Journal of Minimal Access Surgery

[Download PDF]
Year : 2021  |  Volume : 17  |  Issue : 2  |  Page : 141--146

Laparoscopic splenectomy after trauma: Who, when and how. A systematic review

Pietro Fransvea1, Gianluca Costa2, Angelo Serao3, Francesco Cortese4, Genoveffa Balducci2, Gabriele Sganga1, Pierluigi Marini5,  
1 Division of Emergency Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University of Rome, Rome, Italy
2 Department of Translational Medicine, Sant' Andrea Teaching Hospital, Sapienza University of Rome, Rome, Italy
3 Department of General Surgery, Ospedale Dei Castelli, Ariccia, Rome, Italy
4 Emergency Surgery and Trauma Care Unit, St Filippo Neri Hospital, Rome, Italy
5 Department of General and Emergency Surgery, St. Camillo Forlanini's Hospital, Rome, Italy

Correspondence Address:
Dr. Pietro Fransvea
Division of Emergency Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University of Rome, Rome


Importance: A deep knowledge of the indication for laparoscopic splenectomy (LS) in trauma case can lead trauma surgeon to offer in a wider number of situations a minimally invasive approach to a common injuries. Objective: To present and review the advantages and disadvantages of laparoscopic approach for spleen trauma and to identify patient whose can benefit from a minimally invasive approach versus patient that need open surgery to assess the whole severity of trauma. Evidence Review: A systematic review was performed according to the PRISMA statement in order to identify articles reporting LS after trauma. A literature search was performed through MEDLINE (through PubMed), Embase and Google Scholar from January 1990 to December 2018. Studies conducted on animals were not considered. All other laparoscopic procedures for spleen trauma were excluded. Results: Nineteen articles were included in this study, reporting 212 LS after trauma. The most study includes blunt trauma patient. All LS were performed in haemodynamically stable patient. Post-operative complications were reported in all articles with a median post-operative morbidity rate of 30 patients (14.01%), including 16 (7.5%) post-operative deaths. Conclusions and Relevance: This article reports the feasibility and safety of a minimally invasive approach for common trauma injuries which can help non-advanced laparoscopic skill trauma surgeon to develop the best indication to when to adopt this kind of approach.

How to cite this article:
Fransvea P, Costa G, Serao A, Cortese F, Balducci G, Sganga G, Marini P. Laparoscopic splenectomy after trauma: Who, when and how. A systematic review.J Min Access Surg 2021;17:141-146

How to cite this URL:
Fransvea P, Costa G, Serao A, Cortese F, Balducci G, Sganga G, Marini P. Laparoscopic splenectomy after trauma: Who, when and how. A systematic review. J Min Access Surg [serial online] 2021 [cited 2021 Apr 17 ];17:141-146
Available from:

Full Text


Spleen injuries, as reported in literature, represent the most common event among abdominal traumas.[1],[2],[3],[4],[5],[6],[7] Spleen trauma prognosis is strictly related to the severity of the splenic injury and the trauma in general. The treatment of blunt splenic injuries (BSI) has changed significantly during the last 30 years with the non-operative management (NOM) that has become a standard of care both in children and in adults.[8],[9],[10] However, a number of issues regarding the management of adult patients with BSI are still unresolved. Presently, the criteria for NOM of BSI included haemodynamic stability on admission or after initial resuscitation, no peritoneal signs or any associated injuries necessitating laparotomy.[11],[12],[13] The presence of multiple injuries, high-grade splenic injury, a large haemoperitoneum, age and high Injury Severity Score (ISS) are reported as risk factors for failure of NOM. The feasibility, indications and risks of selection for NOM in such instances are less clear. In these cases, the laparoscopic approach could allow spleen removal, full abdominal cavity investigation and haemoperitoneum evacuation with autotransfusion.[14],[15],[16],[17] We performed a systematic review of the published cases of laparoscopic splenectomy (LS) after trauma to explore feasibility and safety of this procedure. Here, we present this analysis.


