The spleen is one of the most commonly injured organs in the abdominal cavity. The incidence of splenic injury in abdominal trauma can reach as high as 40–50%; splenic rupture accounts for 20–40% of closed abdominal injuries and approximately 10% of open abdominal injuries. Spleens with chronic pathological changes (e.g., schistosomiasis, malaria, lymphoma) are more prone to rupture. Based on pathological anatomy, splenic rupture can be categorized into three types: central rupture (occurring in the deep parenchyma of the spleen), subcapsular rupture (occurring in the peripheral parenchyma), and true rupture (involving the splenic capsule). In the first two types, the splenic capsule remains intact, limiting the amount of bleeding, and thus clinical signs of intra-abdominal hemorrhage may be absent, making diagnosis more difficult. In such cases, splenic hematomas can eventually be reabsorbed. However, subcapsular hematomas may rupture under external force, leading to massive bleeding and conversion to true splenic rupture, causing an abrupt clinical deterioration. Approximately 85% of splenic ruptures observed in clinical practice are true ruptures. The upper pole and diaphragmatic surface are commonly affected, with fractures of the corresponding ribs often present. When rupture occurs on the visceral surface, especially near the splenic hilum, hilar tears may result, often causing massive bleeding and rapid shock, with fatal outcomes if treatment is delayed.
There is no universally accepted standard for classifying or grading splenic injuries. The following grading system is often applied:
- Grade I: Subcapsular splenic rupture or mild damage to the capsule/parenchyma, with the length of the splenic laceration ≤5.0 cm and depth ≤1.0 cm as observed during surgery.
- Grade II: Splenic laceration with a length >5.0 cm and depth >1.0 cm, without involvement of the hilum, or involvement of segmental vessels.
- Grade III: Rupture extending to the splenic hilum or partial severance of the spleen, or damage to lobar vessels.
- Grade IV: Extensive splenic rupture or damage to the splenic pedicle or main splenic artery/vein.
Management
The principle of managing splenic rupture is "saving life first, preserving the spleen second." Post-splenectomy patients, especially infants and young children, have reduced resistance to infections and may develop overwhelming postsplenectomy infection (OPSI), primarily caused by pneumococcal bacteria, which can be fatal in severe cases. Therefore, spleen-preserving approaches should be considered whenever possible.
Management methods include:
Nonoperative Treatment
In cases without shock or with transient shock that is easily corrected, and where ultrasonography or CT imaging confirms localized, superficial splenic lacerations without injury to other abdominal organs, nonoperative management can be pursued. This requires close monitoring of blood pressure, pulse, abdominal signs, hematocrit levels, and imaging changes. When indications are properly observed, the success rate of this approach is high. Key measures include absolute bed rest for at least one week, fasting, blood transfusion and fluid replacement, as well as the administration of hemostatic agents and antibiotics.
Surgical Intervention Indications
If continued bleeding, concurrent injuries to other organs, or other conditions unsuitable for nonoperative treatment are observed during monitoring, immediate surgical exploration is recommended to avoid delays in treatment.
Surgical Exploration
The full extent of the injury should be thoroughly assessed. For mild injuries (Grade I or II), spleen preservation is feasible. Depending on the type and extent of the injury, techniques such as hemostasis with biological glue, physical coagulation, simple sutures, splenic artery ligation, or partial splenectomy may be employed. If the injury is severe, such as fragmentation of the central portion of the spleen, hilar tears, or the presence of large volumes of non-viable tissue, effective hemostasis via repair becomes impractical, and total splenectomy becomes necessary.
Special Circumstances
In field conditions or in cases of pathological splenic rupture, total splenectomy should be performed.
Delayed Splenic Rupture
This condition refers to large subcapsular hematomas, or localized hematomas encapsulated by the omentum or other surrounding tissues following true splenic rupture, which may rupture under minor external force, causing massive hemorrhage. Known as delayed splenic rupture, it typically occurs within two weeks of the injury, though cases have been reported months later. It necessitates clinical attention. Once identified, immediate surgery is required.