Traumatic spleen rupture

　　1. Etiology

　　The spleen is very fragile in nature and rich in blood supply. When subjected to external force, it is prone to rupture and bleeding. In clinical practice, spleen injuries or ruptures caused by direct or indirect external force are called traumatic or injurious spleen rupture. Traumatic spleen rupture can be further divided into open and closed types. In addition, there are spontaneous spleen rupture and iatrogenic spleen rupture.

　　Open traumatic spleen rupture is often caused by stab wounds or shrapnel injuries, and is often accompanied by other organ injuries. Closed traumatic spleen rupture is caused by direct or indirect violence such as falling, boxing, or traffic accidents, and is the most common type of abdominal injury in clinical practice.

　　Second, pathogenesis

　　The high incidence of splenic injuries can be explained by their mechanism of injury. In 1965, Gieseler's experiment proved that not only direct trauma to the left abdomen can cause splenic injury, but indirect blows can also cause splenic injuries. The close adhesion of the spleen to the gastric wall and the tight fixation of the surrounding ligaments limit the sudden movement of the spleen, especially when the pressure in the abdominal cavity increases dramatically. The upper and lower poles of the spleen are very narrow, and its diaphragmatic surface is curved into an extremely convex shape, while its base is excessively extended, making the spleen extremely prone to transverse rupture. During trauma, the pressure inside the spleen and inside the stomach both increase, and the increased blood storage inside the spleen also increases its risk of injury.

　　Indirect冲击力 during pregnancy may also cause sudden injury to the spleen, even a small hematoma may cause rupture of the splenic parenchyma in the later stages of pregnancy. The expansion of the uterus increases the pressure in the abdominal cavity, raising the spleen further, and it is tightly fixed by surrounding ligaments. In this situation, even a slight increase in abdominal pressure may cause the spleen to bend or rupture even more.

　　Extreme changes in the tensile force of the ligaments radiating from the spleen surface can also lead to splenic injury. This mechanism of injury can explain spleen injuries during the process of rapid deceleration. Direct trauma, such as trauma to the upper left quadrant of the abdomen, plays a secondary role in the causes of splenic injuries. When trauma occurs, during the moment of inhalation, the spleen is easily injured as it moves towards the caudal and lateral sides,脱离了周围胸廓的保护，and is in the direction of force. The contraction of the left costal arch bruises the spleen. Generally, only the elastic thoracic cage of children and young adults is susceptible to this, and it often occurs with rib fractures, where rib fragments can also directly pierce the spleen. Compared with abdominal blunt trauma, the occurrence of splenic injuries caused by penetrating injuries such as incisions, stabbings, and gunshot wounds is much lower. All incisions below the sixth rib on the left side, including the entrance or exit of bullets, should be considered for the possibility of splenic injury and injury to other abdominal organs. Even if the entrance and exit of gunshot wounds are far from the upper left quadrant of the abdomen, splenic injury may occur. The decelerating bullet head often travels a considerable distance subcutaneously or subfascially upon entering the abdominal cavity, and a bullet with high kinetic energy often changes direction due to surrounding tissues (such as peritoneal tissue), leading to an entirely unexpected process that may injure the spleen or other organs.

　　Most splenic lacerations are perpendicular to the spleen axis, along the edges between splenic segments, making it difficult to damage the major blood vessels near the hilum of the spleen. There is rarely any injury to the splenic segmental vessels, and such transverse lacerations generally result in moderate bleeding volume and a relatively short bleeding time. Longitudinal lacerations cross the boundaries between splenic segments and often cause severe bleeding; 40% of splenic injuries are multiple lacerations. Splenic injuries are classified according to the degree of injury, ranging from small lacerations of the spleen capsule to complete rupture of the spleen. Only one-third of the lacerations occur on the convex surface of the spleen, while other injuries often involve damage to the hilum of the spleen. Lacerations on the凹面 of the spleen are often more dangerous than those on the diaphragmatic surface because the hilum is enveloped by a thick layer of splenic parenchyma and splenic vessels.

　　If the spleen parenchyma is injured but the spleen capsule has not been ruptured, a subcapsular hematoma will occur, which is not easily detected until the spleen is injured and a large amount of blood accumulates in the peritoneal cavity. If the spleen capsule can withstand pressure, the hematoma will slowly absorb and form fibrous scars or pseudocysts. Bleeding from some small lacerations often stops spontaneously, while large amounts of peritoneal fluid can accumulate in the splenic凹面 and large vascular lacerations, which can be quickly diagnosed due to accompanying symptoms of acute blood volume decrease and shock. However, bleeding from such bleeding or larger vascular rupture can occasionally stop spontaneously, which may be due to some of the following reasons: decreased pressure and blood pressure in the spleen vessels, clot formation, omentum occlusion, retraction of the vascular endothelium, and thrombosis within the vascular lumen. The rechanneling of intrasplenic blood flow may also play a certain role, as there are cases of arterial and venous shunting. Sometimes, especially after spleen injury in children and young adults, bleeding may stop during surgery. Therefore, although the spleen has been extensively damaged, a relatively stable circulation may appear sometimes, but rebleeding may occur at any time, especially after large amounts of fluid resuscitation.

　　1. Classification of spleen rupture

　　(1) Central rupture: deep rupture of the spleen parenchyma, with the superficial parenchyma and spleen capsule intact, and a hematoma forming in the spleen marrow, causing the spleen to gradually enlarge and slightly bulge. There are three outcomes for this type of spleen rupture: first, uncontrolled bleeding, continuous enlargement of the hematoma, and worsening of the laceration to the point of rupture; second, secondary infection of the hematoma; third, the hematoma can gradually absorb or become organized.

