Abstract
Introduction
Iatrogenic splenic injury is a recognized complication in abdominal surgery. The aim of this paper is to understand the medico-legal issues of iatrogenic splenic injuries. We performed a literature review on PubMed and Scopus using iatrogenic splenic or spleen injury and iatrogenic splenic rupture as keywords. Iatrogenic splenic injury cases were identified. Most cases were related to colonoscopy, but we also identified cases related to upper gastrointestinal procedures, colonic surgery, ERCP, left nephrectomy and/or adrenalectomy, percutaneous nephrolithotomy, vascular operations involving the abdominal aorta, gynecological operation, left lung biopsy, chest drain, very rarely spinal surgery and even cardiopulmonary resuscitation. There are several surgical procedures that can lead to a splenic injury. However, from a medico-legal point of view, it is important to assess whether the cause can be attributed to a technical error of the operator rather than being an unpredictable and unpreventable complication. It is important for the medico-legal expert to have great knowledge on iatrogenic splenic injuries because it is important to evaluate every step of the first procedure performed, how a splenic injury is produced, and whether the correct treatment for the splenic injury was administered in a judgment.
1 Introduction
Iatrogenic splenic injury is a recognized complication in abdominal surgery that results in an increased risk of morbidity and mortality, increased operation time, and a longer hospitalization [1,2]. Numerous risk factors are associated with iatrogenic splenic injury, such as previous surgeryadhesions, underlying pathology, morbid obesity, advanced age and location of primary incision (exposure of the left upper quadrant) [3]. It is also important to know how this type of injury is produced to evaluate medical professional liability. Therefore, in many cases, a splenectomy is required after an injury and can cause permanent impairment. The aim of this review is to evaluate cases of iatrogenic injury of the spleen and analyze the related medico-legal cases.
2 Methods
A review of the literature on iatrogenic splenic injuries was conducted. The research was performed using PubMed and Scopus with the following keywords:
iatrogenic AND spleen OR splenic AND injuries OR injury
iatrogenic AND splenic OR spleen AND rupture
Furthermore, scientific articles were identified using the reference lists of eligible studies or articles citing the eligible studies.
To include papers in our review, we decided to employ the subsequent criteria:
papers written in English;
full text available;
papers that report clinical data of the case under examination.
3 Results
We identified 55 papers reporting 88 cases according our criteria. Colonoscopy was the procedure most related to spleen injury, but cases related to upper gastrointestinal procedures, colonic surgery, ERCP, left nephrectomy and/ or adrenalectomy, percutaneous nephrolithotomy, vascular operations involving abdominal aorta, gynecological operation, left lung biopsy, chest drain, very rarely spinal surgery and even cardiopulmonary resuscitation were also described. The management of splenic injury included splenectomy (n.=57) and conservative treatment (n.=30). The cases are summarized in Table 1.
Cases selected from the literature
| Author | Publication Year | Patient (age; sex) | Procedure | Spleen Injury | Treatment |
|---|---|---|---|---|---|
| Zappa etal. [4] | 2016 | 73 M | colonoscopy | grade III subcapsular hematoma | splenectomy |
| Lahat etal. [5] | 2016 | 61 F | colonoscopy | splenic injury grade III | splenectomy |
| Lahat etal. [5] | 2016 | 68 F | colonoscopy | splenic injury grade II | conservative |
| Lahat etal. [5] | 2016 | 85 M | colonoscopy | splenic injury grade III | splenectomy |
| Lahat etal. [5] | 2016 | 54 F | colonoscopy | splenic injury grade III | splenectomy |
| Lahat etal. [5] | 2016 | 65 F | colonoscopy | splenic injury grade III | splenectomy |
| Lahat etal. [5] | 2016 | 61 F | colonoscopy | splenic injury grade II | conservative |
| Bogner et al. [6] | 2015 | 38 M | thoracoscopic corpectomy and | rupture | splenectomy |
| replacement of the vertebral | |||||
| body | |||||
| Girietal. [7] | 2015 | 67 M | open left nephrectomy | 2 cm long, 1 cm deep splenic | conservative |
| tear | |||||
