Surgical Science, 2013, 4, 525-529
Published Online December 2013 (
Open Access SS
Traumatic Splenic Injuries in Khartoum, Sudan
Isameldin O. Ibrahim1, Aamir A. Hamza2*, M. E. Ahmed3
1Department of Surgery, Omdurman Teaching Hospital, Khartoum, Sudan
2Department of Surgery, College of Medicine and Health Sciences, Bahri University, Khartoum, Sudan
3Department of General Surgery, Faculty of Medicine, Khartoum University, Khartoum, Sudan
Email: *
Received October 28, 2013; revised November 20, 2013; accepted November 27, 2013
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Background: Spleen injuries are most commonly associated with blunt abdominal trauma and represent a potentially
life-threatening cond ition. Objectives: To study th e pattern of splenic injuries of the p atient, managemen t instituted an d
its outcome at Khartoum. Patients and Methods: This is a prospective, analytic and hospital-b ased multicenteric study,
conducted at the three main Teaching hospitals at Khartoum. The study was carried over a period from April 2012 to
February 2013. It includes all patients, diagnosed as traumatic splenic injury. Excluded were patients with history of
splenic disease, iatrogenic injury or spontaneous rupture. Results: The study included 47 patients: their mean age was
26.4 years (SD ± 14.5). Most of them 41 (87.2%) were in the first four decades of life. Males were predominant 41
(87.2%), with a male to female ratio of 6.8:1. The majority of our patients had blunt abdominal trauma 39 (83%), of
whom, road traffic accident accounted for 51.1% and none reported cases of gunshot. Isolated splenic injury was found
in 23 (48.9%), and Haemodynamic stability was seen in 27 (57.4%) on presentation. The initial haemoglobin assess-
ment revealed <9 gram/dl in 53.2%. CT scan was performed to 24 (51.1%), of whom 66 patients were Grade I and II
and none of our patients were diagnosed as Grade V. Blood transfusion was required in 42 (89.4%). Operative treatment
was adopted in 66% (61.7% total splenectomy and 4.3% splenorrhaphy), while selective non-operative management
was successful in 16 (34%) of the patients. Higher intra-operative grade of splenic injury was found to be significantly
associated with blunt abdominal trauma, haemodynamic instability and associated intra-abdominal in juries. 44 patients
(93.6%) were discharged home in a general good condition . The morbid ity and mortality were seen in 8.5% and 6.4% re-
spectively. Conclusion: Splenic injuries usually follow blunt abdominal trauma, particularly after road traffic accidents.
It is common during the first four decades of life with males being frequently affected. The great success rate of adopt-
ing selective non-operative management is worthwhile.
Keywords: Blunt Splenic Trauma; Nonoperative Management; Splenectomy; Splenic Injury
1. Introduction
The incidence of splenic injury in poly trauma patients
was reported to be 44% and combined splenic and he-
patic lesions in (18%) [1]. Splenic injuries represent ap-
proximately 25% of all blunt injuries to the abdominal
viscera. Penetrating injuries also frequently involve the
spleen along with other abdominal o rgans [2]. The recent
trend in management of splenic trauma is preservation
whenever possible. This can be non-operative or opera-
tive splenorrhaphy [3]. This follows the evolution in
treatment of traumatic injuries of liver and spleen from
aggressive to damage control surgery to non-operative
[4]. Trends in management have changed over the years.
Traditionally, laparotomy and splenectomy were the
standard management. Presently, selective non-opera-
tive management (SNOM) of splenic injury is the most
common management strategy in haemodynamically
stable patient [5,6]. Laparoscopic splenectomy was suc-
cessfully carried out for the first time in colonoscopic
grade IV splenic injury [7]. Patients who are haemody-
namically stable can be safely treated with SNOM [8,9].
The splenic arterial embolization in haemodynamically
stable patients has been attributed to the relatively high
failure rate of such a treatment (10% - 31%), with a re-
*Corresponding a uthor.
sultant need for secondary splenectomy, and to the po-
tential of missing other intra-abdominal injuries that re-
quire laparotomy [9].
