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Surgical technic for treatment of splenic rupture
Surgical Technic for Treatment of Splenic Rupture
Wolfgang Ruf, MD, Honolulu, Hawaii David Pon, Honolulu, Hawaii Virginia Pressler, BA, Honolulu, Hawaii J. Judson McNamara, MD, Honolulu, Hawaii
Splenectomy is known to predispose to subsequent overwhelming infection. Although this problem probably affects persons of all ages, it occurs most often in children. The recognition of this problem has stimulated interest in methods of preserving the spleen if possible in the event of accidental injury. The purpose of this study was to develop a surgical technic to control bleeding after traumatic splenic injury and thus to preserve the spleen. Efforts to control bleeding from an injured spleen with simple suture maneuvers often fail because of the friable soft character of the spleen; therefore we attempted to develop a method to distribute over a larger area the pressure exerted on the tissue by the sutures. This result was achieved using a flexible bolster strip of silicone rubber. Material and Methods The spleen in baboons (papio anubis) of 12 to 16 kg body weight is comparable in weight and size to the spleen in children aged 2 to 3 years. In addition, the histologic structure of the baboon spleen closely resembles that of the human spleen [I]. One dog was included in the study to determine if the technic can be applied to a larger, more vascular splenic mass. Nine baboons and one dog were anesthetized with 6 cc of Sernylane (phencyclidine hydrocholride); anesthesia was maintained with intravenous thiopental, 1 cc every 30 minutes. The animals breathed spontaneously. After venous and arterial cutdowns for intravenous infusions and pressure monitoring, respectively, a 6 to 8 cm incision 2 to 3 cm below the left costal margin was made and the spleen exposed. The traumatic injury consisted of an incision along the transverse axis involving two-thirds of the From the Cardiovascular Research Laboratory. Queen’s Medical Center, University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii. Reprint requests should be addressed to J. Judson McNamara, MD, Harkness Pavilion, 4th Floor, Queen’s Medical Center, 1301 Punchbowl Street, Honolulu, Hawaii 96613.
Volume 137, May 1979
thickness of the spleen. Additionally, two nutrient vessels to the lower pole of the spleen were ligated and divided, and a partial splenectomy was performed along the line of ischemic demarcation. The resulting fish-mouthed margins of the excision site allowed easy closure with minimal mobilization (Figure 1). Two Silastic@ strips 1.8 mm thick, 4 mm wide, and 70 mm long with approximately 14 holes, 5 mm apart, were used as bolsters along the wound edges; the incisions were closed with seven to eight deep U stiches leading through each hole and through the spleen tissue and coming out at the corresponding hole of the opposite strip (Figure 2). Tying up the sutures closed the wound and stopped the bleeding. At the site of resection, two strips were placed along the anterior and posterior wound edges at the surface and the bottom, and the spleen tissue was compressed between bolsters using monofilament sutures on a straight needle (Figure 3). Blood loss was estimated by weighing the sponges. The length and depth of each incision, the weight of the resected pole, and the weight and size of the spleen were recorded. In addition, heart rate and arterial pressure both before and after operation were recorded. After the animals were killed at 7 to 14 days, the spleen was exised after macroscopic inspection and specimens were taken along the longitudinal axis for histologic examination, one from the area of incision and one through the resection edge. Results
Table I shows the data obtained for each animal and the mean values for the variables measured. The larger weight and size of the dog spleen is shown. The blood loss after incision was significantly greater than after resection (47.8 f 13 versus 24 f 9.6 ml, p <0.05). The dog lost more blood during both resection (86.6 ml) and incision (97.4 ml) than any baboon. Bleeding from the incision was usually so severe that it could not be expected to stop spontaneously, yet in some animals bleeding from the spleen tissue
603
Ruf et al
Figure 2. Diagram of the suture technic at incision. Figure 1. Diagram of fhe spleen after resection and incision. Note the wedge-shaped excision out of the spleen after resection.
