Monday, June 25, 2007

Two Spleen...


If the concept of "a little bit pregnant" isn't a useful one, it turns out it IS possible for a spleen to be "a little bit ruptured." It wasn't always the case. Not much more than a couple of decades ago, the algorithm was pretty straightforward: a) see ruptured spleen; b) remove ruptured spleen. No need for a mnemonic. Very surgical. Now, God help us, we have lots of choices. a) see ruptured spleen; b) admit to ICU; c) insert thumb in ass; d) get lots of blood tests. If operating, it's repair spleen, remove part of spleen, remove all of spleen. If removing, slice up a few pieces and stick them somewhere (actually, that's a cool concept, and I liked to do it: theory being it might take hold and provide the immunity unique to the spleen). 

Some of the early work in splenic salvage for trauma was done where I trained, one of the first major designated trauma centers in the US. Here is an early article by a guy I taught a thing or two when I was chief resident and he was junior, and one of my professors. And here is an article that suggests it's all a bunch of b.s. Hard to know. Data suggest it's very much worth the effort in young kids, in whom the immune consequences of splenectomy seem to be greater than in adults. As I said in the previous posts, much of the data on OPSI (Overwhelming Post Splenectomy Infection) is muddied by not always separating those who lost their spleens for trauma from those with hematological problems. Still, I'd say there's general agreement among surgeons, this one included, that operative salvage and non-operative observation need to be in our bag of tricks. Judgment; that damnable, infuriating and aggravating judgment. Is what it takes.

Patient with multiple bad injuries -- head, liver, spleen, couple of femurs -- in shock, getting pint after pint of blood. No brainer: get that thing outta there. Middle school footballer, isolated spleen injury on CT scan, little crack in the surface, small collection of blood, stable normal vital signs. No brainer: park the kid and keep an eye on him (although, assuming he recovers without surgery, telling him how long to take it easy, and how easy, is matter of some uncertainty...) Woman in auto accident, small crack in liver, bleeding slowly from the inferior pole of her spleen, broken leg. Brainer. Toddler ran into coffee table at home, tender belly, squirming, spleen with fracture and collection of blood on CT scan, pulse a little fast. Brainer. And, I assure you, that last one in particular is not at all comfortable. 

The CT scan has both made life more complicated and easier in this regard. Complicated, in that it was the ability of the CT scan to identify injuries without the need for exploration that was part of what raised the tricky issue of non-operative management of an injury. Easier, in that time has allowed the development of CT image criteria by which it's possible to be at least somewhat predictive about what sort of injuries are likely to resolve on their own, and which will need intervention. Yin and yang. Tough stuff.

Word has it -- double sourced, as they say -- that a certain surgeon with an operation named after him often injured the spleen when he did that particular operation. As was routine for even small injuries back then, he'd take it out. AND CHARGE FOR IT! Peeling a bit of the capsule off the spleen occurs not rarely when rooting around in that part of the belly; in the past, lots of spleens were removed because of it. Now, simple application of any of several topical agents -- powders, cloths, glues -- is almost sure to stop the sort of bleeding that that creates. Repair of a bigger injury is a bigger deal: sutures don't get much purchase in that soppy substance. Likewise, deciding when it's hopeless before losing lots of blood in the effort is a skill best learned -- and applied -- early.

If you don't mind joining me for another of my trips to "back in the day," I'll mention that during training, about the worst thing anyone could do in the ER was miss the diagnosis of ruptured spleen. It happened, but not often. In those early days we didn't have CT scans or ultrasounds on which to rely, so the prime directive was always to consider the possibility. In the multiply-injured for whom a laparotomy was inevitable, it wasn't a problem. In the questionable situations, we'd very often do a "diagnostic peritoneal lavage," or DPL, or "peri-dial," in which a catheter is popped into the belly, saline infused then returned, and the fluid analyzed. High tech in the extreme, the criterion by which there was judged to be enough blood in the effluent to warrant laparotomy was inability to read newsprint through the fluid in the clear plastic drain tube (cell counts were done, too. But this was shown to be pretty reliable). Be wrong, you got some 'spleenin to do... 

Our chief at the trauma center would almost never criticize us for having a look and finding nothing; to miss something serious -- that could be cause for the rapid ending of a career. It may be true (it is, I'd say) that CT scans are over-used nowadays, but missed injury in a trauma victim is pretty rare now, because of them, and because of ultrasound, now available in many ERs, used by the ER docs, not radiologists. Progress, for sure.