| Girietal. [7] | 2015 | 58 M | open left nephrectomy | 3 cm long, 1 cm deep splenic | conservative |
| tear | |||||
| Girietal. [7] | 2015 | 54 M | open left nephrectomy | 3 cm long, 1 cm deep splenic | splenectomy |
| tear | |||||
| Girietal. [7] | 2015 | 64 F | open left nephrectomy | 2 cm long, 2 cm deep splenic | conservative |
| tear | |||||
| Riddetal. [8] | 2015 | 69 F | colonoscopy | large hematoma surrounding the | splenectomy |
| spleen with capsular avulsion | |||||
| Mulkerin etal. [9] | 2015 | 64 M | colonoscopy | large subcapsular hematoma | splenectomy |
| Voore[10] | 2015 | 52 F | colonoscopy | hematoma | splenectomy |
| Angelietal. [11] | 2015 | 63 F | colonoscopy | Laceration and decapsulation of | splenectomy |
| the upper pole | |||||
| Angelietal. [11] | 2015 | 62 F | colonoscopy | subcapsular hematoma | conservative |
| Grammatopoulos et al.[12] | 2014 | 64 M | ERCP | rupture at the hilum | splenectomy |
| Sevincetal. [13] | 2014 | 57 M | colonoscopy | rupture | splenectomy |
| Brennan etal. [14] | 2014 | 75 F | colonoscopy | lower pole splenic laceration | conservative |
| Gremida etal. [15] | 2014 | 74 M | colonoscopy and polypectomy | sub-capsular splenic hematoma | splenectomy |
| Weaver etal. [16] | 2013 | 66 M | ERCP | rupture | splenectomy |
| Chow etal. [17] | 2013 | 84 F | colonoscopy | grade III or IVsplenic laceration | conservative |
| Malik etal. [18] | 2013 | 61 M | colonoscopy | Grade III splenic lesion | splenectomy |
| Malik etal. [18] | 2013 | 46 F | colonoscopy | Grade III splenic lesion | splenectomy |
| Zandonà etal. [19] | 2012 | 80 M | colonoscopy follow-up and | rupture of the splenic capsule | splenectomy |
| biopsies for colorectal neoplastic | |||||
| disease | |||||
| Asnisetal. [20] | 2012 | 28 M | elective splenectomy for massive | following incision, huge abdom- | splenectomy |
| enlarged spleen | inal bleeding due to splenic | ||||
| rupture | |||||
| Elessawy et al. [21] | 2012 | 40 F | laparoscopic excision of uterine | superficial tear of the capsule | splenectomy |
| myoma | |||||
| Gaffneyetal. [22] | 2012 | 48 M | ERCP | Laceration with subcapsular | conservative |
| hematoma | |||||
| Henneman et al | 2012 | 44 F | laparoscopic Roux-en-Y gastric | subcapsular splenic hemorrhage | conservative |
| [23] | bypass | ||||
| Garancini et al. [24] | 2011 | 77 M | colonoscopy | complete laceration of splenic | splenectomy |
| capsule | |||||
| Darraghetal. [25] | 2011 | 58 F | chest drain fora thick walled | chest drain traversing the spleen | conservative |
| empyema in the left lung | with associated hemorrhage | ||||
| Pothulaetal. [26] | 2010 | 64 M | screening colonoscopy with | splenic laceration | splenectomy |
| polipectomy | |||||
| Binning etal. [27] | 2010 | 60 M | T12 corpectomy and fusion using | rupture | splenectomy |
| a thoracoscopic approach | |||||
| Arruabarrena etal | 2010 | 61 M | laparoscopic left nephrectomy | rupture | splenectomy |
| [28] | |||||
| Murariuetal.[29] | 2010 | 55 F | colonoscopy | rupture | splenectomy |
| Desaietal. [30] | 2010 | 62 M | percutaneous nephrolithotomy | Nephrostomy tube through the | conservative |
| spleen | |||||
| Wind etal. [31] | 2009 | 49 M | mechanical cardiopulmonary | rupture found at the autopsy | none |
| resuscitation | |||||
| Kiosoglous etal | 2009 | 47 F | colonoscopy | splenic tear | splenectomy |
| [32] | |||||
| deVriesetal. [33] | 2009 | 81 M | colonoscopy | large hematoma in the spleen | splenic |
| embolization | |||||
| deVriesetal. [33] | 2009 | 66 F | colonoscopy | hemorrhage | splenectomy |
| Kamathetal. [34] | 2009 | 70 M | colonoscopy | splenic tear | splenectomy |
| Kamathetal. [34] | 2009 | 56 M | colonoscopy | splenic laceration | splenectomy |
| Kamathetal. [34] | 2009 | 46 F | colonoscopy | splenic injury with hemoperito- | splenectomy |
| neum | |||||
| Kamathetal. [34] | 2009 | 40 F | colonoscopy | splenic injury with hemoperito- | splenectomy |
| neum | |||||
| Kamathetal. [34] | 2009 | 45 F | colonoscopy | splenic injury | splenectomy |
| Kamathetal. [34] | 2009 | 64 F | colonoscopy | splenic injury | splenectomy |
| Kamathetal. [34] | 2009 | 59 F | colonoscopy | splenic injury | splenectomy |
| Kelly [35] | 2009 | 73 M | chest drain for a left-sided | bleeding point in the spleen with | conservative |
| empyema thoracis | surrounding hematoma | ||||
| Skipworth etal | 2009 | 71 F | colonoscopy | shattered spleen | splenectomy |