after resection was minimal. In all experiments the bleeding ceased immediately after the sutures were tied up. Figure 4 shows a representative photograph of the spleen at the end of the operation. When the spleens were examined 7 to 14 days later, no hematoma or signs of blood loss from the operation area were detected. Adhesions to the abdominal wall were noted, and parts of the omentum were attached to the operative sites. A capsule of connective tissue had formed around the strips in the animals that were allowed to survive for 14 days. Histologic examination of eight animals disclosed wound healing with scar formation (Figures 5 and 6). There were no areas of infarction, interstitial hemorrhage, or signs of inflammation. Arterial pressure was 114 f 4.8 mm Hg before and 112 f 5.2 mm Hg after operation, and heart rate was 132 f 8.4 mm Hg before and 142 f 9.2 mm Hg after operation; neither change was significant. Two animals showed formation of an incapsulated abscess around the spleen. The strips were loosely attached to the spleen, floating partially in the pus. Nevertheless, even in these animals, healing with formation of scar tissue had occurred. Comments
Splenectomy is a relatively simple and safe surgical procedure for treatment of splenic injury. Nevertheless, since King and Schumacker [2] first reported their long-term follow-up of 100 children after splenectomy, it has been repeatedly documented that children up to age 3 years have a higher incidence of sepsis and infection and a higher mortality rate than the general population [3-121. This finding emphasized the need for a safe procedure for controlling
604
Figure 3. Diagram of the suture technic at resection.
bleeding from an injured spleen. Several methods have been used to preserve the spleen after injury. Although an increasing number of successful splenorrhaphies or hemisplenectomies or partial resections [13-171 and simple suturing of lacerations of the splenic capsule [16] have been reported, most surgeons generally hesitate to suture lacerations of the spleen because every new stitch generates fresh bleeding, and too often the suture simply cuts through the tissue when tied. Other technics for controlling splenic bleeding involve the use of surface hemostatic agents [18] or the repair of hepatic and splenic injuries with tissue adhesives like cyanomethacrylate [B--24]. Although these technics have been successfully applied even in traumatic hemorrhage in man [21,25], they are predominantly used in stopping superficial oozing from capsular avulsion injuries.
The American Journal of Surgery
Surgical Technic for Splenic Rupture
TABLE I
Individual Experimental Data Incision
Resection Body Weight
Spleen Weight
Spleen Size
(kg)
(gm)
(cm)
1
13.3
52.4
2
13.6
40.9
3
12.3
23.3
4
13.4
16.0
5
11.8
16.4
6
13.6
35.8
7
15.0
34.7
8
11.4
18.8
9
11.4
18.5
10
16.0
70.8
13.2 f 0.5
29.7 f 5.0
Animal no.
(dog) Mean fSEM
5.5 x 4.0 X 1.8 .6.0 X 4.0 X 1.8 4.8 X 4.7 X 1.8 5.5 x 4.0 x 2.0 5.4 X 3.8 X 1.8 6.0 X 4.5 x 2.0 6.0 X 4.0 x 2.0 5.8 X 4.0 X 1.8 6.0 X 4.0 x 2.0 21.0 x 4.0 x 4.0
Weight
Op Time (min)
Blood Loss (ml)
Length (mm)
Depth (mm)
3.8
13
19.0
4.0
1.3
1.4
13
28.0
3.0
2.8
9
6.2
1.1
11
3.4
BloodLoss (ml)
Observation
12
None
Abscess
1.2
12
None
4.0
1.3
10
37
18.7
4.0
1.5
9
12
9
22.7
3.8
0.9
9
26
4.3
13
38.0
3.0
1.5
13
91
3.4
12
9.7
4.0
1.4
7
97
2.1
9
9.4
4.0
1.4
11
26
3.1
7
10.9
4.0
1.6
11
46
13.0
17
86.6
4.0
1.8
13
94
11.3 f 0.9
24 f 9.6
3.9 f 0.1
1.4 f 0.1
10.5 f 0.6
f
3.8 1.7
OpTime (min)
f
Abscess
47 13
Note: Op = operating; SEM = standard error of the mean.
The technic described in this report makes it possible to control bleeding from hemorrhage due to major splenic injury. Silastic is commonly implanted in the body for a variety of reasons, including plastic surgery (breast and ear prostheses), bone and joint surgery (finger-ankle prostheses), and cardiovascular surgery (patches, tubing, pacemakers, and artificial hearts). These experiences, where Silastic often remains in the body for years, and our own results
demonstrate that Silastic is extremely biocompatible. In our experiments, two significant abscesses were observed at the site of the repaired spleen. Both animals had residual infection in the left pleural cavity due to experiments performed before the spleen suture, and thus the pathway of abscess formation in these animals might have been hematologic. The spleens in these two animals were diffusely enlarged
Figure 4. photograph of the sftes at the end of the operation.
