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Chapter 23

Contents

CHAPTER XXIII

Wounds of the Spleen (341 Casualties)

H. Leon Poole, M. D.

The experience of the 2d Auxiliary Surgical Group with wounds of the spleen was at some variance with previous experiences with these injuries. The frequency was greater, the proportion of multivisceral injuries was larger, and the damage to the organ was more severe than previous records showed, but the case fatality rate was lower, probably because policies of treatment, including operative approaches, were different.

Records of 3,546 abdominal wounds sustained by the American Expeditionary Forces in World War I include only 49 instances1 of injury to the spleen, a frequency of 1.4 percent. Bailey,2 in 1942, reported only 54 splenic injuries among British troops and estimated their frequency at 5.6 percent. Jolly3 reported a percentage of 4.6 injuries of the spleen in a series of 238 cases of abdominal injuries in the Spanish Civil War. Giblin4 reported 3 splenic injuries among 90 abdominal wounds observed during the El Alamein campaign. Splenic injuries occurred in 32 cases, 5.1 percent of the total number, in the two periods covered by Ogilvie's5 report in 1942 on abdominal wounds in the Western Desert.

In contrast to these figures, the surgeons of the 2d Auxiliary Surgical Group observed 341 instances of splenic injury in the 3,154 patients with abdominal injuries treated during 1944 and 1945 (10.8 percent) (table 79). This was greater than the frequency of 6.4 percent (22 of 346 abdominal injuries) recorded by the same surgeons in 1943.

Two hundred and fifty-three of the three hundred and forty-one wounds (74.2 percent) were thoracoabdominal injuries. In their entire experience from 1943 through 1945, the group surgeons treated a total of 903 thoracoabdominal injuries, in which the left diaphragm was involved 468 times. There were 277 wounds of the spleen (59.2 percent) in these 468 cases.

NATURE OF INJURY

The agents causing injury to the spleen were in general of the same type and operated with essentially the same frequency as those responsible for other abdominal injuries. Blast was recorded as the cause of three wounds. Of

1(1) The Medical Department of the United States Army in the World War. Washington: U. S. Government Printing Office, 1927, vol. XI, pt. 1. (2) This number does not include two cases of injury to the spleen among American troops in Russia.
2Bailey, Hamilton: Surgery of Modern Warfare. Edinburgh: E. & S. Livingstone, 1941-42.
3Jolly, Douglas W.: Field Surgery in Total War. New York: Paul B. Hoeber, Inc., 1941.
4Giblin, T.: Abdominal Surgery in the Alamein Campaign. Australian & New Zealand J. Surg. 13:37-64, July 1943.
5Ogilvie, W. H.: Abdominal Wounds in the Western Desert. Surg., Gynec. & Obst. 78: 225-238, March 1944.


292

TABLE 79.-Essential data in 341 injuries of spleen

Type of wound

Cases


Frequency

Deaths

Case fatality rate


In 3,154 abdominal injuries

In 341 splenic injuries

 

 


Percent

Percent

 

 

Univisceral

100

3.2

29.3

12

12.0

Multivisceral

241

7.6

70.7

73

30.3


Total cases

341

10.8

100.0

85

24.9

Thoracoabdominal

253

8.o

74.2

67

26.5

Abdominal

88

2.8

25.8

18

20.5


Total cases

341

10.8

100.0

85

24.9


the 3 non-battle-incurred injuries in the series, 2 were the result of accidental falls and 1 the result of a vehicular accident.

All degrees of damage were present after wounding, ranging from small fissures to complete fragmentation of the body of the spleen. In a few instances, the organ was penetrated. Severe lacerations, penetrations, and perforations produced essentially the same gross lesions as a splenic fracture; that is, irregular rents in the capsule radiating from the track of the causative agent. Injury to the splenic pedicle, without injury to the body of the organ, occurred 8 times and subcapsular hematoma 3 times. From the standpoint of degree, the injuries were classified as severe in 61.3 percent of the cases, as moderate in 29.3 percent, and as slight in only 9.4 percent.

Active hemorrhage from the injured spleen was only occasionally encountered when the abdomen was opened. In these cases, either the pedicle was injured or the body of the organ was seriously damaged. Unless, however, the injury was slight, there was always evidence of previous hemorrhage, and active bleeding usually recurred during the maneuvers incidental to splenectomy. In some instances of thoracosplenic injury in which very little blood was encountered in the peritoneal cavity, an extensive left-sided hemothorax was present. The finding was so commonly associated with injuries of the spleen, in fact, that their presence was suspected whenever a large hemothorax was present in association with missile wounds in the lower portion of the left chest. This phenomenon was probably the result of negative intrapleural pressure, which caused the blood in the upper abdomen to be sucked up through the diaphragmatic rent.