2. Patients and Methods
This is a prospective, observational and an alytic study. It
is a hospital based, Multicenteric, conducted at the three
main Teaching hospitals at Khartoum “Omdurman,
Khartoum and Khartoum North”. The study was carried
over a period extending from April 2012 to February
2013. It includes all patients, diagnosed as traumatic
splenic injury by clinical assessment, investigations, or
surgery. Excluded were patients with history of splenic
disease, injury due to surgery or spontaneous rupture.
Consecutive no n probability sampling was adop ted. Data
were collected using, questionnaire. The variables in-
clude personal data, presenting features, blood and radio-
logical investigations, treatment, operative findings and
post-operative complications. Patient’s informed consent
was obtained, together with ethical clearance. Statistical
analysis methods used were frequencies and 95% confi-
dence intervals (CI) for categorical data, mean, standard
deviation, frequencies and compared the data, using Stu-
dent’s t-test and Chi-square tests when appropriate with
significance taken at P value < 0.05.
3. Results
The study included 47 patients, their mean age was 26.4
years (SD ± 14.5) and ranging from 2 to 65 years. Most
of them 41 (87.2%) were in the first four decades of life.
One third was in the age group 21 - 30 years Table 1.
Males were predominant 41 (87.2%), with a male to
female ratio of 6.8:1. The majority of our patients had
blunt abdominal trauma 39 (83%), the rest 8 (17%) were
resulted from penetrating injuries. Road traffic accident ,
fall off a height, falling object and other assault ac-
counted for 51.1% 19.1%, 8.5% and 4.3% respectively,
Table 2. Worth mentioning all penetrating cases were
knives stab and no reported cases of gunshot, shotgun or
impalement in this study. Only five patients (10.6%)
Table 1. Age distribution in the study population (n = 47).
Age (years) Frequency (%)
0 - 10 08 (17.0)
11 - 20 90 (19.1)
21 - 30 14 (29.8)
31 - 40 10 (21.3)
41 - 50 30 (6.4)
51 - 60 01 (2.1)
>60 20 (4.3)
Total 47 (100)
presented to the surgical casualty within the first hour,
more the half between 1 - 6 hours and 36.6% after six
Trauma does not respect any system, it involved the
abdominal only in 23 (48.9%), whereas that associated
with chest injury in 11 (23.4), head and neck 9 (19.1%)
and extremities 4 (8.5%) respectively. With respect to the
associated intra-abdominal injuries, in the vast majority
of our patients, isolated splenic injury was found to be
involved in 33 (70%) of the occasions and other organs
were affected to lesser extend Table 3. Haemodynamic
stability was seen in 27 (57.4%) on presentation, the rest
were shocked. The initial haemoglobin assessment re-
vealed <9 gram/dl in 53.2%, and >9 gram/dl in 46.8% of
our patie nts.
CT scan was performed to 24 (51.1%) and Focused
Abdominal Sonography for Trauma (FAST) to 5 (10.6%)
of the patients. Grade I and II were seen equally by the
CT scan in 33.3% each, whereas Grade III and Grade IV
were seen in 12.5% and 20.8% respectively and none of
our patients was di agnosed as Grade V b y the scan.
Blood transfusion was required in 42 (89.4%) and 16
(34%) patients received more than four pints of blood, 15
(31.9%) received 1 - 2 pints, 11 (23.4%) received 3 - 4
pints and only 5 pati e nt s ne eded no bloo d t r ansfusio n.
Operative treatment was adopted in 66% (61.7% total
splenectomy and 4.3% Splenorrhaphy), while ‘SNOM’
in 16 (34%) of the patients. In the latter group initially
they were 19 patients however the conservative measures
Table 2. Mode of trauma causing splenic injury.
Mode of trauma Frequency Percent
Road traffic accident 24 51.1%
Fall off a height 09 19.1%
Stab wound 08 17.0%
Gunshot 00 0.00%
Others 06 12.8%
Total 47 100
Table 3. Associated intra-abdominal injuries.