Volume137,May1979
605
Ruf et al
Figure 5. Photograph of the tissue of the resection site. Note the formation of scar tissue and the absence any of signs of hematoma Infarction. or The arrow indicates the border bet ween the connective tissue (scar) and the normal spleen tissue. The x’s indicate the position of the strip on both sides of the compressed tissue.
(5 X 9 X 2.8 cm), heavier (52.4 and 34.7 g) than average, and even more friable, probably because of the pleural sepsis. However, at the time of operation the presence of pleural infections was unsuspected. Blood loss during repair of the resection (24 f 9.6 ml) was smaller than during incision repair (47.8 f 13 ml). No infarct of the peripheral portion was observed in any animal after resection or incision, although the incision usually involved two-thirds of the organ. These results are consistent with the observations of Upadhyaya et al [26], who described a significantly greater blood loss after horizontal than after vertical laceration, as well as the development of an infarct in the peripheral portion of the horizontally incised spleen. The authors attributed these findings to the specific segmental blood supply of the spleen, with branches running at right angles to the longitudinal axis. The smaller hemorrhage observed in our study after resection and excision of a wedge of spleen tissue was probably related to the ligation of nutrient vessels before splenic resection. The observation that no necrosis of the peripheral part occurred after the incision supports the theory of segmental blood supply of the spleen [26,27]. Summary Figure 6. ifistoi~ic appearance 1 week after incision, with the formatk3n of scar &sue. The arrow indicates the border between the connective tissue and the normal spleen tissue. The X’s indicate position the the of strip on both sides of the incision.
606
In nine baboons and one dog, a technic for suturing the injured spleen and also providing immediate control of hemorrhage is described. By placing Silastic strips along the wound edges of the
The American Journal of Surgery
Surgical
transverse incision into the spleen and along the surface and bottom edges of the wound after resection, it was possible to control bleeding with deep U sutures passing through the Silastic bolsters and the spleen tissue. The procedure appears to provide a reliable method of salvaging splenic tissue and thus avoiding the hazard of postsplenectomy sepsis.
References 1. Lineback P: The Anatomy of Rhesus Monkey. New York, Hafner, 1961, p 226. 2. King H, Schumacker HB: Spienic studies. I. Susceptibility to infection after splenectomy performed in infancy. Ann Surg 135: 239, 1952. 3. Baifanz JR, Nesbit ME, Jarvis C, Krivit W: Overwhelming sepsis following splenectomy for trauma. J Pediab 88: 458, 1976. 4. Diamond LK: Splenectomy in childhood and the hazard of overwhelming infection. Pediatrics 43: 886, 1969. 5. Ein SH, Shandling B, Simpson JS, Stephens CA, Bandi SK, Biggar WD, Freedman MH: The morbidity and mortality of splenectomy Jn childhood. Ann Surg 185: 307, 1977. 6. Eraklis AJ, Filler RM: Splenectomy in childhood: a review of 1,413 cases. J Pediatr Surg 7: 382, 1972. 7. Horan M, Colebatch JH: Relation between splenectomy and subsequent infection. Arch Dis Child 37: 398, 1962. 8. Lowdon AGR, Stewart RJM, Walker W: Risk of sericus infection following spienectomy. Br h&d J 1: 466, 1966. 9. Lucas RV Jr, Krivit W: Overwhelming infection in children foilowing spienectomy. J Pediatr 57: 185, 1960. 10. Singer DB: Post Splenectomy Sepsis in Perspectives in Pediatric Pathology. Chicago, Yearbook Medical, 1973. pp 285-311. 11. Smith CH, Erlander ME, Schullman I. Stern G: Hazard of severe infection in splenectomized infants and children. Am J Dis Child 92: 507, 1956. 12. Thurman WG: Splenectomy and immunity. Am J Dis Child 105: 138. 1963.