　　(2) Subcapsular rupture: partial rupture of the peripheral part of the subcapsular spleen parenchyma, with the capsule still intact, causing blood to accumulate under the capsule.

　　(3) True rupture: simultaneous rupture of the splenic capsule and parenchyma, resulting in massive intra-abdominal hemorrhage. This type of rupture is the most common, accounting for more than 85% of spleen ruptures.

　　2. The grading of spleen rupture is intended to more rationally handle injuries of different degrees.

　　(1) Based on ultrasound, CT, intraoperative DSA, and clinical manifestations, the American Association for the Surgery of Trauma (AAST) published the organ injury grading standard in 1989, categorizing spleen rupture into the following 5 grades:

　　Grade 1: Subcapsular hematoma without expansion, surface area less than 10%, capsular tear without bleeding, depth less than 1cm.

　　Grade 2: Subcapsular hematoma without expansion, surface area 10% to 50%, or intraparenchymal hematoma without expansion, hematoma diameter less than 5cm, capsular tear with active bleeding, or intraparenchymal laceration depth 1 to 3cm, but without injury to the splenic trabecular vessels.

　　Grade 3: Subcapsular hematoma is expansile or the surface area is greater than 50%, subcapsular hematoma rupture with active bleeding, intraparenchymal hematoma greater than 5cm or expansile, or实质裂伤深度大于3cm or injury to the splenic trabecular vessels but without loss of blood supply to the splenic segments.

　　Grade 4: Rupture of intraparenchymal hematoma with active bleeding, laceration involving splenic segments or splenic hilum vessels, resulting in large pieces of spleen tissue (more than 25%) losing blood supply.

　　Grade 5: Complete rupture of the spleen, injury to the splenic hilum vessels, and complete loss of blood supply to the entire spleen.

　　(2) The 6th National Academic Symposium on Splenic Surgery held in Tianjin in September 2000 approved the grading standard for the degree of spleen injury. The Splenic Surgery Group and Collaborative Group of the Chinese Society of Surgery recommend it as a national unified standard.

　　Grade 1: subcapsular rupture of the spleen or mild injury to the capsule and substance, with the length of spleen injury seen during surgery ≤5cm, depth ≤1cm.

　　Grade 2: total length of splenic laceration is 5cm, depth ≥1cm, but the hilum is not involved, or splenic segmental vessels are damaged.

　　Grade 3: injury to the hilum of the spleen or partial transection of the spleen, or injury to the splenic lobe vessels.

　　Grade 4: extensive splenic rupture or injury to the splenic pedicle, splenic artery, or splenic vein trunk.

　　Splenic rupture can be associated with various multiple injuries. According to statistics, in closed abdominal or lower chest injuries, only the spleen is involved in 30%; while injuries to other organs or tissues are more common. Multiple injuries associated with splenic rupture can occur within or outside the abdominal cavity, with the incidence rate decreasing in order of chest (including rib fractures), kidney, spinal cord, liver, lung, brain, small intestine, large intestine, pancreas, and stomach, etc. The misdiagnosis rate of multiple injuries associated with splenic rupture is 11% to 66%, and the condition is usually severe, complex, with many complications, and a high mortality rate. According to statistics, the mortality rate of isolated splenic rupture is 10%; with other organ injuries, it is 25%; with multiple injuries involving ≥4 organs, it is 45.5%; and with more than 5 organs, it is 100%.

　　1. Symptoms and signs of splenic rupture

　　The degree and speed of bleeding, the nature and severity of the rupture, and the presence of injuries to other organs, such as associated injuries or multiple injuries, can result in different manifestations. Patients with subcapsular rupture or central rupture mainly present with left upper abdominal pain, which can be exacerbated during respiration. At the same time, the spleen is often enlarged, with tenderness and generally no obvious abdominal muscle tension, and few patients experience nausea or vomiting. Other signs of internal bleeding are also usually absent. If an incomplete rupture progresses to a complete rupture, acute symptoms will appear rapidly, and the condition will deteriorate quickly. Once a complete rupture occurs, the first symptom will be peritoneal irritation. In cases of slow and moderate bleeding, abdominal pain may be limited to the left hypochondrium. If the bleeding is more extensive and spreads to the entire abdomen, it can cause diffuse abdominal pain, but the left hypochondrium remains the most significant. Reflected vomiting is common, especially in the early stages of the disease. Sometimes, due to blood stimulation of the left diaphragm, it can cause referred pain in the left shoulder (the distribution area of the fourth cervical nerve), which is usually exacerbated during deep breathing and is called Kehr's sign. Subsequently, the patient may develop obvious symptoms of internal bleeding within a short period, such as thirst, palpitations, tinnitus, weakness of the limbs, rapid breathing, decreased blood pressure, and confusion; severe cases may die within a short period due to excessive bleeding and circulatory failure. Physical examination may reveal general tenderness and muscle rigidity of the abdominal wall, most pronounced in the left upper abdomen. The spleen dullness area in the left hypochondrium is often enlarged as well. If there is a large amount of blood accumulated in the abdomen, mobile dullness can also be found. However, due to the presence of clotting masses around the spleen, when the patient lies on the left side, the right腰部 may present a hollow sound, while when lying on the right side, the left腰部 often presents a fixed dullness, known as Ballance's sign.

　　2. Classification

　　In addition to spontaneous splenic rupture, generally, traumatic splenic rupture can be divided into 3 types clinically:

　　1. Immediate splenic rupture:

　　It is what is usually called splenic rupture in clinical practice, accounting for 80% to 90% of traumatic splenic rupture, where the spleen ruptures immediately during the trauma, leading to intra-abdominal hemorrhage, hemorrhagic shock, and in severe cases, death can occur within a short period due to acute massive hemorrhage.

