Splenorrhaphy (Splenic Salvage)
[Blunt / penetrating] splenic injury, AAST Grade [II / III], with [hemodynamic instability / failed nonoperative management / peritonitis]
Same
Splenorrhaphy: [argon beam / suture / topical hemostatic agents / mesh wrap]
[***, MD/DO]
[Resident name]
General endotracheal. Massive transfusion protocol [activated / on standby]. Arterial line.
Patient presents with [blunt / penetrating] abdominal trauma and AAST Grade [II / III] splenic laceration on CT. [Hemodynamic instability despite 2L crystalloid and [X] units pRBC / failed nonoperative management, re-bleed at [X] hours.] [Angioembolization not available / not feasible.] Operative management indicated. [Spleen salvage planned given [pediatric patient / hemodynamics improving with resuscitation].] Risks including re-bleeding and need for splenectomy discussed with [patient / family]. Consent [obtained / waived].
AAST Grade [II / III] splenic laceration: [capsular tear [X] cm, not involving hilum / moderate depth laceration, hilar vessels intact]. [Active arterial bleeding from [polar / midpole] vessel.] [Parenchyma viable at [X]%.] Repair feasible.
The patient was positioned supine. A midline laparotomy [/ left subcostal incision] was performed. The spleen was mobilized by dividing the splenocolic, splenorenal, splenophrenic, and gastrosplenic ligaments (with careful ligation of the short gastric vessels). The spleen was medialized onto a laparotomy pad.
[Temporary vascular control: The splenic artery was identified at the superior border of the pancreas and temporarily occluded with a vessel loop or atraumatic clamp to achieve a bloodless operative field for repair.]
The splenic laceration was identified and assessed. [Manual compression held while hemostasis was achieved.] The following repair techniques were employed:
[ARGON BEAM COAGULATION: Applied to capsular tears and surface lacerations; excellent hemostasis achieved.]
[SUTURE: Horizontal mattress sutures of [0-chromic / 0-Vicryl] were placed across the laceration to achieve hemostasis. Pledgeted sutures used at [hilar bleeding point].]
[TOPICAL HEMOSTATIC AGENTS: Oxidized cellulose / Gelfoam / topical thrombin applied to parenchymal surface.]
[MESH WRAP: Polyglycolic acid (Dexon) mesh wrap applied circumferentially to stabilize the splenic parenchyma.]
Hemostasis confirmed. No active bleeding from repair site. The spleen was returned to the [left upper quadrant / replaced without torsion]. [A closed-suction drain was placed near the spleen.]
[If repair failed, splenectomy performed: see concurrent splenectomy note.]
Fascia closed. Skin closed. Patient tolerated the procedure well.
None
None
[X] mL
[Closed-suction drain if pancreatic tail injury concern / None]
Patient taken to trauma ICU for monitoring. CT at 48-72 hours to assess repair.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Blunt / penetrating] splenic injury, AAST Grade [II / III]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Splenorrhaphy: [argon beam / suture / topical hemostatic / mesh wrap]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; MTP [active / standby]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with AAST Grade [II / III] splenic injury and [hemodynamic instability / failed NOM]. [Angioembolization not feasible.] Splenic salvage attempted. Risks including re-bleeding and need for splenectomy discussed. Consent [obtained / waived].
FINDINGS: Grade [II / III] laceration: [capsular / parenchymal, hilar vessels intact]. Active bleeding from [polar / midpole] vessel. Repair feasible.
DESCRIPTION OF PROCEDURE:
[Midline laparotomy / left subcostal incision.] Spleen mobilized; splenocolic, splenorenal, splenophrenic, and gastrosplenic ligaments divided (short gastrics ligated). [Temporary splenic artery occlusion at superior pancreatic border.] Laceration assessed. [Argon beam to surface lacerations.] [Horizontal mattress sutures 0-chromic across laceration; pledgets at hilar point.] [Topical hemostatic agents applied.] [Mesh wrap applied circumferentially.] Hemostasis confirmed; no active bleeding. Spleen returned to LUQ. [Drain placed — pancreatic tail injury concern.] Fascia and skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [LUQ drain / None]
DISPOSITION: Patient to trauma ICU. CT at 48-72 h to assess repair.
Signed: .ME, .MYDEGREE
.TODAYVariants
Conversion to splenectomy
Document that repair was attempted and failed (specify reason: uncontrollable hemorrhage, hilar vessel injury, inadequate parenchymal integrity) before proceeding to splenectomy. Post-splenectomy vaccination for encapsulated organisms (S. pneumoniae, N. meningitidis, H. influenzae type b) should be administered approximately 14 days post-op for optimal immunogenicity; document plan at time of discharge.
Nonoperative management failed (angioembolization)
Document NOM duration, imaging, embolization performed, and indication for operative intervention. Grade and extent of injury at time of operation vs. initial CT.
Charting Tips
- Document AAST injury grade (2018 revision integrates CT vascular findings — contrast blush or pseudoaneurysm upgrades injury to Grade IV even with lower parenchymal grade) and laceration characteristics.
- State repair techniques used in order (argon beam, suture, topical hemostatic agents, mesh wrap). Document that hemostasis was confirmed before closing.
- Inspect and document the pancreatic tail status — the tail is immediately adjacent to the splenic hilum and is at risk during splenorrhaphy and splenectomy. Document "tail of pancreas inspected, no injury identified" or describe pancreatic findings.
- Inspect and document the left diaphragm. Left-sided blunt trauma frequently injures both spleen and diaphragm concurrently.
- Drain placement near the spleen is not evidence-based for detecting re-bleeding; serial hemoglobin, hemodynamic monitoring, and CT are the appropriate tools. Drain is appropriate only if pancreatic tail injury is suspected (amylase-rich leak).
- If converting to splenectomy, document the specific reason (uncontrollable hemorrhage, hilar injury, inadequate repair).
- Postoperative vaccination for encapsulated organisms (Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b) should be administered approximately 14 days post-op for optimal immunogenicity. Document vaccine administration or plan.
Documentation & Reimbursement Considerations
- Report Splenorrhaphy (Splenic Salvage) as the primary service when it is the definitive operation performed.
- Topical hemostatic agents (oxidized cellulose, gelatin, thrombin) applied during splenorrhaphy are included in the procedure and are not separately billed by the surgeon. They may be separately billed as facility supply charges.
- Operative billing is unaffected.
- 90-day global: post-splenorrhaphy imaging and clinic visits are bundled. Readmission for delayed splenic rupture within 90 days uses related unplanned return-to-the-operating-room reporting if re-operation is required.
- Pediatric splenic trauma is primarily managed nonoperatively per APSA guidelines (activity restriction and LOS stratified by AAST grade). Document AAST injury grade and indication for operative management.