A 35-year-old motorcyclist sustains grade IV splenic laceration (splenic laceration involving segmental vessels with devascularisation >25% of spleen) per AAST grading. He is haemodynamically stable with a systolic BP of 108 mmHg responding to resuscitation. What is the MOST appropriate initial management?
- A Angioembolization of the splenic artery followed by observation ✓
- B Immediate splenectomy
- C Non-operative management (NOM) with observation in ICU alone
- D Exploratory laparotomy for splenorrhaphy
Explanation
For haemodynamically stable patients with grade IV splenic injury, angiography and splenic artery embolization (SAE) significantly improves the success rate of non-operative management (NOM) from approximately 47-60% (observation alone) to 85-97%. The EAST and WSES guidelines recommend angioembolization for grade IV-V injuries in stable patients and for grades III-IV with vascular blush on CT. Embolization can be proximal (main splenic artery) or distal (selective branch), preserving splenic immune function better than splenectomy. Pure NOM without embolization is reserved for grade I-II injuries. Failure of NOM mandates splenectomy with post-splenectomy vaccination.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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