　　2. Delayed (delayed) splenic rupture:

　　It is a special type of traumatic splenic rupture, accounting for about 10% of closed splenic rupture, with a symptom-free period of more than 48 hours between trauma and splenic rupture and hemorrhage (Baudet latent period).

　　3. Latent splenic rupture:

　　After splenic trauma, there is only subcapsular hemorrhage or minor lacerations, symptoms are not obvious, and even there is no clear history of trauma to trace back to, making diagnosis difficult to confirm. It is not diagnosed until symptoms such as anemia, a mass in the upper left abdomen, a splenic pseudocyst or rupture, or massive intra-abdominal hemorrhage appear. This type is rare, accounting for less than 1% of closed splenic rupture.

　　In general, patients with splenic rupture can have the following 3 stages clinically:

　　1. Early shock stage:

　　It is a reflexive shock after abdominal trauma.

　　2. Latent stage:

　　The patient has recovered from the early shock, but the symptoms of internal bleeding are not yet obvious. This stage can vary in length, from 3 to 4 hours, generally more than 10 hours to 3 to 5 days, and in some cases, such as subcapsular hemorrhage or minor lacerations, it can last up to 2 to 3 weeks before entering the stage of obvious bleeding. During this period, the patient's mild shock symptoms have passed, and severe bleeding symptoms have not yet appeared, so the situation is generally good; except for pain, tenderness, and muscle spasm in the left hypochondrium, there is only a slight local mass, and the abdomen is slightly distended; radiation pain in the left shoulder is not common. However, if a timely diagnosis cannot be made at this time, it is actually a major reason for the poor prognosis of most patients. Therefore, it is necessary to be cautious and not to be careless or make mistakes due to the unclear history of trauma, the patient's condition being good, without obvious symptoms of internal bleeding, and without typical Kehr sign or Ballance sign.

　　3. Late bleeding stage:

　　This diagnosis is without doubt at this stage, the bleeding symptoms and signs are very obvious, the patient's condition has deteriorated, and the prognosis is relatively serious.

　　Open wounds caused by sharp objects are more common during war times. Regardless of where bullets or shrapnel enter the abdominal cavity, they may injure the spleen. Such open wounds are often accompanied by other visceral injuries and require early laparotomy surgery. It is difficult and not necessary to diagnose whether there is a splenic rupture before surgery. It should be noted that abdominal injuries with symptoms of internal hemorrhage are more urgent for surgery than those with simple hollow organ injuries.

　　1. Develop good living habits, quit smoking and limit alcohol intake. Smoking, according to the World Health Organization's prediction, if people stop smoking, the world's cancer will decrease by 1/3 after 5 years; secondly, do not drink excessively. Cigarettes and alcohol are extremely acidic substances, and people who smoke and drink for a long time are prone to acidic体质.

　　2. Do not eat too much salty and spicy food, do not eat overheated, cold, expired, and deteriorated food; for the elderly, the weak, or those with certain genetic predisposition to diseases, eat some cancer-preventive foods and alkaline foods with high alkalinity according to circumstances to maintain a good mental state.

　　Blood routine tests often show progressive decline in red blood cells and hemoglobin, while white blood cells can increase to about 12×10^9/L, which is a response to acute hemorrhage.

　　1. Abdominal X-ray examination

　　Abdominal X-ray films can be taken for injured patients to observe changes in the contour, shape, size, and position of the spleen, along with the image of rib fracture, which is very helpful for diagnosing splenic injury.

　　2. Abdominal ultrasound examination

　　When the spleen is injured, it can show irregular spleen contours, image interruption, suspected subcapsular hematoma, and visible progressive splenic enlargement and double contour imaging. At the same time, it can show more than 100ml of effusion in the abdominal cavity. When the spleen capsule breaks, the surface of the spleen is not smooth and even, with interrupted continuity, and a strip-like dark band can be palpated. The splenic parenchyma echo is still uniform, and unequal amounts of fluid dark areas can be detected around the spleen, in the anterior liver, between the liver and kidney, and in the iliac fossa. When both the capsule and the splenic parenchyma are broken, the spleen capsule break can be seen, and one or more irregular hypoechogenic areas can be detected within the splenic parenchyma. Around the spleen, in front of the liver, between the liver and kidney, and in the iliac fossa, a large amount of fluid dark areas can be detected. In the case of delayed splenic rupture, it requires multiple ultrasound examinations to detect parenchymal rupture.

　　3. Abdominal CT examination

　　CT can determine the presence and extent of splenic injury with very high sensitivity and specificity. Subcapsular hematoma under the spleen capsule appears as localized subcapsular hemorrhage, resembling a crescent or half-moon shape, accompanied by corresponding parenchymal compression flattening or serration. The density of the initial hematoma is approximately equal to that of the spleen, and the CT value of hematoma exceeding 10 days gradually decreases, becoming lower than the density of the splenic parenchyma. Enhanced CT shows splenic parenchyma enhancement while the hematoma remains unchanged, forming a significant density difference. The blood clot with equal density on the unenhanced scan is an important supplementary examination method. Hematomas within the splenic parenchyma often appear as circular or oval areas of isodensity or low density. A single splenic laceration can be seen as a linear low-density area within the enhanced splenic parenchyma. Multiple splenic lacerations often manifest as a粉碎性 spleen, presenting as multiple low-density areas, usually involving the splenic capsule, and accompanied by abdominal hemorrhage. The non-enhanced part of the spleen suggests injury or arterial embolism of the supplying segment of the spleen.