| [36] | |||||
| Petersen et al. [37] | 2008 | 65 M | colonoscopy | laceration | splenectomy |
| Petersen etal.[37] | 2008 | 70 F | colonoscopy | laceration | splenectomy |
| Petersen et al. [37] | 2008 | 38 M | sigmoidoscopy | hilar laceration | splenectomy |
| Petersen et al. [37] | 2008 | 72 F | colonoscopy | laceration | splenectomy |
| Petersen et al. [37] | 2008 | 66 F | colonoscopy | capsule avulsion | splenectomy |
| Petersen et al. [37] | 2008 | 80 F | colonoscopy | capsule avulsion | splenectomy |
| Petersen et al. [37] | 2008 | 68 F | colonoscopy | capsule avulsion and tear in the | splenectomy |
| lower pole | |||||
| Petersen et al. [37] | 2008 | 67 F | colonoscopy | capsule avulsion and tear | splenectomy |
| Choetal. [38] | 2008 | 63 F | ERCP | Laceration | splenectomy |
| Khan etal. [39] | 2008 | 48 M | left lung biopsy | ruptured subcapsular splenic | unavailable |
| hematoma | |||||
| Gayer et al. [40] | 2008 | 81 F | left hemicolectomy and oment- | one infarct containingtiny air | conservative |
| ectomy | bubbles | ||||
| Gayer et al. [40] | 2008 | 66 F | total colectomy | a subcapsular collection | conservative |
| Gayer et al. [40] | 2008 | 81 F | left hemicolectomy | two infarcts | conservative |
| Gayer et al. [40] | 2008 | 70 M | anterior resection and subse- | a subcapsular collection | conservative |
| quent repair of an anastomotic | |||||
| leak | |||||
| Gayer et al. [40] | 2008 | 67 M | abdominoperineal resection of | one infarct | conservative |
| colon and colostomy | |||||
| Gayer et al. [40] | 2008 | 21 F | left adrenalectomy and nephrec- | one infarct | conservative |
| tomy | |||||
| Gayer et al. [40] | 2008 | 57 F | bilateral salpingooophorectomy | laceration | conservative |
| and omentectomy | |||||
| Heyworth et al. [41] | 2008 | 44 F | thoracolumbar spinal fusion | intracapsular hematoma with | splenectomy |
| extracapsular extension | |||||
| Duarte [42] | 2008 | 50 F | colonoscopy | 4 x 10 cm perisplenic hematoma | conservative |
| Laloretal. [43] | 2007 | 82 F | colonoscopy | rupture | splenectomy |
| Di Lecceetal. [44] | 2007 | 64 M | colonoscopy | rupture | splenectomy |
| Sin etal. [45] | 2007 | 52 M | anterior L1-L2 corpectomy and | laceration | splenectomy |
| fusion of osteomyekutus of the | |||||
| lumbar spine | |||||
| Carey eta l. [46] | 2006 | 52 M | percutaneous nephrostolitho- | transsplenic percutaneous renal | conservative |
| tomy | access | ||||
| Prowda et al. [47] | 2005 | 48 F | colonoscopy | subcapsular and perisplenic | conservative |
| hematoma | |||||
| Prowda et al. [47] | 2005 | 85 F | colonoscopy | subcapsular and perisplenic | conservative |
| hematoma | |||||
| Goitein etal. [48] | 2004 | 39 F | colonoscopy | capsular tear | splenectomy |
| Rinzivilloetal. [49] | 2003 | 71 M | colonoscopy | approximate 6-cm tear towards | splenectomy |
| the diaphragmaticface | |||||
| Kingsleyetal. [50] | 2001 | 54 F | ERCP | rupture | splenectomy |
| Chang etal. [51] | 2000 | 31 F | laparoscopic salpingoplasty to | a small tear (3 cm long and 1 cm | conservative |
| correct bilateral hydrosalpinges | deep) with active bleeding in the | ||||
| and reform the fimbriated tubal | inferior splenic tail | ||||
| ends | |||||
| Tse et al. [52] | 1999 | 67 F | colonoscopy | Capsular lesion | splenectomy |
| Santiago etal. [53] | 1998 | 20 F | percutaneous renal surgery | splenic hematoma | conservative |
| Ahmed etal. [54] | 1996 | 72 F | colonoscopy | rupture | splenectomy |
| Levineet al. [55] | 1987 | 62 F | colonoscopy | subcapsular and perisplenic | splenectomy |
| hematomas and splenic lacer- | |||||
| ation | |||||
| Sagaretal. [56] | 1987 | 74 M | benign esophageal stricture | splenic hematoma | conservative |
| Castelli [57] | 1986 | 71 F | colonoscopy | rupture | splenectomy |
| Mearns et al. [58] | 1973 | 50 F | pleural biopsy | subcapsular hematoma with rupture near the upper pole and 1to 4 cm track passing into the pulp | splenectomy |
| Mearnsetal. [58] | 1973 | 33 F | chest drain to aspire a pleural effusion | subcapsular hematoma | conservative |
| Mearns et a l. [58] | 1973 | 66 F | chest aspiration in the seventh left intercostal space in the mid-axillary line | large subcapsular hematoma extending over the entire convex aspect of the surface and an enveloping perisplenic hematoma | splenectomy |
4 Discussion