In doing elective open splenectomy, I liked to wear a headlight. It gets dark up there behind the ribs. Delivering the spleen into the midline, light isn't a problem. It's in the cleaning up after: that empty space where the spleen used to be is high up and back there a ways. Getting it up and out involves dividing the filmy but firm attachments between the lateral surfaces of the spleen and the peritoneal gutter in which it lies. In a dry field, it may be done sharply: long-handled scissors, or extended-length cautery with a nice bend in the tip. When the area is full of blood, you tend to do it dickless (in the sense of not dicking around. And what the heck, this is already an NC-17 blog, right?) Reach in -- in large people, it can be up to the elbow -- paddle the spleen with your fingers, like playing a sticky piano, to sense how bad it is; diggle your fingertips into the peritoneal attachments until it breaks free. Once the spleen is out, one of my favorite -- if simple -- maneuvers is the stuffing of a large sponge into the hole and then slowly rolling it back out, while looking carefully at the raw surfaces left behind as they ooze up from under the sponge, like rising dough. Spotlight, cautery, suction held by the assistant at the wound's edge to inhale the smoke: clean and dry by the time the sponge rolls to the surface.

A belly full of blood changes everything: it's about assessing and getting control as fast as possible, while not missing something important. Suctioning blood in that circumstance is too slow: you slush it out with your hands -- gelatinous black clots sliding across and out of your palms, over your fingers, like sickness itself, as you dip and dip again. And you sponge blood and clots out with pad after pad: keep 'em coming, please. I need a bunch of 'em. Force wads of dry pads into the corners while you look at the bowels, the retroperitoneum (where missed injuries are highly lethal), then come back to where the action seems to be. A broken spleen doesn't usually spurt, it oozes. Clots and liquid, in a sorry soup. Venous blood is darker than arterial; if the patient is in shock, it gets so purple it's almost black, and that's a scary sight. Rising through and around clots, it's like those satellite views of a muddy river delta: colors swirling and unmixed. It could be beautiful if it weren't so threatening. Seems like some posts on trauma might be worth considering at this point...

13 comments:

rlbates said...

Nice explanation. And I remember those days of DPL so you wouldn't miss a spenic injury. Dates us, doesn't it?

Tom said...

So, now I have learned from your blog as well as a few other medblogs that I can do just fine without my spleen, gallbladder, and appendix. I'm curious-just how many body parts could I function without? If you stripped the human body down to its most essential needs, just how many bits are superfluous?

Sid Schwab said...

tom: good question. You could lose at least half your liver, one kidney, your stomach (although you'd need vitamin B12 injections), your pancreas (although you'd have to take insulin and digestive enzymes), over half your small intestine, all of your large intestine, one lung. Thyroid (take pills), adrenals (take pills). Thymus (after infancy).

SeaSpray said...

Sounds like a dramatic surgery.

Good question Tom and interesting answers.

SeaSpray said...

Dr S. - What happens to the adrenal gland if a kidney is removed?

Sid Schwab said...

usually it's left in place, which isn't hard to do...

Lynn Price said...

Sid, I've had a number of people tell me I could do quite nicely without my brain. Tell me they're kidding.

Sid Schwab said...

lynn: hard to know, without trying...

Anonymous said...

Allow me to point out that the genitals only cost money -- have you looked at movie ticket prices or a decent restaurant's menu lately? -- and that the extremities are perfectly superfluous once the orthopaedic surgeon's new yacht is paid off. :-)

Regarding the head, politicians on both sides of the aisle, along with the ankle-biting bottom-feeders, prove that it can be eliminated, te be replaces with a hairdryer to generate hot air.

Cheers,
Felix.

Sid Schwab said...

I'd actually considered mentioning the limbs, but didn't because it seemed too much like a surgeon... hadn't thought about the genitals, though. Says something, I guess...

enrico said...

Nothing to say here except I enjoyed the post. And as always, I have no idea how surgeons on the whole manage to do so much in such tight spaces. I'm a pianist and no stranger finger/wrist dexterity, but the positioning of the spleen, trying to get your hand around the left side, butting up against the ribs, not nicking this or that, it just seems so frustrating to constantly work in such close quarters.

The tradeoff for the size of incision (for the exposure/mobilization of the organ) vs. the patient's healing/comfort and all the variables on each side (infection, etc.) -- I'm getting stressed just thinking about it. :P

makeminetrauma said...

Wonderful. You have such a gift for descriptive phrases that create vivid visuals. You put me right back in the OR every time, which must be why I have become addicted to your blog. The free medical education is just the icing on the cake.
I am not new a new reader, just a new commenter.
I had a mole removed once.....

buckeye surgeon said...

Non-operative treatment rules the day in Trauma surgery nowadays. Even in busy urban trauma centers, fewer patients end up in the OR. Trauma surgeons function more as critical care specialists rather than operative surgeons. In many centers, we've seen the development of a concept called "Emergency General Surgery" as a way for trauma surgeons to keep sharp. All late night appendices and free air cases go to the in-house trauma attending. Strange concept. As a practicing general surgeon, isn't that what I'm supposed to be doing? Anyway, the issue raises the question; is trauma a viable sub-specialty in the realm of surgery given that hardly any actual surgery is ever done?