Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives.

The spleen is one of the organs most commonly injured by blunt abdominal trauma. It plays an important role in immune response to infections, especially those sustained by encapsulated bacteria. Nonoperative management (NOM), comprising clinical and radiological observation with or without angioembolization, is the treatment of choice for traumatic splenic injury in patients who are hemodynamically stable. However, this strategy carries a risk of failure, especially for high-grade injuries. No clear predictors of failure have been identified, but minimally invasive surgery for splenic injury is gaining popularity. Laparoscopic surgery has been proposed as an alternative to open surgery for hemodynamically stable patients who require surgery, such as after failed NOM. We reviewed research articles on laparoscopic surgery for hemodynamically stable patients with splenic trauma to explore the current knowledge about this topic. After presenting an overview of the treatments for splenic trauma and the immunological function of the spleen, we try to identify the future indications for laparoscopic surgery in the era of NOM.

Mechanical hepaticojejunostomy: can we use a circular stapler as a viable and safe alternative? -a retrospective study of a single center.

BACKGROUND: Since the first years of the 1980s, some authors described the use of mechanical stapler for the creation of anastomosis in biliary surgery. However, the use of these devices has not spread during the following decades, and nowadays most centers usually craft hand-sewn anastomosis. METHODS: We retrospectively collected data from medical records, surgical registries and computerized databases about the use of mechanical circular staplers for the creation of hepaticojejunostomy at our institution. RESULTS: From 2012 to 2020, 11 stapled hepaticojejunostomy for both neoplastic and non-neoplastic diseases were performed at our institution. The mean age of the patient was 74, with a sex distribution of 5 men and 6 women. The mean preoperative common bile duct diameter was 19 mm. Preoperative blood samples showed mean total bilirubin of 6.95 mg/dL. No intraoperative complications were reported. Two patients (18%) had minor postoperative complications (1 wound dehiscence and 1 episode of melena that required blood transfusions), while no major complications occurred. No patients developed biliary fistula or anastomotic dehiscence. No one dies within 30 days from surgery. The mean postoperative length of stay was 13 days. CONCLUSIONS: According to our limited experience, stapled hepaticojejunostomy seems to be a safe and effective technique in selected patients.

Delayed Rupture of a Normal Appearing Spleen After Trauma: Is Our Knowledge Enough? Two Case Reports.

BACKGROUND Non-operative management is considered the gold standard for hemodynamically stable patients with splenic injuries. Delayed splenic rupture is a well-known complication of non-operative management in splenic trauma, with a relevant impact on mortality and morbidity. Most of the reported cases of delayed splenic rupture presented splenic injury at admission imaging or no imaging investigations were performed. We report 2 cases of delayed splenic rupture after blunt trauma, in which multidetector computed tomography (CT) scan at admission did not show any splenic injury.   CASE REPORT Two patients were admitted to our emergency surgery unit after abdominal trauma with left rib fractures, but no solid organ injuries were detected at CT scan. Some days after the trauma, both patients suddenly developed hemorrhagic shock due to splenic rupture and required emergency splenectomy. CONCLUSIONS Trauma patients' management and follow-up remains challenging for surgeons, because of sudden clinical changes that can occur. Delayed splenic rupture with inconspicuous admission CT scan is a rare event. In some cases, it seems to be related to a poor CT quality, but this explanation cannot be adopted in all cases. Moreover, there is no standardization for imaging follow-up in the case of a normal CT scan at admission, in order to prevent delayed hemorrhage. In this context, every element that can identify patients with higher risk of delayed splenic rupture is of great importance. We suggest that lower left rib fractures can be associated with delayed splenic rupture, and we propose some explaining hypothesis.