The spleen is situated in the left upper quadrant running along the 9th rib, and it is surrounded by a peritoneal capsule [59]. The spleen’s function is not fully understood; however, it is important in circulatory filtration, immune responses, hemopoiesis, iron reutilization, and blood and immune cell reservoir function [59]. The spleen represents the largest accumulation of lymphoid tissue in the body [59]. Cassar et.al., defined iatrogenic splenic injury as any unintentional damage caused to the spleen by the surgeon or the assistant(s) during a surgical procedure [1]. The true incidence of iatrogenic splenic injuries is difficult to assess due to variability in reporting and documentation [1,60]. In the literature, iatrogenic splenic injuries have been reported after various surgical procedures, such as upper gastrointestinal procedures, colonic surgery, colonoscopy, ERCP, left nephrectomy and/or adrenalectomy, percutaneous nephrolithotomy, vascular operations involving abdominal aorta, gynecological operation, left lung biopsy, chest drain and very rarely spinal surgery [4-59,61-64] .These injuries are also described in cases of cardiopulmonary resuscitation [31,65-67]. As noted in Table 1, the procedure most related to iatrogenic splenic injury is colonoscopy; however, splenic injury is not a frequent complication of colonoscopy [34]. The risk factors for splenic injury during colonoscopy are categorized as patient and operator dependent. Patient associated risk factors include splenomegaly, adhesions between spleen and colon from prior surgery, neoplasm, and inflammation, such as diverticular disease, pancreatitis, inflammatory bowel disease, endometriosis, and infection (malaria, typhoid fever, Epstein-Barr virus-induced mononucleosis, anticoagulation) [68]. Operator-dependent risk factors include supine position, inexperienced operator, biopsy polypectomy, excess tractions, direct injury, and multiple previous colonoscopies [68]. In addition, various maneuvers during colonoscopy, such as hooking the splenic flexure to straighten left colon, applying external pressure on the left hypochondrium, slide by advancement and alpha maneuver, are risk factors for splenic injury [19,68]. The significance of splenic injury and subsequent splenectomy during colon surgery has been well documented [69]. Merchea et al. performed a study on 13,897 colectomies and reported a total of 71 splenic injuries (0.42%), of which 44 (76%) required a splenectomy [60]. Masoomi et al., analyzed data from 975,825 individuals who underwent colorectal resection during the period of 2006 to 2008 and found that the rate of splenic injury was 0.96%, of which 84.75 were treated with splenectomy [2]. These iatrogenic injuries account for approximately 20% of all spleen procedures performed in the US [70]. According to Masoomi et al., the most common procedure associated with splenic injury is transverse colectomy [2]. During colectomy, the majority of splenic injuries are capsular tears due to traction [60]. An important risk factor is previous abdominal operations, which contribute to the presence of adhesions in the splenic region [60]. Finally, it must be highlighted that colonic surgery performed laparoscopically is less associated with splenic injury compared with laparothomic procedures [2,71,72]. Cases of splenic injury have also been described in upper gastrointestinal surgery [56]. Splenic injury is also a rare complication of ERCP [12,38,50]. The mechanism by which the injury is produced remains unclear, but it postulated that bowing of the endoscope in the long position with torsion on the greater curvature of the stomach plays a key role [12,16]. In particular, this maneuver may cause splenic capsular tears or vascular avulsion by traction on the short gastric vessels [22,38]. In addition, increased manipulation resulting from difficulty accessing the ducts and a prolonged procedure resulting from activities, such as obtaining biopsies or brushings, are also potentially associated with increased risk of injury [16]. Furthermore, positioning a chest drain can produce splenic injury. This complication is typically related to a malpositioning of the intercostal chest drain [73] or percutaneous procedures, such as lung biopsy or nephrolithotomy. Kong et al. evaluated visceral injuries produced by misplaced intercostal chest drains and found that 6 out of 58 patients experienced a splenic injury (3 isolated splenic injuries