Volume 137, May 1979
Technic
for Splenic Rupture
13. Christo MC: Segmental resections of the spleen. Report on the first eight cases operated on. Hospital (Rio) 62: 575, 1962. 14. def3oer J, Sumner-Smith G, Downie HG: Partial splenectomy technique and some hematoiogic consequences in the dog. J Pediatr Surg 7: 378, 1972. 15. LaMura J, Chung-Fat SP, San Filippo JA: Spienorrhaphy for the treatment of splenic rupture in infants and children. Surgery 81: 497, 1977. 16. Mishalany H: Repair of the ruptured spleen. J Pediatr Surg 9: 175. 1974. 17. Shirkey AL, Wukasch DC, Beall AC, Gordon WB, DeBakey ME: Surgical management of spienic injuries. Am J Surg 108: 630, 1964. 18. Morgenstern L: Splenic and general surgery. Proceedings of Symposium on Microfibrillar Collagen Hemostat, San Francisco, April 4-6, 1975. 19. Collins JA, Pani KC, Lehman RA, Leonard F: Biological substrates and cure rates of cyanoacrylate tissue adhesives. Arch Surg 93: 428, 1966. 20. Heisterkamp CA, Matsumoto T, Hardaway RM: Hemostasis with cyanoacrylate. A new method. Wit Med 134: 1508, 1969. 21. Matsumoto T: Tissue adhesives in fatal hemorrhage from solid organs. Milit Med 132: 951. 1967. 22. Drda R, Wiznitzer T. Goldberg GM. Ezer M: Repair of hepatic and splenic injuries by autoplastic peritoneal patches and butyl-2-cyanoacryiate monomer. An experimental study. J Surg Res 17: 365, 1974. 23. Vasko JS, &ockman SK: Clinical and experimental experiences with plastic adhesives. Ann Surg 162: 123, 1965. 24. Wojnar VS, German Al, Moghul TH. Scarano D: Liver, spleen and kidney wounds. Experimental repair with topical adhesive. Arch Surg 89: 237, 1964. 25. Collins JA, James PM, Levitsky SA, Bredenburg CE, Anderson RW, Leonard FL, Hardaway RM Ill: Cyanoacrylate adhesives as topical hemostatic aids. Il. Clinical use in seven combat casualties. Surgery 65: 260, 1969. 26. Upadhyaya P. Nayak NC, Moitra S: Experimental stuffy of spienic trauma in monkeys. J Pediatr Surg 6: !67. 1971. 27. Huu N: Tenitoires arterieis del la rate. Ii. Etude experimentale; possibilites de resection partielie reglee de la rate. Presse Med64: 1749, 1956.
607
Wolfgang Ruf, MD, Honolulu, Hawaii David Pon, Honolulu, Hawaii Virginia Pressler, BA, Honolulu, Hawaii J. Judson McNamara, MD, Honolulu, Hawaii
Splenectomy is known to predispose to subsequent overwhelming infection. Although this problem probably affects persons of all ages, it occurs most often in children. The recognition of this problem has stimulated interest in methods of preserving the spleen if possible in the event of accidental injury. The purpose of this study was to develop a surgical technic to control bleeding after traumatic splenic injury and thus to preserve the spleen. Efforts to control bleeding from an injured spleen with simple suture maneuvers often fail because of the friable soft character of the spleen; therefore we attempted to develop a method to distribute over a larger area the pressure exerted on the tissue by the sutures. This result was achieved using a flexible bolster strip of silicone rubber. Material and Methods The spleen in baboons (papio anubis) of 12 to 16 kg body weight is comparable in weight and size to the spleen in children aged 2 to 3 years. In addition, the histologic structure of the baboon spleen closely resembles that of the human spleen [I]. One dog was included in the study to determine if the technic can be applied to a larger, more vascular splenic mass. Nine baboons and one dog were anesthetized with 6 cc of Sernylane (phencyclidine hydrocholride); anesthesia was maintained with intravenous thiopental, 1 cc every 30 minutes. The animals breathed spontaneously. After venous and arterial cutdowns for intravenous infusions and pressure monitoring, respectively, a 6 to 8 cm incision 2 to 3 cm below the left costal margin was made and the spleen exposed. The traumatic injury consisted of an incision along the transverse axis involving two-thirds of the From the Cardiovascular Research Laboratory. Queen’s Medical Center, University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii. Reprint requests should be addressed to J. Judson McNamara, MD, Harkness Pavilion, 4th Floor, Queen’s Medical Center, 1301 Punchbowl Street, Honolulu, Hawaii 96613.