　　Splenic laceration is shown as a linear, patchy, or irregular low-density shadow within the spleen, often accompanied by signs of peritoneal hemorrhage. The density of intrasplenic hematoma changes over time. Fresh hematoma is isointense or slightly higher in density. As time goes on, hemoglobin dissolution and the increase in hematoma water volume lead to a gradual decrease in hematoma density, making it easier to diagnose. Subcapsular hematoma of the spleen shows isointense or slightly higher than splenic density on CT, similar to intrasplenic isointense hematoma. CT plain scan is prone to missed diagnosis, and enhanced CT is required for diagnosis. Literature suggests that approximately 1% to 15% of patients with splenic injury show normal findings on immediate CT scans after injury, while CT scans performed 48 hours later can reveal splenic injury signs. Generally, these latent periods are around 3 weeks, with a few lasting several months or even years. CT scans not only have sensitivity and specificity for diagnosing splenic injury but can also further estimate the degree of injury, thereby guiding the formulation of clinical treatment plans and predicting the prognosis of patients.

　　4. Diagnostic peritoneal lavage

　　Although it cannot indicate the location of the injury or the degree of injury, it is very helpful in determining the indications for laparotomy exploration. The diagnostic accuracy rate reaches over 90%. Due to the widespread application of ultrasound and CT, peritoneal puncture seems to be limited in application.

　　5. Radionuclide imaging examination

　　MRI is generally not used for emergency patient examinations due to reasons such as long imaging time and difficulties in approaching MRI machines with certain rescue equipment. However, after the condition is stable or when the condition is complex, especially when checking for bleeding and hematoma, MRI is a relatively effective examination method. The various pathological changes after splenic injury are reflected on MRI images similar to CT findings. At the same time, MRI can perform coronal and sagittal imaging, which is more comprehensive than CT in displaying overall changes and other organ injuries related to abdominal trauma. The changes in MRI signal intensity of bleeding are related to the time of bleeding. In the early stage of intrasplenic hemorrhage and hematoma formation, the bleeding area shows isointensity on T1-weighted imaging and low signal area on T2-weighted imaging. When bleeding occurs between 3 to 14 days, the T1-weighted image shows white high-intensity signal, and the T2-weighted image also shows high-intensity images.

　　6. Selective mesenteric arteriography

　　This is an invasive examination with high specificity and accuracy, which can not only make a specific and clear diagnosis but can also perform selective splenic artery embolization treatment at the same time.

　　1. What kind of food is good for the body after traumatic splenic rupture: Rational diet. It is recommended to eat nutritious, easily digestible, and easy-to-absorb foods, have small and frequent meals, light in taste, eat more fresh vegetables, fruits, beans, and mushrooms, eat more soup and stewed dishes, and can eat pork, duck meat, and pigeon meat. You can also eat dates, peanuts, red beans, and so on.

　　2. Foods to avoid for traumatic spleen rupture: Do not eat beef, mutton, dog meat, chicken, fish and shrimp, chili and other spicy foods, do not eat greasy, fried, pickled, smoked foods, do not eat cold foods, etc.

　　1. Treatment

　　In the past, it was believed one-sidedly that 'the spleen is not an essential organ for life', and the spleen has a rich blood supply, fragile tissue, and difficult hemostasis. For a long time, splenectomy has been the only choice for treating various types of splenic rupture. However, modern spleen research has proven that the spleen has multiple functions, especially the understanding of the risk of post-splenectomy severe infection (OPSI) has led surgeons to gradually form the concept of 'spleen preservation' and establish the principles for the treatment of splenic trauma: saving life first, preserving the spleen second; the younger the age, the more inclined to splenic preservation surgery; the quality and quantity of the preserved spleen must have sufficient splenic function; appropriate splenic preservation surgery or the combined application of several methods should be selected according to the type and severity of the injury.

　　1. Conservative treatment

　　For some patients with subcapsular or superficial spleen rupture, if the bleeding is not severe, vital signs are stable, and there are no associated injuries, conservative treatment can be carried out under strict dynamic observation. The specific indications are:

　　(1) According to the AAST classification (or the classification of the Chinese Splenic Surgery Group) standard, it is grade I;

　　(2) Age less than 50 years;

　　(3) No other abdominal organ injuries;

　　(4) No pathological splenic rupture, no abnormalities in coagulation function;

　　(5) Hemodynamic stability, blood transfusion volume not exceeding 400-800ml;

　　(6) Dynamic monitoring by imaging (ultrasound, CT) shows that there is no expansion of hematoma, no increase in blood clots, or very little contrast agent leakage from splenic artery angiography;

　　(7) Have the conditions for transfer surgery and intensive care. In the above indications, hemodynamic stability is the most important content, and it is also a prerequisite for deciding whether to perform conservative treatment. In recent years, with the accumulation of experience, it has been found that some AAST level II spleen injuries can also be cured without surgery, and the age can be relaxed to 55 years or even higher. However, it is still necessary to adopt a cautious attitude towards conservative treatment for splenic trauma, especially in medium and small hospitals where monitoring methods and rescue measures are not sufficient, and it is not advisable to advocate excessively, even in large hospitals with conditions. Because in terms of saving lives, splenic trauma surgery is more reliable than conservative treatment with less risk. The main measures of conservative treatment include: absolute bed rest, fasting and water, gastrointestinal decompression, blood transfusion and fluid replacement, the use of hemostatic drugs and antibiotics, etc. After about 2-3 weeks, it is possible to get out of bed for slight activity, and it should be avoided to engage in vigorous activities within 3 months after recovery.