A systematic review was performed according to the PRISMA statement in order to identify articles reporting LS after trauma. A literature search was performed through MEDLINE (through PubMed), Embase and Google Scholar from January 1990 to December 2018. The following keywords and/or medical subject heading terms were used in combination 'laparoscopy' 'minimal invasive', 'spleen trauma', 'spleen injuries', 'splenectomy'. All articles were reviewed and discussed by four different reviewers, and any discrepancies were resolved in a consensus meeting. Only the papers focusing on LS for traumatic lesions of the spleen among adult population were included. Any paper was excluded from the study group whenever it was not possible to quantify the number of patients undergoing LS after trauma. Whenever the same group of authors presented multiple papers through the years, the papers were considered, but the real number of treated patients was quantified. Studies conducted on animals were not considered. All conservative laparoscopic procedures for spleen trauma were excluded. The search was limited to English language papers but not restricted according to study type. PRISMA flow chart is reported in [Figure 1]. The following criteria were identified and analysed: patient age and gender, indication for LS procedure, type and mechanism of injuries, Abbreviated Injury Scale (AIS) of the spleen, ISS, technical tips aiming to reduce complications such as pre-operative splenic embolisation. The following surgery outcomes were considered: operative time (defined as the 'skin-to-skin' time), blood loss, conversion from minimal invasive to open approach, length of hospital stay (defined as the number of nights the patient stayed in the hospital), intraoperative and post-operative complications (defined as any deviation from the normal post-operative course), including mortality.{Figure 1}


From 1990 to December 2018, 212 LS after trauma were retrieved from 19 articles [Table 1].[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35] Median was 30.84 years, ranging from 17 years to 69 years. Pre-operative immunisation (usually with polyvalent pneumococcal vaccine, meningococcal vaccine, as well as confirmation of previous Haemophilus influenzae Type B vaccine) was rarely reported. Clinical features are summarised in [Table 2]. Trauma mechanism: among 212 LS, 198 (93.4%) were performed for blunt trauma and 14 LS (6.6%) for penetrating trauma. Type of injury: AIS of the spleen was specified in 192 cases. The median AIS was 3,2 ISS was specified in 172 cases. The median ISS was 16.81 (range: 4–26,9). Clinical status: Haemodynamic status and Glasgow Coma Scale (GCS) were reported in 7 and 12 articles, respectively. 18 patients were unstable before operation and median GCS was 14,5. Pre-operative embolisation was reported in three articles, all patients of these articles underwent LS after failure of conservative management attempt with embolisation. Blood loss: excluding haemostatic procedures in an emergency, blood transfusion was reported in four articles with no massive transfusion protocol evidenced. Mean operative time of LS without any other procedure was reported in nine articles, with a mean operative time of 106,6 min. Elapsed Time from hospital arrival to surgery was reported in nine series with a median rate of 5,5 days. Outcomes are summarised in [Table 3]: Conversion from laparoscopy to laparotomy: among the 212 reported laparoscopic procedures, 0 (0%) required conversion to laparotomy. Post-operative complications were reported in all articles with a median post-operative morbidity rate of 30 patients (14.01%) including 16 (7.5%) post-operative deaths. Length of hospital stay was reported in 16 articles. A mean hospital stay of 5,85 days was recorded.{Table 1}{Table 2}{Table 3}


