Trauma is the leading cause of death in people between 15 and 40 years. In blunt abdominal trauma (BAT), the spleen is the most organ most commonly injured (30-45%). The goal of nonoperative management (NOM) is to reduce the number of nontherapeutic laparotomies as much as possible achieving a success rate between 75 and 80%.

We report the case of a 16-year-old male patient admitted to the emergency department after a collision between a motorcycle and a car 30 minutes before. He was hemodinamically stable, with a Glasgow score of 15/15. The abdomen was soft, depressible and nontender. Serial Focused Assessment with Sonography for Trauma (FAST) exam did not show free fluid or solid organ injury. The patient was discharged after being monitored for 24 h but was readmitted 96 hours later hemodynamically stable with abdominal pain in the left hypochondrium over the past 24 hours. The abdomen was slightly tender in the left hypochondrium without rebound tenderness. The computed tomography (CT) scan demonstrated grade III spleen injury with laceration according to the American Association for the Surgery of Trauma (AAST) splenic injury scale⁵, without injury to other organs. The hematocrit showed a gradual decline in serial testing. On day 5 after readmission surgery was decided due to hemoperitoneum and a blush >1 cm (Fig. 1) on ultrasound and CT scan.

Figure 1 The arrow indicates a blush > 1 cm associated with hemoperitoneum. 

As our hospital has not on-site catheterization laboratory facilities, we decided to manage this case through laparoscopy. We observed progression to grade IV injury according to AAST⁵. Hemostasis was obtained with electrocoagulation on the lower pole of the spleen capsule. Small lacerated trabecular vascular branches were visualized over the traumatic area and were selectively clipped to control bleeding (Fig. 2). Additional hemostasis was provided with the use of absorbable hemostatic gelatin sponge. The patient had favorable postoperative outcome with no signs of bleeding on CT scan. There were no complications after on long-term follow-up at 24 months.

Figure 2 Hemostasis and selective clipping of lacerated trabecular vessels. 

A multidisciplinary team leaded by the surgeon is essential in NOM. Counting with trauma networks in hospitals within a specific programmatic area decreases the rate of splenectomy and favors the use of NOM. At present, there is consensus to perform NOM in all patients with grade I and II injuries according to the AAST. For patients with more severe injuries, NOM is still under debate. Delayed splenic rupture increases morbidity. In most cases, rupture is not delayed but represents failure of previous diagnostic imaging tests to visualize spleen injuries³. This type of injury is one of the causes for changing the NOM strategy but does not contraindicate it.

The aim of NOM is to reduce the number of non-therapeutic laparotomies, with rates up to 25%¹, and the possible laparotomy-related complications. Spleen resection can lead to complications as increased risk of subsequent infections, venous thrombosis and delayed production of immunoglobulins. For this reason, modern surgical spleen-preserving techniques have been developed, including spleen repair, use of hemostatic elements or meshes. Scarborough et al. demonstrated higher rate of complications in patients undergoing immediate splenectomy than those undergoing NOM⁶.

Computed tomography scan with intravenous contrast agent is useful for making the diagnosis and for detecting the presence of blush, which is an indication for angiography. In centers without on-site interventional catheterization procedures, blush size (< or > 1 cm), intraparenchymal or extraparenchymal blush location, and presence or absence of hemoperitoneum⁴.

Dolejs et al.² analyzed the rate of late splenectomies in centers with and without angiography. They observed that splenectomy rate was stable over time at angiography centers but decreased in those without angiography centers and with standardized protocols.

Laparoscopy has well-known benefits that have been widely reported in the literature, as shorter length of hospital stay, reduced risk of incisional hernias, rapid return to work, and better cosmetic results.

Our intention with this case report is to show how we managed this patient in a center without onsite angiography. The laparoscopic approach was useful in our attempt to preserve the spleen with selective hemostasis considering the level of trauma.