　　2. Splenic preservation surgery

　　There are many methods for splenic preservation surgery, and the operator needs to make specific choices based on the condition of splenic trauma, the conditions of the hospital, and the operator's own experience. It is necessary to retain not less than 1/3 of the spleen volume and good blood supply of a normal person in order to effectively maintain the normal function of the spleen.

　　(1) Local physical or biological glue hemostasis technique: For those with small and superficial grade I splenic injuries, absorbable gelatin sponge can be used to fill and compress the rupture site after laparotomy to stop bleeding. It can also be stopped by biological glue, microwave or argon gas coagulation, spleen rupture ligation, or mesh hemostasis surgery, etc. If the indications are appropriately selected, it is indeed a reliable and simple method of treatment.

　　(2) Suture repair: Suture repair can be performed for grade I and II splenic ruptures with small incisions and without injury to large blood vessels. The reason is that the spleen rupture is often transverse, consistent with the direction of the intrasplenic large blood vessels, and does not involve the main trunk of the interlobar vessels but rather the trabecular vessels. Therefore, for patients with small incisions, local physical or biological glue hemostasis technology is ineffective, and there are no hemodynamic changes, the use of suture repair technology for hemostasis is relatively safe and effective. However, this procedure must be determined based on the patient's intraoperative bleeding status, the presence of other complications, and the emergency surgery conditions. For critically ill patients with poor hemostasis effect, poor surgical skills, and without emphasizing suture repair, otherwise, it may lead to excessive blood loss and endanger the patient's life.

　　(3) Spleen artery ligation or intraoperative embolization: Spleen artery ligation can reduce the pressure of the spleen artery by 50 to 60 mmHg, making the spleen smaller in volume and more tenacious, which is convenient for suturing and achieves a more effective hemostasis. After spleen artery ligation, it usually does not cause splenic infarction, as the blood supply can be compensated by the surrounding ligamentous vessels. However, some studies have found that after ligation of the main trunk of the spleen artery, the spleen cannot clear Streptococcus pneumoniae from the blood flow, and there is still a possibility of life-threatening infection. Intraoperative splenic artery embolization is rarely used in clinical practice due to the difficulty in controlling the embolization range and the potential for complications such as ectopic embolism, splenic infarction, and infection. X-ray fluoroscopic splenic artery embolization (SAE) via femoral artery puncture and catheter placement is also known as medical splenectomy and should belong to the category of conservative treatment. Although some successful experiences have been accumulated in the treatment of splenic injuries in recent years, the incidence of complications such as bleeding and infection is still high, and it often requires embolization of the main trunk of the spleen artery to effectively stop bleeding, and its therapeutic value is still controversial.

　　(4) Partial splenectomy: Suitable for grade II and partial grade III splenic rupture, and those with good blood supply to part of the spleen. It is particularly suitable for cases where a part of the spleen has ruptured severely and is difficult to retain. After laparotomy, the blood vessels of the damaged part of the spleen are freed and ligated according to the distribution of the spleen segments. A clear demarcation line appears between the normal tissue and the damaged part, and a large needle and absorbable suture are used to perform intermittent or continuous locking suture ligatures at the demarcation point, followed by the removal of the non-vital part of the spleen using an anatomical knife, electrical knife, laser, or ultrasonic aspirator (CUSA). Bleeding encountered at the断面 should be stopped firmly, and finally, a piece of omentum tissue is used to cover the incision. In recent years, microwave tissue coagulation technology has been used to form a coagulation zone along the planned resection line of the spleen, followed by the separation and resection of the injured or diseased part of the spleen with a surgical knife. This method is simple, stops bleeding effectively, and has satisfactory results, making it valuable for further application.

　　(5) Laparoscopic spleen-preserving surgery: Laparoscopy not only allows for clear diagnosis but also facilitates the determination of the degree of injury. Routine continuous insufflation with carbon dioxide, maintaining a pressure of 12-14mmHg, is used to first understand the degree of spleen injury and the condition of other abdominal organs. Then, the accumulated blood around the spleen is aspirated, and the spleen is exposed. For Grade I and II ruptures, biological glue spraying, electrocoagulation for hemostasis, and packing with hemostatic sponges can be used; for Grade III spleen rupture, a comprehensive hemostasis method should be adopted, which may involve packing the orifice with a vascular omentum and then suturing. After hemostasis, observe for 15 minutes; if there is no bleeding, place a drainage tube around the spleen to complete the surgery. Laparoscopic spleen-preserving surgery is mainly applicable to young patients with mild clinical manifestations and related examinations, identifying mild spleen injury, stable hemodynamics, and without combined or multi-organ injury in abdominal closed injuries. It should be emphasized that it is unwise to use laparoscopic spleen-preserving hemostasis for severe spleen rupture (Grade IV or above) with a large amount of bleeding, as the success rate is extremely low.

　　(6) Autologous spleen tissue transplantation: Not all spleen injuries can be successfully treated by spleen-preserving methods. Approximately 60% of spleen injuries require splenectomy to control bleeding and save lives. For patients with simple spleen injuries such as spleen avulsion, splenic fragmentation, splenic hilum tear, splenic hilum blood clot, and failure of splenic repair, who have relatively minor contamination of intra-abdominal solid organs and hollow organs, as well as Grade III and IV non-pathological spleen rupture, autologous spleen transplantation can be performed to compensate for spleen function. Spleen tissue transplantation can be classified into various types such as intraperitoneal, intra-splenic bed, intraperitoneal fold, and intrabdominal rectus muscle types, even including splenic cell portal vein or intrapulmonary injection. Among them, intraperitoneal sac transplantation is the most commonly used method, which involves cutting the spleen into thin slices of a certain size, generally about 2.0cm×2.0cm×0.5cm in size, fixing them in the rich vascular area of the omentum, and then folding the free margin of the omentum to form an omental sac, stitching several times around it. One spleen slice can be used for 5 to 6 or more times, and it is generally believed that transplanting more than 1/4 to 1/3 of a normal spleen can be effective. It should be pointed out that although spleen tissue transplantation can exert a certain immune function, its function is far inferior to that of a normal spleen. Therefore, under the premise of preserving life, the spleen should be preserved as much as possible, and autologous spleen tissue transplantation should only be considered for patients who absolutely require splenectomy.