Multivisceral and associated injuries-One hundred of the three hundred and forty-one wounds of the spleen (29.3 percent) were univisceral (table 79). Eighty-two of these occurred in thoracoabdominal injuries. The proportion


293

of univisceral injuries is lower than that reported in other wars. One-third of the 49 splenic injuries recorded among American Expeditionary Forces in World War I were univisceral,6 as were 59.2 percent of the 54 cases reported among British troops by Bailey7 in 1942. Jolly,8 while citing no exact figures, stated that univisceral injuries were "rare" in the Spanish Civil War. Ten of the twenty-two injuries of the spleen treated by the 2d Auxiliary Surgical Group in 1943 were univisceral.

The 241 multivisceral injuries of the spleen in this series were chiefly associated with wounds of the stomach (100 cases), the colon (92 cases), the left kidney (84 cases), the small intestine (53 cases), the liver (50 cases), and the pancreas (22 cases). The jejunum was most frequently involved in wounds of the small intestine, the duodenum being injured only three times. The most commonly involved portions of the colon were the splenic flexure, the left transverse colon, and the upper portion of the descending colon. In a number of instances, two separate portions of the colon were injured.

Other structures were injured with much less frequency. The adrenal gland was injured in three cases and the gallbladder once. Major vascular channels, including the gastroepiploic artery, the left renal vein, the celiac axis, and the thoracic aorta, were involved in four instances. A second wounding agent had made a separate entry in each of the three cases in which the urinary bladder, the sigmoid colon, and the rectum were also injured.

Severe associated injuries, which were themselves multiple in 20 instances, occurred in 128 cases (34.6 percent). The most important were as follows: 53 soft-tissue injuries with 14 deaths, 36 compound fractures with 10 deaths, 13 spinal cord injuries with 6 deaths, and 6 amputations with 1 death. These injuries were often so severe that they contributed materially to the development of shock prior to surgery and to the development of complications after operation.

CLINICAL CONSIDERATIONS

Shock was an extremely common clinical finding in injuries of the spleen (table 80). Its absence, however, could not be taken to indicate that the spleen was not involved in the injury. It was mentioned as not present when the patient was first seen in 78 of 319 recorded cases (24.4 percent), in 48 of which the injury was multivisceral. Mild shock was present in 13.5 percent of the injuries and moderate or severe shock in 62.1 percent.

Tenderness and muscle defense in the left upper quadrant of the abdomen were always present in splenic injury. Pain referred to the left shoulder and to the base of the neck was observed in a few cases. The frequency of extensive left-sided hemothorax has already been commented on.

6See footnote 1, p. 291. 
7
See footnote 2, p. 291. 
8See footnote 3, p. 291.


294

TABLE 80.-Influence of degree of shock and type of wound on case fatality rates in 319 injuries of spleen1

Degree of shock


Univisceral wounds

Multivisceral wounds

Total

Cases

Deaths


Case fatality rate

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

None

30

1

3.3

48

2

4.2

78

3

3.8

Mild

18

1

5.6

25

5

20.0

43

6

14.o

Moderate

29

3

10.3

66

15

22.7

95

18

18.9

Severe

16

7

43.8

87

49

56.3

103

56

54.4


Total

93

12

12.9

226

71

31.4

319

83

26.0


1These data are missing in 22 cases.

TREATMENT

The "surgical abstention" practiced in World War I was never seriously considered as a method of treatment for wounds of the spleen managed in World War II by the 2d Auxiliary Surgical Group. It was the general opinion that splenectomy was the procedure of choice in all cases and that it was imperative in every injury of more than minimal severity. It was performed in 299 of the 341 wounds in this series (87.7 percent) (table 81), in 9 instances with supplemental drainage.

Three of the forty-one patients in whom splenectomy was not performed died on the operating table, before the operation could be completed. In one severe injury in which the splenic vein was severed, surgery was limited to ligation of the vein. In 12 cases (table 81) in which the injury was not severe, drainage, pack, or suture was considered sufficient. In the majority of these cases, though not in all, the lesion consisted merely of a small fissure, with no active hemorrhage and little or no evidence of previous hemorrhage. In the remaining cases, the other visceral injuries or the associated injuries were of such severity that they took precedence over the splenic injury, or it was thought that the addition of splenectomy to the procedures already accomplished would be beyond the limits of the patient's tolerance.

Suture of the spleen, which was carried out in seven cases, proved an inadequate and unsatisfactory measure for the control of active hemorrhage, the prevention of subsequent hemorrhage, and the repair of damage to the spleen; the risk of secondary hemorrhage, in fact, was substantial. Moreover, this measure was as time consuming as splenectomy. The supplementary use of a muscle strip, which was employed in one case, was no more effective than simple suture. Packing of the spleen also proved an ineffective method of management. 