Volume 137, May 1979
thickness of the spleen. Additionally, two nutrient vessels to the lower pole of the spleen were ligated and divided, and a partial splenectomy was performed along the line of ischemic demarcation. The resulting fish-mouthed margins of the excision site allowed easy closure with minimal mobilization (Figure 1). Two Silastic@ strips 1.8 mm thick, 4 mm wide, and 70 mm long with approximately 14 holes, 5 mm apart, were used as bolsters along the wound edges; the incisions were closed with seven to eight deep U stiches leading through each hole and through the spleen tissue and coming out at the corresponding hole of the opposite strip (Figure 2). Tying up the sutures closed the wound and stopped the bleeding. At the site of resection, two strips were placed along the anterior and posterior wound edges at the surface and the bottom, and the spleen tissue was compressed between bolsters using monofilament sutures on a straight needle (Figure 3). Blood loss was estimated by weighing the sponges. The length and depth of each incision, the weight of the resected pole, and the weight and size of the spleen were recorded. In addition, heart rate and arterial pressure both before and after operation were recorded. After the animals were killed at 7 to 14 days, the spleen was exised after macroscopic inspection and specimens were taken along the longitudinal axis for histologic examination, one from the area of incision and one through the resection edge. Results
Table I shows the data obtained for each animal and the mean values for the variables measured. The larger weight and size of the dog spleen is shown. The blood loss after incision was significantly greater than after resection (47.8 f 13 versus 24 f 9.6 ml, p <0.05). The dog lost more blood during both resection (86.6 ml) and incision (97.4 ml) than any baboon. Bleeding from the incision was usually so severe that it could not be expected to stop spontaneously, yet in some animals bleeding from the spleen tissue
603
Ruf et al
Figure 2. Diagram of the suture technic at incision. Figure 1. Diagram of fhe spleen after resection and incision. Note the wedge-shaped excision out of the spleen after resection.
after resection was minimal. In all experiments the bleeding ceased immediately after the sutures were tied up. Figure 4 shows a representative photograph of the spleen at the end of the operation. When the spleens were examined 7 to 14 days later, no hematoma or signs of blood loss from the operation area were detected. Adhesions to the abdominal wall were noted, and parts of the omentum were attached to the operative sites. A capsule of connective tissue had formed around the strips in the animals that were allowed to survive for 14 days. Histologic examination of eight animals disclosed wound healing with scar formation (Figures 5 and 6). There were no areas of infarction, interstitial hemorrhage, or signs of inflammation. Arterial pressure was 114 f 4.8 mm Hg before and 112 f 5.2 mm Hg after operation, and heart rate was 132 f 8.4 mm Hg before and 142 f 9.2 mm Hg after operation; neither change was significant. Two animals showed formation of an incapsulated abscess around the spleen. The strips were loosely attached to the spleen, floating partially in the pus. Nevertheless, even in these animals, healing with formation of scar tissue had occurred. Comments
Splenectomy is a relatively simple and safe surgical procedure for treatment of splenic injury. Nevertheless, since King and Schumacker [2] first reported their long-term follow-up of 100 children after splenectomy, it has been repeatedly documented that children up to age 3 years have a higher incidence of sepsis and infection and a higher mortality rate than the general population [3-121. This finding emphasized the need for a safe procedure for controlling
604
Figure 3. Diagram of the suture technic at resection.
bleeding from an injured spleen. Several methods have been used to preserve the spleen after injury. Although an increasing number of successful splenorrhaphies or hemisplenectomies or partial resections [13-171 and simple suturing of lacerations of the splenic capsule [16] have been reported, most surgeons generally hesitate to suture lacerations of the spleen because every new stitch generates fresh bleeding, and too often the suture simply cuts through the tissue when tied. Other technics for controlling splenic bleeding involve the use of surface hemostatic agents [18] or the repair of hepatic and splenic injuries with tissue adhesives like cyanomethacrylate [B--24]. Although these technics have been successfully applied even in traumatic hemorrhage in man [21,25], they are predominantly used in stopping superficial oozing from capsular avulsion injuries.
The American Journal of Surgery
Surgical Technic for Splenic Rupture
TABLE I
Individual Experimental Data Incision
Resection Body Weight
Spleen Weight
Spleen Size
(kg)
(gm)
(cm)
1
13.3
52.4
2
13.6
40.9
3
12.3
23.3
4
13.4
16.0
5
11.8
16.4
6
13.6
35.8
7
15.0
34.7
8
11.4
18.8
9
11.4
18.5
10
16.0
70.8
13.2 f 0.5
29.7 f 5.0
Animal no.