　　3. Total splenectomy

　　Compared with splenectomy, the spleen-preserving technique is relatively complex and may lead to postoperative bleeding. Under the principle of 'preserving life first, then preserving the spleen', total splenectomy is a relatively safe surgical option for treating spleen rupture. The indications for total splenectomy include:

　　(1) Type IV or above spleen rupture.

　　(2) Elderly patients.

　　(3) The injury is severe and life-threatening; it is crucial to complete the surgery as soon as possible.

　　(4) The spleen-preserving technique is still not effective in stopping bleeding.

　　(5)The surgeon lacks proficiency or experience in splenic preservation surgery and is not confident.

　　Proper preoperative preparation is crucial for the efficacy of surgery. If there is no obvious shock before surgery, the pulse does not exceed 100 times/min, and the systolic pressure is not less than 100mmHg, there is no need to give a large amount of blood transfusion prematurely; as the blood pressure may rise too much, there is a risk of blood clot detachment leading to further massive hemorrhage, so blood transfusion preparation should still be made, and blood transfusion should be administered quickly when the abdominal wall is incised. If there is already a shock before surgery, on the one hand, emergency surgery should be prepared, and on the other hand, blood transfusion and fluid resuscitation should be given quickly to correct shock and improve circulation. Once the blood pressure recovers to 80-100mmHg, surgery should be performed immediately. If the patient has shock and the blood pressure cannot rise or the pulse does not improve after transfusing 400-800ml of blood, it indicates that severe internal hemorrhage is still ongoing; at this time, arterial blood transfusion should be adopted, with pressure and rapid blood transfusion, and surgery should be performed without delay. Because patients with massive hemorrhage often only have a real turn-around after abdominal止血; if it is necessary to wait for the situation to 'improve' before surgery, it is equivalent to waiting for a rabbit to come to the tree, which is a waste of time.

　　During surgery, after the spleen is removed to stop bleeding, it is necessary to check whether other organs are injured to avoid missing them and affecting the prognosis. If there is no injury to other organs in the abdomen, the accumulated blood in the abdomen can still be collected, filtered, and used as autologous blood transfusion.

　　4. Surgical treatment principles for spleen rupture combined with multiple injuries

　　(1)Combination of craniocerebral injury: Most patients may have altered consciousness or unclear history or inaccuracy in the expression of abdominal signs. When intracranial hypertension occurs, changes in blood pressure, pulse, or respiration may present as a false appearance, and laparoscopy is not suitable, which brings difficulties to diagnosis and treatment, especially abdominal organ injuries including splenic injury, which are prone to misdiagnosis or missed diagnosis. It should be pointed out that coma accompanied by hypotension or hypotension that cannot be corrected after the treatment of craniocerebral injury, or shock that is not suitable for correction, is not common in simple craniocerebral injury and should be highly vigilant for the possibility of spleen rupture or other abdominal organ hemorrhage or hemorrhage in other parts.

　　In the treatment, it is necessary to consider the overall condition comprehensively, such as:

　　①In the absence of cerebral hernia, spleen rupture and intraperitoneal hemorrhage should be treated first, and timely laparotomy and splenectomy should be performed. Various splenic preservation techniques should not be used. While treating abdominal injuries, measures to prevent brain edema should also be taken.

　　②If there is a cerebral hernia or intracranial hematoma or its expansion seen on CT, MRI, or B-ultrasound, craniotomy should be performed first, followed by laparotomy, or both can be performed simultaneously. However, if ventricular drainage and decompression can be performed first and the intracranial lesions are still stable, the abdominal injury can be treated first, followed by craniotomy.

　　(2)Combination of intrathoracic organ injuries: Rupture of the spleen combined with intrathoracic organ injuries can involve the heart, great vessels, lungs, trachea, esophagus, thoracic duct, and so on. The consequences of injury to these organs or tissues are often severe, such as rapid massive hemorrhage, hemorrhagic shock, which often does not allow time for rescue or death on the scene; or open or tension pneumothorax, abnormal breathing, pericardial tamponade, and so on, leading to a series of serious life-threatening respiratory and circulatory dysfunction or sudden cardiac arrest.

　　Therefore, when treating severe abdominal injuries or splenic rupture, one should be alert to the possibility of simultaneous chest visceral injuries. Similarly, when treating chest injuries, one should not ignore the possibility of abdominal visceral injuries or splenic rupture. It should be known that diaphragmatic rupture injury or thoracoabdominal injuries are not easy to diagnose clearly; determining the source of hemothorax or hemothorax when there is diaphragmatic rupture is not easy either. In monitoring hemodynamic indicators, the central venous pressure (CVP) measurement is easily affected by the presence of chest visceral injuries, leading to inaccurate judgment and possible mistakes. Clinically, the possibility of simultaneous abdominal organ injuries should be considered when encountering the following situations:

　　①Injuries to the left chest located below the fourth rib of the anterior chest, the sixth rib of the lateral chest, and the eighth rib of the posterior chest, especially with diaphragmatic rupture;

　　②Penetrating injuries with entry and exit points in the chest or abdomen;

　　③Firearm injuries (bullets or shrapnel) entering from the chest or abdomen and staying in the chest or abdomen, with the wound channel passing through the spleen;

　　④Injuries to the left lower chest accompanied by intra-abdominal hemorrhage and hemorrhagic shock, etc. When the condition permits, choose general X-ray, B-ultrasound, CT, and other imaging examinations (thorax and abdomen) as well as thoracoscopy or laparoscopy to assist in diagnosis.

