, autotransplan- tation, etc.) was frequently and successfully per- formed by authors in the past by laparotomic proce- dure [2, 17]. Such a method allows one to preserve functioning and effective splenic tissue and to avoid hyposplenism [10, 11, 13, 16]. In our experience, videolaparoscopic surgery ap-  912 pears important as a method with which to perform minimal invasive elective (biliary lithiasis, inguinal hernia, appendicitis, etc.) and emergency surgery (acute cholecystitis, perforated ulcer, intestinal ob- struction). In spleen-injured patients, such a method provides a completion of diagnosis, allowing one to identify the real site and size of lesions. Besides, it allows one to treat patients conservatively with minimal surgical stress. From the reported cases, the combination of con- servative surgical therapy and videolaparoscopy showed encouraging results; therefore, it can be suc- cessfully performed in spleen-injured patients with steady hemodynamic conditions. References 1. Balz J, Minton JP (1975) Mesenteric thrombosis following sple- nectomy. Am Surg 181:126 2. Calise F, Sicoli F, Tricarico A, Napoli V (1990) Le lesioni trau- matiche di milza. In: Staudacher V, Bevilacqua G, Andreoni B (eds) Manuale di chirurgia d urgenza e terapia intensiva chirur- gica. Masson, Milan, pp 636--648 3. Coin D (1983) Evaluation of hemostatic agents in experimental splenic lacerations. Am J Surg 145:256 4. De Watteville JC, Testas P (1991) In: Testas P, Delaitre B (eds) Chirurgie digestive per voie coelio-scopique. Malaine, Paris, pp 170-187 5. Eichner ER (1979) Splenic function: normal, too much and too little. Am J Med 66:311-318 6. Fitzgerald JB, Crawford ES, De Barey ME (1960) Surgical con- siderations of non penetrating abdominal injuries: an analysis of 200 cases. Am Surg 100:22 7. Katkhouda N, Mouiel J (1991) A new surgical technique of treatment of chronic duodenal ulcer without laparotomy by vid- eocoelioscopy. Am J Surg 161:361-364 8. King H, Shumacker HB Jr (1952) Splenic studies. 1. Suscepti- bility to infection after splenectomy performed in infancy. Ann Surg 136:239 9. Kram HB (1984) Splenic salvage using biologic glue. Arch Surg 119:1309 10. Lang Nielsen J, Hanberg Sorensen F, Sarso P (1982) Implanta- tion of autologous splenic tissue after splenectomy for trauma. Br J Surg 69:529-530 11. Mahon PA (1985) Non operative management of adult splenic injury due to blunt trauma: a warning. Am J Surg 149:716 12. Morris DH, Bullock FD (1919) The importance of the spleen in resistance to infections. Ann Surg 70:513 13. Patel J, Williams JS, Shmigel B (1981) Preservation of splenic function by autotransplantation of traumatized spleen in man. Surgery 90(4): 613 14. Shelling G, Block T, Gokel M (1988) Application of a fibrinogen- thrombin-collagen-based hemostatic agent in experimental inju- ries of liver and spleen. J Trauma 28:472 15. Singer DB (1973) Postsplenectomy sepsis. In: Rosenberg HS, Bolande RP (eds.) Perspectives on pediatric pathology. Chi- cago: Year Book Medical Publishers. p 285 16. Tavassoli M, Ratzan ILl, Crosby WH (1973) Studies on regen- eration of heterotopic splenic autotransplants. Blood 415:701 17. Tricarico A, Sicoli F, Calise F, Napoli V, Minieri F, Apolito A, Farina R, Castello G (1987) L autotransplantation splenique dans les traumatismes de la rate. Ann Chir 41(8): 601--616 18. Tricarico A, Tartaglia A, Taddeo F, Triscino G, Sessa R, Sessa E, Giannini S, Ragucci P (1992) La colecistectomia video- laparoscopica: indicazioni, risultati, prospettive. Quad Med Chir 8(2): 148-152
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