Organ injured Frequency Percent
Spleen only 33 70.2%
Small bowel & mesentery05 10.6%
Stomach 04 8.5%
Large bowel 02 04.3%
Liver 01 02.1%
Kidney 01 02.1%
Others 01 02.1%
Total 47 100
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were successful in 84.2% of them and three patients were
operated. These converted patients were all initially
haemodynamically stable, and on laparotomy no associ-
ated intra-abdominal injuries were found but the splenic
trauma was grade IV in two patients and grade III in the
third one. Fortunately three of the shocked patients were
treated non-operatively after stabilization; two of them
had associated chest injuries and the third with head and
neck injury.
The amount of haemoperotenium in the operated
group, was found to be <50 0 ml in 4 (12 .9%), 500 - 1000
ml in 13 (41.9%) and >1000 ml in 14 (45.2%), Figure 1.
Higher intra-operative grade of splenic injury was
found to be significantly associated with; blunt abdomin-
al trauma, haemodynamic instability on presentation,
need for blood transfusion, presence of large amount of
haemoperotenium and associated intra-abdominal inju-
ries Table 4.
Post-operatively 7 (14.9%) were ad mitted to the Inten-
sive Care Unit “ICU”, 5 (10.6%) to the High Depend-
ency Unit “HDU” and the rest to the general ward. Forty
four patients (93.6%) were discharged home in good
general condition
Morbidity and Mortality
The morbidity in our study occurred in four patients
(8.5%), two cases of minor surgical site infection, one
developed over-whelming post splenectomy sepsis
Figure 1. Fluid (Blood) detected by FAST in splenic injury.
(a) In Morison’s pouch. (b) In the pelvis (Rectovesicular
Table 4. Factors predicting higher grade of splenic injuries.
Factor P value
Blunt trauma 0.002
Haemodynamic instability 0.023
Need for blood transfusion 0.036
Presence of haemoperotenium 0.000
Associated abdominal injuries 0.002
(OPSS) and one had mesenteric vascular occlusion.
There are three deaths (6.4%) in this study. All received
operative management, two after fail conservation. As-
sociated extra-abdominal injuries were found in two of
them (left haemothorax/massive intracranial bleeding).
The length of hospital stay in our series varies between
one week in (25%) to three weeks in (17%) and the rest
57% between one and three w e eks.
4. Discussion
The mean age of 26.4 years (SD ± 14.5) in our study was
found to be consistence with the reported age in another
study done in Nigeria, mean of 24.2 ± 15.2 years [10].
However it was lower than 38 ± 16 (SD) years [11] and
32 years [6].
The male’s gender constitutes the great majority
78.2% in our study. This was found to be similar to the
reported in the literature 63% [12,1 3] and 76% [6], how-
ever our males where seven times the females number
6.8:1, which was higher compared to 3.9:1 [11], 2.2:1
[10], and 1.9:1 [14]. This can be explained by the fact
males were breadwinners and the increase road traffic in
the capital.
4.1. Mode of Trauma in Splenic Injury
Blunt abdominal trauma was the commonest cause of
splenic injury in our study (83%). This is comparable to
the reported mode of trauma in other studies which range
from 78% to 100% [5,10,12,13,15]. Motorcycle accidents,
assaults, fall from height, and sports, were the varieties
causing blunt splenic injuries [15]. Jason J. Hallman, et
al., on their study of 338 splenic trauma as an adverse
effect of torso-protecting side airbags, occupants involv-
ed in left-side impacts without SAB, sustained injuries to
their abdomen in 8.2% [16]. In our study, road traffic
accidents were the reason in half the patients. This is
similar to other studies, 42.9% [12], 57% [11], however,
it is lower than 75.3% [10], 78% [13], 84% [6] and 91%
[14] in other series. Falling off a height rank second in
our study as a cause of blunt splenic injury which is com-
parable to [5,10]. Our third cause was assaults and none
of our patients inflicted sport injuries. All penetrating
splenic injuries we received were cases of knives stab
and no reported cases of gunshot. This contrasts the find-
ing in Los Angeles, California were gunshot accounted
for 70.4% of penetrating injuries to the spleen [17], this
discrepancy might be attributed to variations in cultural
context of the different communities, as knives were be-
ing carried by some of Sudanese tribes as part of their
traditional heritage and self-defense weapon.