　　(3) Multiple abdominal injuries: Although spleen injury is the most common, statistical data shows that among abdominal外伤, solitary spleen rupture accounts for only 30%, and it is not uncommon to have other abdominal organ injuries, such as liver, abdominal large blood vessels, mesentery, omentum, etc., leading to intra-abdominal hemorrhage, retroperitoneal organ or tissue injury leading to retroperitoneal hematoma, and gastrointestinal hollow viscus injuries leading to peritonitis, etc.

　　The principle of treatment is to control hemorrhagic injuries (such as bleeding from the liver, spleen, and large blood vessels) first, and then deal with gastrointestinal penetrating injuries; to deal with the digestive tract with severe contamination (such as lower gastrointestinal tract) rupture first, and then deal with those with light contamination (such as upper gastrointestinal tract). It should be emphasized that the abdominal exploration should be carried out in an orderly manner to prevent the omission of injuries during surgery. Look for hemorrhagic injuries along the areas where blood clots accumulate or there is a lot of blood, or use hands to determine the rupture of solid organs such as the spleen and liver. After controlling active bleeding, a comprehensive exploration of abdominal organs should be conducted. The presence of free gas, bile, intestinal contents, feces, or high amylase, as well as inflammatory exudate, in the abdominal cavity suggests the presence of hollow viscus injuries, and it is necessary to examine the entire gastrointestinal tract (including the duodenum, ascending and descending colon located behind the peritoneum), biliary tract, and urinary system, etc. Look for hollow viscus injuries along the areas with thick pus crust, fibrin deposition, or abundant pus and omentum migration. For the first discovery, it can be temporarily clamped, and then dealt with appropriately after a comprehensive exploration is completed. The abdominal exploration can be checked in order:

　　①The stomach, duodenum, jejunum, ileum, and their mesentery, ascending and transverse colon and their mesentery, descending colon and rectum, kidneys;

　　② Pelvic organs (bladder, ureter, and in females, uterus and appendages, etc.)

　　③ Explore the extrahepatic bile duct, hepatic artery, and portal vein along the gallbladder, lesser omentum orifice, and hepatoduodenal ligament;

　　④ Incise the gastrocolic ligament to expose the lesser omentum sac and examine the posterior wall of the stomach and pancreas;

　　⑤ Perform a Kocher incision, and incise the lateral peritoneum of the ascending colon, and if necessary, incise the lateral peritoneum of the descending colon to explore retroperitoneal organs and tissues such as the head of the pancreas, the hook-like part, the second, third, and fourth segments of the duodenum, kidneys, ureters, abdominal aorta and its branches, inferior vena cava and its tributaries, etc.

　　The retroperitoneal space can be divided into 3 regions. The first region is located centrally, extending from the diaphragmatic hiatus of the esophagus and aorta upwards to the iliac spine downwards, containing the abdominal aorta, inferior vena cava and their branches, pancreas, and duodenum, etc. Hematomas in this region often originate from injuries to the pancreas and/or duodenum and major blood vessels, and require exploration and incision for treatment. The second region is located laterally to the first region, extending from the diaphragm upwards to the iliac crest downwards, containing the retroperitoneal parts of the kidneys and colon. Hematomas in this region often indicate injuries to the kidneys or colon. For treatment, it is generally recommended to perform exploration and incision, especially in cases with crepitus or fecal contamination, and urinary extravasation. Only in cases where the diagnosis of kidney injury without urinary extravasation and hemodynamic stability is confirmed, can exploration and incision be avoided. The third region includes the entire pelvic cavity, with the anterior part located below the bladder, and the posterior and lateral parts located below the iliac spine and iliac crest, respectively. Fractures of the pelvis are the most common cause of retroperitoneal hematomas in this region. Bleeding can originate from the fracture surface, injuries to the iliac vessels and their branches, and most can stop spontaneously. Hematomas in this region rarely require surgery or exploration, but it is necessary to be highly vigilant for the possibility of associated injuries to the rectum or bladder. The location of retroperitoneal hematomas determines the method of surgical exploration. The first region can be explored using the Koeher incision, incising the lateral retroperitoneum of the duodenum, freeing the duodenum and head of the pancreas forwards, and exploring the inferior vena cava, abdominal aorta, and head of the pancreas and duodenum. By incising the gastrocolic ligament, the lesser omentum sac can be accessed to expose the pancreas and hilum of the spleen. Incising the retroperitoneum superior or inferior to the pancreas can explore the dorsal aspect of the pancreas, superior mesenteric vessels, and abdominal aorta, etc. Exploration of the right kidney can be performed by freeing the colic flexure downwards, pulling the ascending colon and duodenum medially; exploration of the left kidney can be done by incising the splenorenal ligament, pulling the spleen and descending colon medially. If exploration of the third region is needed, it is necessary to control the inferior vena cava and abdominal aorta below the kidney, or to ligate the internal iliac vessels first, before incising the retroperitoneal hematoma. When thorough exploration does not reveal major vessel injuries, extensive bleeding at the wound site can be controlled by packing and compression with gauze, and draining outside the abdomen. Postoperatively, as the condition stabilizes, the gauze can be gradually removed in stages within 5 to 7 days. For pelvic extraperitoneal hematomas associated with rectal or bladder injuries, exploration and incision can be performed by incising the fascia around the rectum. Repair of bladder tears can be done, and a catheter can be left in place for urinary management. For rectal injuries, debridement of the wound site is required before repair, and most often, a transverse or sigmoid colostomy is performed, and a drain should be placed in the pre-sacral space.