and 3 combined splenic and diaphragmatic injuries) [73]. Splenic injuries during left nephrectomy are also reported in literature. In 1996, Cooper et al. reported that 4.3% of left nephrectomies resulted in splenectomy [74]. In more recent papers, the rate was between 4.2% and 5.13% [7,75]. In the case of thoracoscopic spinal surgery, the spleen can be vulnerable to iatrogenic injury due to its proximity to the thoracolumbar junction [6]. According to the American Association for the Surgery of Trauma (AAST), splenic injuries are classified as grade I) subcapsular hematoma <10% of surface area, capsular laceration <1 cm depth; grade II) subcapsular hematoma 10-50% of surface area; intraparenchymal hematoma <5 cm in diameter, laceration 1-3 cm depth not involving trabecular vessels; grade III) subcapsular hematoma >50% of surface area or expanding, intraparenchymal hematoma >5 cm or expanding, laceration >3 cm depth or involving trabecular vessels, ruptured subcapsular or parenchymal hematoma; grade IV) laceration involving segmental or hilar vessels with major devascularization (>25% of spleen); grade V) shattered spleen, hilar vascular injury with devascularized spleen [76]. The management of an iatrogenic splenic injury can be conservative or a splenectomy can be performed. The decision to attempt splenic salvage depends on the severity of the injury, the patient’s hemodynamic stability, and the surgeon’s experience [3]. The techniques used in conservative treatment include splenorrhaphy, topical hemostasis, suture repair, mesh repair and segmental resection [3]. Conservative management during laparoscopy can occasionally be arduous; therefore, recent advancements in surgical hemostatic agents have provided beneficial therapeutic alternatives [77]. In addition, radiofrequency fulguration has been used to achieve hemostasis to the spleen [78]. When it is not possible to salvage the spleen, a splenectomy must be performed. Splenectomy can be performed using either an open or laparoscopic method [79]. In many cases, as reported in table 1, a splenectomy is required. As described by Falsetto et al., splenectomy has its own early complications, such as 1) acute gastric dilatation, collapse of the left lung base and thromboembolic events; 2) blood loss requiring transfusions at an increased rate compared with patients who did not have a splenectomy; 3) infections [80]. After the surgical procedure, it should be noted that splenectomized patients are more susceptible to infections [postsplenectomy overwhelming infection (OPSI)] [81]. Finally, there are several surgical procedures that can lead to a splenic lesion; however, from a medico-legal point of view, it is important to assess whether the cause can be attributed to a technical error of the operator rather than an unpredictable and unpreventable complication of a particular surgical procedure. These considerations are important in the management of litigation for an iatrogenic splenic injury. To reduce claims, it is very important to correctly inform the patient of the risk of a splenic injury during a procedure and to describe every maneuver in the operation report.
5 Conclusions
Colonoscopy is the procedure most often associated with these injuries. However, these injuries may be observed in cases of upper gastrointestinal procedures, colonic surgery, ERCP, left nephrectomy and/or adrenalectomy, percutaneous nephrolithotomy, vascular operations involving the abdominal aorta, gynecological operation, left lung biopsy, chest drain, very rarely spinal surgery and even cardiopulmonary resuscitation. From a medico-legal point of view, iatrogenic splenic injury can represent a source of litigation. In the assessment of the possible liability of the physician, it is critical to evaluate the eligibility for the first intervention, the clinical status and patient characteristics before the intervention, and the technical execution of the procedure. Finally, in cases where a splenic injury has been determined, the indication for splenectomy or conservative treatment must be assessed because the treatment itself can determine some functional consequences for the life of the subject in addition to the risks and complications related with the splenectomy intervention itself.
Conflict of interest statement: Authors state no conflict of interest.
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