Iatrogenic splenic injury
Iatrogenic injury to the spleen is a recognised complication of abdominal surgery but the extent of the problem is often under-estimated. This may be due to failure to report splenic injury on the operation note or inaccurate recording of the indication for splenectomy. In this review article we have tried to estimate the incidence of iatrogenic splenic injury during abdominal surgery, the morbidity and mortality associated with splenic injury and the risk factors for injury to the spleen. We have also identified the common types and mechanisms of injury to the spleen and have made suggestions as to how splenic injury can be avoided and, when it occurs, how it should be managed.
A Medline literature search was performed to identify articles relating to "incidental splenectomy", "iatrogenic splenic injury", "iatrogenic splenectomy" and "splenectomy as a complication of common abdominal procedures". The relevant articles from the reference lists were also obtained.
Up to 40% of all splenectomies are performed for iatrogenic injury. The risk of splenic injury is highest during left hemicolectomy (1-8%), open anti-reflux procedures (3-20%), left nephrectomy (4-13%) and during exposure and reconstruction of the proximal abdominal aorta and its branches (21-60%). Splenic injury results in prolonged operating time, increased blood loss and longer hospital stay. It is also associated with a two to ten-fold increase in infection rate and up to a doubling of morbidity rates. Mortality is also reported to be higher in patients undergoing splenectomy for iatrogenic injury. The risk of injury to the spleen is higher in patients who have previously undergone abdominal surgery, in the elderly and in obese patients. A transperitoneal approach significantly increases the risk of splenic injury during left nephrectomy compared with an extraperitoneal approach and the risk is even higher if the indication for surgery is malignancy. Excessive traction, injudicious use of retractors and direct trauma are the commonest mechanisms of injury.
The incidence of iatrogenic splenic injury is underestimated because of poor documentation. Splenic injury during abdominal surgery can be reduced by achieving good exposure and adequate visualisation, avoiding undue traction and by early careful division of splenic ligaments and adhesions. When the spleen is injured splenic preservation is desirable and often feasible, but this should not be at the expense of excessive blood loss
Available from: Anastasia Oikonomou
- "Iatrogenic splenic injury is a rare complication and may be caused during abdominal surgery, cardiac surgery, and colonoscopy [18, 19]. Splenic injury includes contusion, laceration, hematoma, active hemorrhage, posttraumatic pseudoanerysm, and posttraumatic infarction. "
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ABSTRACT: Splenic cysts are rare entities and are classified as true cysts or pseudocysts based on the presence of an epithelial lining. Congenital nonparasitic true cysts can be epidermoid, dermoid, or endodermoid, present at a young age, and are commonly located in the upper pole of the spleen. Surgical treatment is recommended for symptomatic, large (more than 5 cm), or complicated cysts. Depending on cyst number, location, relation to hilus, and the major splenic vessels, the surgical options include aspiration, marsupialization, cystectomy, partial cystectomy (decapsulation), and partial or complete splenectomy. Laparoscopic techniques have now become the standard approach for many conditions, including the splenic cysts, with emphasis on the spleen-preserving minimally invasive operations. We present the successful extended partial laparoscopic decapsulation of a giant epidermoid splenic cyst in a young female patient that, although asymptomatic, was unfortunately followed by complete splenectomy five days later due to a misinterpreted abdominal CT suggesting splenic postoperative ischemia.
Available from: Antonio E Martin-Ucar
- "We had expected that more advanced tumours, bulky nodal masses and awkward tissue manipulation would be more likely to result in accidental splenic injury. It has been previously reported that the cause of iatrogenic trauma to the spleen is most often traction on splenic ligaments or adhesions  . We had a very significant difference in incidence of splenectomy between the different types of operations used at our institution (Table 1). "
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ABSTRACT: There are limited and conflicting data available concerning the incidence of inadvertent splenectomy and its impact on the outcome in patients who have undergone oesophagectomy. The aim of this study is to identify the factors associated with a likelihood of inadvertent splenectomy and its influence on early and long-term outcome in patients having oesophagectomy for oesophageal carcinoma.
A consecutive series of 738 oesophagectomies performed between 1991 and 2004 was analysed. In our practice, the spleen was removed only if damaged intraoperatively. Routine chemo- and immunoprophylaxis would subsequently be used. Multivariate analysis with logistic and Cox models determined significant variables.
Of the 738 oesophagectomies, 48 (6.5%) had splenectomy. Neoadjuvant chemotherapy was administered to a minority of patients; none subsequently had splenectomy. There were significant differences between types of operation (Ivor-Lewis 18 (9.0%), left thoracolaparotomy 14 (9.9%) and left thoracophrenotomy 15 (3.9%), p=0.01). Splenectomy was more common with advanced N stage disease (OR=0.44 [0.20-0.95]; p=0.04). Splenectomy resulted in more blood transfusions (median, 2 units vs 0 units; p=0.03) more anastomotic leaks (7 [14.6%] vs 42 [6.1%]; p=0.02) but not an increase in pulmonary complications (p=0.64) or in-hospital mortality (1 [4.6%] vs 37 [5.4%]; p=0.30). Splenectomy did not significantly affect median survival (551 [332-770] days vs 627 [554-700] days; p=0.63).
Although inadvertent splenectomy increased the morbidity of oesophagectomy, it did not impair survival. Type of operation and advanced N stage are important risks for splenectomy. Though best avoided, most of the consequences of splenectomy can be managed. An unexpected relationship between splenectomy and anastomotic leaks needs further investigation.
Available from: utoronto.ca
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