Haemodynamic instability was defined by a systolic
blood pressure of less than 90 mm Hg refractory to re-
suscitation maneuvers [11]. It was one of the presenting
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features of our patients and seen in 42.6%. This contrast
the reported 6.6% in the literature [17] and possibly the
paucity of efficient ambulance system with it is trained
emergency medical personnel’s is a contributory factor.
4.2. Scanning
The primary goal of splenic ultrasonography in the set-
ting of blunt abdominal trauma is to detect the presence
of blood in the left upper quadrant [2]. FAST is used in
haemodynamic stable patients, takes 2 min, has no role in
grading with a sensitivity of 90% [5] and it replace diag-
nostic peritoneal lavage (DPL). It had been done to only
five of our patients (10%), none availability of the ultra-
sound in the emergency room or untrained surgical resi-
dents may be responsible for this low percentage of per-
FAST detecting haemoperitoneum should lead to a CT
scan for further evaluation of the nature and extent of
injury [5]. CT scan is the modality used at most institu-
tions. It provides the best evaluation of the sp leen and the
surrounding tissues. It images all of the abdominal or-
gans simultaneously to exclude secondary injury [2]. It
was been performed to half of our patients and revealed
grade III and IV in 33.3%, though these high grades of
splenic injuries were diagnosed in 73% in Clay et al.,
study [18].
4.3. Selective Non-Operative Management
The initial choice of su rgical versus nonsu rgical manage-
ment remains controversial [9]. Observational manage-
ment involves admission to a unit with monitoring of
vital signs, strict bed rest, frequent monitoring of red
blood cell count, and serial abdominal examinations [5].
The American College of Surgeons’ National Trauma
Data Bank (NTDB 4.0) analyzed 35,767 splenic injuries.
There was a significant increase in percentage of SNOM
[19]. This was in line with our trend where SNOM was
adopted in 34% of our patients and similar to 39.5% in
Bertrand, et al., in 2003 [11], but even higher than re-
ported in the literature, 3.5% [17] and 6.8% [10].
4.4. Operative Management
Operative treatment was adopted in 66% of our patients.
Other studies were in the range of 46% - 59.9% [12,14,
15,17]. Total splenectomy 61.7% was the commonest
operation performed in our splenic injured patients. In
the literature the rate range was 32% - 72% [10,12,14,
15,20]. Whereas Splenorrhaphy was practiced in 4.3% of
our patients and this simulate others’ findings [20,21],
but lower than 19.2% in a Nigerian study [10]. None of
our patients underwent partial splenectomy neither
splenic artery embolization. The latter modality of treat-
ment was not practiced in our setting due to lack of ex-
pertise personnel.
4.5. Outcome
Uneventful discharge was seen in 93.6% of our patient
compared to 86.3% in other study [10]. Three patients
died, making a mortalit y of 6.4% in our study. Th is over-
all mortality is comparable to 3.8% [13]. However, it was
lower than 10.9 % [12] and 19% [15] in other studies.
Our study has some limitations. The major limitations
are, no unified guideline was used in the hospitals re-
garding patients with splenic injuries, second FAST was
not adopted universally in abdominal trauma patients,
third the decision to operate was based on clinical judg-
ment, fourth surgical registrar were not trained in the
methods of splenic salvage fifth interventional radiolo-
gist were not available for selective splenic artery em-
bolization in minor grade of splenic injuries
5. Conclusion
In conclusion, splenic injuries in o ur study usu ally follow
blunt abdominal trauma, particularly after road traffic
accidents. It is common during the first four decades of
life with males being frequently affected. The outcome is
excellent and the great success rate of adopting selective
non-operative management is worthwhile in all hospitals.
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DPL: Diagnostic peritoneal lavage,
FAST: Focused Abdominal Sonography for Trauma,
HDU: High Dependency Unit,
OPSS: Over-whelming post splenectomy sepsis,
SNOM: Selective non-operative management.