Since the beginning of modern surgery, splenectomy had been the procedure of choice for splenic injury. To do otherwise was believed to invite disaster as the spleen could not heal on its own and there was a tendency to rupture in a delayed fashion.¹⁹⁸ In 1952, the immunologic dangers of removing the spleen were demonstrated, although this did not alter management.¹⁹⁹ It was not until 1973, when data on incidence and mortality from sepsis from splenectomy became available, that the ramifications of this practice became evident.²⁰⁰ Indeed, overwhelming sepsis occurs in children who have undergone splenectomy at more than 85 times the rate of the normal population and may result in a 50% mortality rate.²⁰¹ This new information led to the revolutionary concept of splenic preservation after splenic injury and has become the priority in children after blunt abdominal trauma.²⁰² This approach is particularly important in children who face a lifelong risk of overwhelming post-splenectomy infections of 3-5%.²⁰³

In 1968, successful nonoperative treatment of select children presumed to have splenic injury was first demonstrated.²⁰² By the 1980s, nonoperative management became the treatment of choice for pediatric blunt splenic trauma.^204-206 Simultaneously, the expanding introduction and use of CT scanning opened up a new avenue for diagnosis and observation of splenic injuries, providing additional confidence in the nonoperative management of solid organ injury. It was not a great leap, therefore, for pediatric surgeons to apply the approach to another commonly injured pediatric organ, the liver, as well as the kidney and pancreas.²⁰⁷

Nonoperative management has been shown to be safe, with success rates by pediatric surgeons of 89-99%.^208-210 There has, however, been a disparity in non-pediatric trauma or non trauma centers to reach the same results as those encountered in pediatric trauma centers.²¹¹ The Trauma Committee of the American Pediatric Surgical Association (APSA) developed evidence-based guidelines for the nonoperative management of hemodynamically stable children with blunt splenic or liver injury.²⁰⁸ Their recommendations were based on analysis of patient data collected from 32 pediatric surgical groups, nonrandomized trials, historical controls from the literature, expert clinical experience, and a consensus conference. But non-pediatric trauma or non trauma hospitals fail to achieve nonoperative success rates commensurate with that of pediatric trauma centers for blunt splenic injuries.^211,212 Management of children by non-pediatric surgeons or in non-pediatric trauma centers is known to have a negative effect on transfusion rates, length of stay, and mortality of pediatric patients who undergo a laparotomy.^213-215 The aggregate conclusions of these authors were that training, experience, and available resources, such as intensivists, blood banking, and a pediatric intensive care unit, were the measures of differences between pediatric surgeons and adult surgeons caring for pediatric patients. Therefore, to be successful in the nonoperative management of pediatric abdominal blunt organ injury requires the following:

Frequent examinations.

• Close monitoring of vital signs.
• Frequent laboratory tests (done with microvalve technique).
• Close monitoring by nursing personnel experienced in the pediatric intensive care unit (PICU).

If these requirements are followed, there should be an increase in nonoperative management of children who are admitted to non-pediatric trauma centers with better outcomes, lower complication rates, and lower transfusion rates.²¹⁵ There must also be a wider dissemination of the APSA guidelines for management of the pediatric trauma victim to these non-pediatric trauma hospitals.²¹⁶ This is especially important since most children with splenic injuries are treated in non-pediatric trauma centers.²⁰⁹

Nonoperative management of injury to solid organs is not without complications. There is an overall 5% nonoperative management failure rate in solid organ injuries, including spleen, liver, kidney, and pancreas.²¹⁷ Multivariate analysis logistic regression analysis controlling of Injury Severity Scores (ISSs) and Glasgow Coma Scales scores (GCSs) found five variables associated with a significantly increased risk for failure of nonoperative management; these included:

• Bicycle-related injury mechanism.
• Isolated pancreatic injury.
• One solid organ injury.
• Summary Abbreviated Injury Scale (sAIS) greater than or equal to 4.
• Isolated grade 5 injury.

Other factors that predict the likelihood of failure of nonoperative management of solid organ injury include the degree of hemoperitoneum noted on physical examination or radiographic studies, the hemodynamic response to fluid therapy, or the finding of contrast blush on CT scans.^150,218-220

Angioembolization has been shown to diminish nonoperative management failure rate in blunt splenic and hepatic injuries.^221-223 However, there may be an increase in complications, including bleeding, bile duct injuries, abdominal compartment syndrome, and abscesses.^224,225 The ideal candidate for angioembolization is the patient with active solid organ bleeding who is hemodynamically stable.²²¹

Analgesics should be considered in children with significant pain. Trauma patients and especially children receive less analgesia than do adults.^226,227 Many excuses have been used as reasons to not give analgesics to pediatric trauma patients. One is the belief that localized pain assists in diagnosis and that the masking of the patient’s symptoms may lead to a delay in diagnosis. Others fear the potential harmful side effects from opioid analgesics, including respiratory depression, hypotension, and altered level of consciousness. Pain control may also not be a priority among trauma medical personnel.^228,229 The surgical literature is full of studies that demonstrate that analgesics do not significantly alter the abdominal examination.^230,231 While these studies are mostly concerned with non traumatic causes of abdominal pain, they still have some validity in the trauma patient. If a small bowel perforation is suspected, the child should receive appropriate antibiotics (Table 5). A pediatric surgeon should be consulted for definitive repair of their injury.



The decision to operate in pediatric patients is based not on the anatomy or radiographic grade of the injury, but on the physiologic response to the injury and the evolution of the physiological response to resuscitation. Indications to operate after blunt abdominal trauma are shown in Table 6. Laparoscopic exploration and repair of traumatic abdominal injuries offers many conceptual advantages over the traditional trauma laparotomy in carefully selected patients and is becoming more popular in children.²³² A minimally invasive approach to the traumatized patient maintains the intestines within the peritoneal cavity, preventing tissue desiccation and minimizing fluid and temperature shifts that may result in ileus and may adversely affect the postoperative course.^233,234 Theoretically, patients who have a laparoscopic approach to the repair of bowel injuries may have less pain, more rapid return of intestinal function, earlier hospital discharge, reduced total health care costs, and an earlier return to out-of-hospital activities.^232,235,236 Furthermore, a minimally invasive procedure may allow for quicker recovery after an exploration with negative findings. Finally, inspection of the abdominal contents with magnification during laparoscopy may aid in the detection of subtle injuries.

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