(dog) Mean fSEM
5.5 x 4.0 X 1.8 .6.0 X 4.0 X 1.8 4.8 X 4.7 X 1.8 5.5 x 4.0 x 2.0 5.4 X 3.8 X 1.8 6.0 X 4.5 x 2.0 6.0 X 4.0 x 2.0 5.8 X 4.0 X 1.8 6.0 X 4.0 x 2.0 21.0 x 4.0 x 4.0
Weight
Op Time (min)
Blood Loss (ml)
Length (mm)
Depth (mm)
3.8
13
19.0
4.0
1.3
1.4
13
28.0
3.0
2.8
9
6.2
1.1
11
3.4
BloodLoss (ml)
Observation
12
None
Abscess
1.2
12
None
4.0
1.3
10
37
18.7
4.0
1.5
9
12
9
22.7
3.8
0.9
9
26
4.3
13
38.0
3.0
1.5
13
91
3.4
12
9.7
4.0
1.4
7
97
2.1
9
9.4
4.0
1.4
11
26
3.1
7
10.9
4.0
1.6
11
46
13.0
17
86.6
4.0
1.8
13
94
11.3 f 0.9
24 f 9.6
3.9 f 0.1
1.4 f 0.1
10.5 f 0.6
f
3.8 1.7
OpTime (min)
f
Abscess
47 13
Note: Op = operating; SEM = standard error of the mean.
The technic described in this report makes it possible to control bleeding from hemorrhage due to major splenic injury. Silastic is commonly implanted in the body for a variety of reasons, including plastic surgery (breast and ear prostheses), bone and joint surgery (finger-ankle prostheses), and cardiovascular surgery (patches, tubing, pacemakers, and artificial hearts). These experiences, where Silastic often remains in the body for years, and our own results
demonstrate that Silastic is extremely biocompatible. In our experiments, two significant abscesses were observed at the site of the repaired spleen. Both animals had residual infection in the left pleural cavity due to experiments performed before the spleen suture, and thus the pathway of abscess formation in these animals might have been hematologic. The spleens in these two animals were diffusely enlarged
Figure 4. photograph of the sftes at the end of the operation.
Volume137,May1979
605
Ruf et al
Figure 5. Photograph of the tissue of the resection site. Note the formation of scar tissue and the absence any of signs of hematoma Infarction. or The arrow indicates the border bet ween the connective tissue (scar) and the normal spleen tissue. The x’s indicate the position of the strip on both sides of the compressed tissue.
(5 X 9 X 2.8 cm), heavier (52.4 and 34.7 g) than average, and even more friable, probably because of the pleural sepsis. However, at the time of operation the presence of pleural infections was unsuspected. Blood loss during repair of the resection (24 f 9.6 ml) was smaller than during incision repair (47.8 f 13 ml). No infarct of the peripheral portion was observed in any animal after resection or incision, although the incision usually involved two-thirds of the organ. These results are consistent with the observations of Upadhyaya et al [26], who described a significantly greater blood loss after horizontal than after vertical laceration, as well as the development of an infarct in the peripheral portion of the horizontally incised spleen. The authors attributed these findings to the specific segmental blood supply of the spleen, with branches running at right angles to the longitudinal axis. The smaller hemorrhage observed in our study after resection and excision of a wedge of spleen tissue was probably related to the ligation of nutrient vessels before splenic resection. The observation that no necrosis of the peripheral part occurred after the incision supports the theory of segmental blood supply of the spleen [26,27]. Summary Figure 6. ifistoi~ic appearance 1 week after incision, with the formatk3n of scar &sue. The arrow indicates the border between the connective tissue and the normal spleen tissue. The X’s indicate position the the of strip on both sides of the incision.
606
In nine baboons and one dog, a technic for suturing the injured spleen and also providing immediate control of hemorrhage is described. By placing Silastic strips along the wound edges of the
The American Journal of Surgery
Surgical
transverse incision into the spleen and along the surface and bottom edges of the wound after resection, it was possible to control bleeding with deep U sutures passing through the Silastic bolsters and the spleen tissue. The procedure appears to provide a reliable method of salvaging splenic tissue and thus avoiding the hazard of postsplenectomy sepsis.