Modern hemostatic agents such as absorbable gelatin sponges were available in overseas theaters during World War II only in limited quantities and


295

for designated purposes. If the situation had been different, the necessity for the removal of only slightly damaged spleens might have been prevented.

TABLE 81.-Methods of treatment in 340 injuries of spleen1

Methods of treatment


Type of wound

Total

Thoracoabdominal


Abdominal

Splenectomy:

 

 

 

    

Cases

224

75

299

    

Deaths

60

13

73

    

Case fatality rate

26.8

17.3

24.4

Other measures:

 

 

 

    

Cases

29

12

41

         

Drainage only

1

2

3

         

Pack

1

1

2

         

Suture

6

1

7

         

No operation on spleen2

21

8

29

    

Deaths

7

5

12

    

Case fatality rate

24.1

41.7

29.3


1The record of 1 patient who died on the operating table does not make clear what had been accomplished when death occurred.
2In the 29 cases in this group, the wound of the spleen, for various reasons, was not attacked. Twenty-one of the operations were performed through a thoracoabdominal incision.

Surgical approach.-The surgical approach to injuries of the spleen in this series (table 82) differed materially from the techniques employed in previously reported series. The most striking departure from earlier methods was the frequent use of a transdiaphragmatic incision in thoracoabdominal wounds. This approach was used in 171 cases, 67.6 percent of the 253 thoracoabdominal injuries and 50.1 percent of the 341 injuries which make up the total series of wounds of the spleen. In the other 82 thoracoabdominal injuries, the abdominal approach was employed in 75 cases (29.6 percent), and both thoracic and abdominal incisions were used in the other 7 cases. Since thoracoabdominal wounds furnished almost three-quarters of the wounds of the spleen, it is not surprising to find that the transthoracic approach was used in so large a proportion of the cases. Anesthesia is an important consideration in this technique, but the ready availability of competent anesthetists, who were provided with adequate equipment, prevented any difficulties in that respect.

The case fatality rates for the transdiaphragmatic and abdominal approaches to thoracoabdominal injuries of the spleen, 19.9 percent against 41.3 percent, are so greatly in favor of the transdiaphragmatic approach as to suggest that all the advantages lay with it. Actually, the marked disparity in the figures should not be interpreted as furnishing a true appraisal of the respective rates by the two techniques. Rather, the lower rate for the transdiaphragmatic


296

TABLE 82.-Surgical approaches in 337 wounds of spleen1

Surgical approach


Type of injury

Total


Thoracoabdominal

Abdominal only

Cases

Deaths


Case fatality rate

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

Transdiaphragmatic

171

34

19.9

0

0

0

171

34

19.9

Abdominal

75

31

41.3

84

18

21.4

159

49

30.8

Transdiaphragmatic and abdominal

7

2

28.6

0

0

0

7

2

28.6


Total

253

67

26.5

84

18

21.4

337

85

25.2


1This information is lacking in 4 cases.

approach is a reflection of the feasibility and ease of intimate surgical exploration of the left upper abdominal quadrant by this incision in appropriate cases. In many of the thoracoabdominal injuries involving the spleen handled by the abdominal route, the multiplicity and location of the visceral injuries made approach from below mandatory. A number of cases showed that it was questionable wisdom to repair the diaphragm from below under these circumstances, although some surgeons followed this plan, on the ground that in a very sick patient it might be better to proceed with celiotomy, in the hope of avoiding two major incisions.

In spite of the advantages of transdiaphragmatic incision in the management of thoracoabdominal injuries involving the spleen, this approach was not used when the thorax was not involved in the wound, for two reasons:

1. It was seldom possible before operation to exclude the presence of other intraperitoneal injuries which could not be properly explored and repaired through the diaphragm.

2. When wounds of the stomach, small intestine, or colon complicated the splenic injury, there was always a risk of contaminating an undamaged pleural cavity during the transdiaphragmatic repair of the gastrointestinal wounds.

Although surgeons were in general agreement, as already mentioned, that the transdiaphragmatic approach was not the best technique for injuries of the spleen confined to the abdomen, there was no agreement as to how this type of injury should be approached. The left rectus and left paramedian incisions were most frequently used. Occasionally the one or the other was extended to the left, but as a rule splenectomy, as well as other operations in the left upper quadrant and other parts of the abdomen, could be accomplished through the original incision. The left subcostal incision and certain transverse incisions also proved satisfactory for splenectomy, though their usefulness


297

was limited by the possibility of other visceral injuries and the fact that full exploration of the peritoneal cavity was difficult or actually impossible through any of them. An additional serious objection, in view of the many instances in which injury to the large bowel complicated the splenic injury, was the fact that all of these incisions utilize the space best adapted for exteriorization of the colon.