　　Injuries to large retroperitoneal blood vessels (such as the abdominal aorta, inferior vena cava, etc.) are mostly caused by penetrating injuries. Most injured individuals die on the scene, and those who are transported to the hospital are often in a near-death state, requiring consideration of the principle of controlling injury for treatment. While treating shock, immediately perform laparotomy and compress the bleeding site or block the aorta between the lesser curvature of the stomach and the left lobe of the liver to temporarily control bleeding, which can last for several minutes. For injuries below the renal artery, the time can be slightly extended (10-15 minutes). Further exploration is necessary, and a good exposure is required. The lateral peritoneum of the right colon can be incised, and the peritoneum along the lateral aspect of the duodenum can be elevated upwards, freeing it retroperitoneally, pulling the right colon, duodenum, and head of the pancreas towards the left, which can provide a more thorough exposure of the inferior vena cava and abdominal aorta. If the injured abdominal aorta is behind or above the pancreas, the lateral peritoneum of the descending colon can be incised, the splenorenal ligament can be incised upwards, and the spleen, pancreas, stomach, and splenic flexure of the colon can be flipped to the right, and if necessary, a combined thoracoabdominal incision can be made for better exposure. After determining the injury, control and repair or anastomosis or vascular transplantation can be performed at the proximal and distal sides of the damaged site using Satinsky clamps. For vascular penetrating injuries, the anterior and posterior walls of the vessel should be repaired, and the posterior wall can be repaired first, followed by the anterior wall. Injuries to the inferior vena cava cannot be repaired and can be ligated below the renal vein level, but for those at a high level, vascular repair or transplantation surgery is required. If there is a suspicion of inferior vena cava injury, it is advisable to establish an upper extremity venous access for fluid resuscitation and other treatments.

　　In practice, ligation or suture is the most reliable method for stopping bleeding from abdominal or retroperitoneal blood vessels, but it should be done cautiously for certain vessels as it may affect blood supply. Ligation of the common hepatic, left gastric, splenic, left colonic, superior hemorrhoidal, and gastroduodenal arteries may not cause obstruction of blood supply to the corresponding organs or tissues; ligation of the right hepatic or left hepatic, and proper hepatic arteries carries a 90% risk; ligation of the superior mesenteric artery >95%; ligation of the distal superior mesenteric artery or ligation of the common iliac artery >50%; ligation of the inferior mesenteric artery

　　(4) The treatment of maxillofacial, neck injuries, and fractures of the spine, pelvis, and limbs: First, treat abdominal splenic rupture injury, perform laparotomy exploration, and simply bandage and immobilize the fracture sites. After properly treating abdominal injuries, consult with specialists for further treatment based on the condition. However, in cases requiring emergency treatment, including maintaining an open airway, priority should be given to rescue measures such as tracheal intubation or tracheotomy.

　　For open injuries with severe bleeding, debridement can be performed first to control bleeding or apply pressure dressing to the wound, or use a tourniquet for temporary treatment. If the situation is urgent and does not interfere with the implementation of laparotomy, it can also be handled simultaneously with laparotomy. When complications such as paraplegia or unstable spinal fractures occur, it is necessary to prevent re-injury or secondary injury. For those who need spinal canal exploration and decompression, fixation surgery, it is generally recommended to wait until the spleen rupture is treated after laparotomy and then consult with specialists for treatment. In paraplegic patients, abdominal symptoms may be masked or atypical, and attention should be paid to this when making judgments.

　　(5) Management of combined chest and abdominal wall injuries: the primary task is to perform emergency surgery, laparotomy, and manage spleen injuries. Only after properly managing spleen injuries and stabilizing the condition can chest and abdominal wall injuries be managed. However, if it is an open injury with active bleeding at the wound, it may be appropriate to first explore and control the wound bleeding or perform it simultaneously with laparotomy. It is usually not necessary to perform laparotomy through the original injury wound, and it is advisable to make another incision (upper midline abdominal incision), which may help reduce intraperitoneal contamination and facilitate intraperitoneal exploration. For skin abrasions, contusions, ecchymoses, or hematomas, the treatment is the same as for soft tissue injuries in other parts. Physical therapy (early cold compress, change to hot compress after 24-48 hours) is the main treatment, and painkillers or intercostal nerve block technique may be administered if necessary. If the hematoma expands or progresses, incision and exploration should be performed to remove the hematoma, ligate bleeding points, and suture the torn muscle wounds.

　　Fractures of the ribs can be externally fixed with adhesive bandages or a chest binder to eliminate abnormal breathing and encourage expectoration and lung expansion to prevent atelectasis and pneumonia.

　　For open wounds, debridement should be performed, and the wound should be sutured in one stage or delayed, and drainage should be placed if necessary. For those with less than 12 hours of injury or light contamination, primary suture of the wound is often possible. Penetrating injuries, especially firearm injuries, are severely contaminated, prone to infection and sinus formation, and often have skin defects at the wound, which cannot be directly sutured. Transfer skin flaps can be used for coverage, or a peritoneal or Marlex mesh can be used for repair if the defect is too large. After the granulation tissue grows, the skin can be grafted. In the future, if an abdominal wall hernia forms, repair surgery can be performed 3 to 12 months later.

　　II. Prognosis

　　According to statistics, the mortality rate of spleen rupture in open injuries

　　For those with simple spleen rupture, timely rescue, complete preoperative preparation, correct surgical choice, and meticulous operation can maximize the reduction of mortality.