References 1. Lineback P: The Anatomy of Rhesus Monkey. New York, Hafner, 1961, p 226. 2. King H, Schumacker HB: Spienic studies. I. Susceptibility to infection after splenectomy performed in infancy. Ann Surg 135: 239, 1952. 3. Baifanz JR, Nesbit ME, Jarvis C, Krivit W: Overwhelming sepsis following splenectomy for trauma. J Pediab 88: 458, 1976. 4. Diamond LK: Splenectomy in childhood and the hazard of overwhelming infection. Pediatrics 43: 886, 1969. 5. Ein SH, Shandling B, Simpson JS, Stephens CA, Bandi SK, Biggar WD, Freedman MH: The morbidity and mortality of splenectomy Jn childhood. Ann Surg 185: 307, 1977. 6. Eraklis AJ, Filler RM: Splenectomy in childhood: a review of 1,413 cases. J Pediatr Surg 7: 382, 1972. 7. Horan M, Colebatch JH: Relation between splenectomy and subsequent infection. Arch Dis Child 37: 398, 1962. 8. Lowdon AGR, Stewart RJM, Walker W: Risk of sericus infection following spienectomy. Br h&d J 1: 466, 1966. 9. Lucas RV Jr, Krivit W: Overwhelming infection in children foilowing spienectomy. J Pediatr 57: 185, 1960. 10. Singer DB: Post Splenectomy Sepsis in Perspectives in Pediatric Pathology. Chicago, Yearbook Medical, 1973. pp 285-311. 11. Smith CH, Erlander ME, Schullman I. Stern G: Hazard of severe infection in splenectomized infants and children. Am J Dis Child 92: 507, 1956. 12. Thurman WG: Splenectomy and immunity. Am J Dis Child 105: 138. 1963.
Volume 137, May 1979
Technic
for Splenic Rupture
13. Christo MC: Segmental resections of the spleen. Report on the first eight cases operated on. Hospital (Rio) 62: 575, 1962. 14. def3oer J, Sumner-Smith G, Downie HG: Partial splenectomy technique and some hematoiogic consequences in the dog. J Pediatr Surg 7: 378, 1972. 15. LaMura J, Chung-Fat SP, San Filippo JA: Spienorrhaphy for the treatment of splenic rupture in infants and children. Surgery 81: 497, 1977. 16. Mishalany H: Repair of the ruptured spleen. J Pediatr Surg 9: 175. 1974. 17. Shirkey AL, Wukasch DC, Beall AC, Gordon WB, DeBakey ME: Surgical management of spienic injuries. Am J Surg 108: 630, 1964. 18. Morgenstern L: Splenic and general surgery. Proceedings of Symposium on Microfibrillar Collagen Hemostat, San Francisco, April 4-6, 1975. 19. Collins JA, Pani KC, Lehman RA, Leonard F: Biological substrates and cure rates of cyanoacrylate tissue adhesives. Arch Surg 93: 428, 1966. 20. Heisterkamp CA, Matsumoto T, Hardaway RM: Hemostasis with cyanoacrylate. A new method. Wit Med 134: 1508, 1969. 21. Matsumoto T: Tissue adhesives in fatal hemorrhage from solid organs. Milit Med 132: 951. 1967. 22. Drda R, Wiznitzer T. Goldberg GM. Ezer M: Repair of hepatic and splenic injuries by autoplastic peritoneal patches and butyl-2-cyanoacryiate monomer. An experimental study. J Surg Res 17: 365, 1974. 23. Vasko JS, &ockman SK: Clinical and experimental experiences with plastic adhesives. Ann Surg 162: 123, 1965. 24. Wojnar VS, German Al, Moghul TH. Scarano D: Liver, spleen and kidney wounds. Experimental repair with topical adhesive. Arch Surg 89: 237, 1964. 25. Collins JA, James PM, Levitsky SA, Bredenburg CE, Anderson RW, Leonard FL, Hardaway RM Ill: Cyanoacrylate adhesives as topical hemostatic aids. Il. Clinical use in seven combat casualties. Surgery 65: 260, 1969. 26. Upadhyaya P. Nayak NC, Moitra S: Experimental stuffy of spienic trauma in monkeys. J Pediatr Surg 6: !67. 1971. 27. Huu N: Tenitoires arterieis del la rate. Ii. Etude experimentale; possibilites de resection partielie reglee de la rate. Presse Med64: 1749, 1956.
607