POSTOPERATIVE COMPLICATIONS

Although the records of 69 patients, 20.2 percent of the total number, were incomplete, it was possible to determine indirectly, from various sources, that a large proportion of this group was evacuated without the development of postoperative complications. Aside from peritonitis and shock, which were present alone or in combination in many cases at operation, major complications were recorded in 21.0 percent of the 341 splenic injuries. Anuria, wound infection, and atelectasis were the most frequent. Portal thrombosis and secondary hemorrhage from the spleen or splenic pedicle apparently did not occur. There was also no mention of accidental injury to the pancreas or stomach incurred during the operative procedure. Among miscellaneous complications were malaria (3 instances); intestinal obstruction, pneumothorax, anaerobic infection, and psychosis (2 instances each); massive gastric hemorrhage, paroxysmal tachycardia, femoral phlebitis, pelvic abscess, jaundice, decubitus ulcer, cardiac failure, spinal meningitis, pulmonary edema, transfusion reaction, and breakdown of the diaphragmatic repair (1 instance each).

Anuria occurred only in patients who had been in severe shock before or during operation or at both times, or who had received large amounts of blood. Eight of the nine instances of atelectasis occurred in patients with thoracoabdominal injuries. Two of the three patients with infections of the left subphrenic space had complicating injuries of the colon. All three instances of pulmonary embolism were fatal. The first occurred in a patient with a univisceral injury of the spleen. The second patient also had a compound fracture of the femur on one side and a traumatic amputation of the leg on the other. The third had severe complicating injuries of the stomach and liver.

CASE FATALITY RATES

The case fatality rate of 24.9 percent (85 cases) in these 341 injuries of the spleen is considerably lower than the 66.7 percent reported by Giblin9 in 1943 from El Alamein, the 50 percent reported by Ogilvie10 in his combined series from the Western Desert in 1944, and the 67 percent reported in American troops in World War I.11

It is also lower than the 33.3-percent rate reported by the surgeons of the 2d Auxiliary Surgical Group in 1943. Except for the latter series and Ogilvie's

9See footnote 4, p. 291. 
10See footnote 5, p. 291.
11See footnote 1 (1), p. 291.


298

series, it is not clear whether the figures cited do or do not include postevacuation studies.

Bailey12 estimated that the case fatality rate in the univisceral wounds of the spleen in his series was 40 percent. In World War I, the British rate for univisceral injuries was 50 percent and for multivisceral injuries 60 percent.13 In the 2d Auxiliary Surgical Group series, these respective rates were 12.0 and 30.3 percent. The rate rose progressively and rapidly as the number of complicating visceral injuries increased, reaching 61.5 percent when three or more organs were involved in addition to the spleen. The case fatality rate of 24.4 percent following splenectomy in this series is to be compared with the "practically 100 percent" reported for this procedure in World War I.14

Death occurred on the operating table in 10 of 67 patients submitted to splenectomy and occurred in the first 24 hours after operation in 23 others (table 83). Three other patients died on the operating table before splenectomy could be performed.

TABLE 83.-Primary cause of death and time of death in 67 fatalities following splenectomy

Cause


On operating table

To 12 hours

12 to 24 hours

1st day

2d through 3d days

4th through 7th  days

After 7th day

Total

Shock

7

13

8

6

4

0

0

38

Anuria

0

0

0

0

6

5

1

12

Peritonitis

0

0

1

0

1

2

1

5

Pulmonary embolism

0

0

0

0

2

1

0

3

Pneumonia

0

0

0

0

0

1

0

1

Atelectasis

0

0

0

1

0

0

0

1

Other

3

1

0

0

1

2

0

7


Total

10

14

9

7

14

11

2

67


In comparing the case fatality rate (table 81) for splenectomized patients (24.4 percent) with the rate for nonsplenectomized patients (29.3 percent), it must be borne in mind that in most of the latter group operation was omitted because the splenic wound was not considered serious. In nine cases, however, either severe multivisceral or severe associated injuries, or both, contraindicated additional surgery, or the complications which caused death could not be attributed solely to wounds of the spleen.

Shock was the primary cause of death in 38 splenectomized patients (table 83) and in 6 others in whom splenectomy was not performed. Peritonitis,

12See footnote 2, p. 291.
13History of the Great War Based on Official Documents. Medical Services Surgery of the War. London: His Majesty's Stationery Office, 1922, vol. I.
14See footnote 1 (1), p. 291.


299

pneumonia, and atelectasis were responsible for one death each in the nonsplenectomized patients. In the remaining cases in this group, the cause of death was either undetermined or unrecorded.

Additional complications in the fatal cases included the vagovagal reflex after bronchoscopy, transfusion reaction, spinal meningitis, massive empyema, bilateral hemothrax, gastric hemorrhage, and disruption of the diaphragmatic repair complicated by atelectasis and by herniation of the stomach and colon into the chest.

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