Growing evidence supports that laparoscopy has become a good alternative in the management of abdominal trauma.[36],[37],[38],[39],[40] Nevertheless, it had a slow acceptance among trauma surgeon. It has become clear that a negative laparotomy carries the risk of increased morbidity and mortality, and that minimally invasive procedures significantly reduce additional surgical trauma or, in the case of negative laparotomies, avoid it entirely.[41],[42],[43] We all realised the advantages of this approach include less post-operative pain, faster recovery, quicker return to everyday activities and low incidence of incisional hernias and surgical site infections.[44],[45] Another advantage described in trauma is that by selecting correctly the patients who are candidates for this approach, we can avoid unnecessary non-therapeutic laparotomies, thus reducing morbidity and mortality. Recognised limits of NOM and major complications after angioembolisation including spleen infarctions (in 19%–100%), abscesses and bleeding (in 6%–27%), persistent pain (in up to 33% of the cases), recent trend towards a mini-invasive attitude, introduction of new tools for dissection and vascular ligation and enhanced visibility have played a role in the recent diffusion of LS after trauma.[46],[47],[48] According to the results of our review and as report by Di Saverio et al.,[36] LS after trauma is feasible and safety only in haemodynamically stable or stabilised patient.[17],[18],[19],[20],[21],[22] The present data indicate that there is no indication for LS for unstable patients who must be treated with open procedure.[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49] Mechanism of injuries is predominantly blunt trauma such as motor vehicles accident and fall from height. Laparoscopy for penetrating trauma is performed only in the centre with high rate of penetrating injuries and advanced experienced surgeon in these fields.[50],[51],[52] In these setting as shown by Sosa et al.,[53] laparoscopy can be 100% accurate in identifying peritoneal stab wounds According to series article review, the attitude is to attempt at first a NOM with or without splenic embolisation and in case of failure of this proceed with LS.[17],[21],[22],[23],[24],[25] In this retrospective data set, we were unable to elucidate the clinical factors prompting the decision to perform surgery; however, prior reports showed that factors which lead to failure of NOM include age older than 55 years, ISS >25, haemoperitoneum >300 mL, rupture of subcapsular haematoma or intraparenchymal pseudoaneurysms active contrast extravasation on computed tomography and delayed bleeding.[54],[55],[56] These findings correlate with the data that emerged from our analysis, which shows that most of the procedures are carried out 24 h after trauma. From a technical point of view, most reports do not concentrate on differences in the surgical technique. There are publications that focus mostly on surgical access to the peritoneal cavity rather than the technique of dissection of the splenic hilum and control of the vascular pedicle of the spleen.[17],[18],[19],[20],[21],[22],[23],[24],[25] Some authors advocate the use of spleen-preserving operations such as splenorrhaphy, partial splenectomy or haemostatic collagen application to avoid the overwhelming post-splenectomy sepsis and immunodeficiency. However, the incidence of post-splenectomy sepsis in adults is very low (<1%). Moreover, whether spleen preservation improves immunologic function remains a matter of debate.[57],[58],[59] Regarding the use of post-operative drainage, it is well known that are directly related to the occurrence of surgical site infections, but unfortunately, there is a lack of reliable data concerning recent use of drains, and we could not include this parameter in our analysis.[60],[61],[62] The results of the current reviews showed less blood loss and longer operating room times with the laparoscopy group. The longer operating times could be associated with the setup of the laparoscopic equipment, as well as technique-related difficulties: intra-abdominal blood obstructing visualisation and morselising the spleen. However, according to the reports, LS is associated with lower post-operative pain, reduced surgical trauma and better cosmetic effect.[17],[18],[19],[20],[23],[24] Moreover, the most important technics advantage of the laparoscopic approach is allowing to carry out a complete exploration of the abdominal cavity to exclude other associated injuries and thus allow the patient to be discharged early avoiding long clinical observation and prolonged imaging examination. Although the conversion rate is widely quiet low, the need to convert splenectomy from a laparoscopic approach to open surgery should probably prompt surgeons not to underestimate LS technical difficulty. In our opinion, the best indication for LS is in the one hand, stable patient with spleen injury that failed NOM, and on the other hand, stable patient with spleen injury and the suspicion for other possible injury such as hollow viscus injuries or diaphragmatic rupture. Not to forget patient who asks for splenectomy for a safety and shorter recovery. The largest series in the literature show how spleen injuries are associated in more than 65% of cases with other intra- and extra-abdominal al injuries. Spleen AIS is not correlated with the choice of approach, while a threshold of lower ISS is correlated with the choice of minimally invasive procedure. Huscher et al.[33] published a case series on LS, and further reports by Huscher, Dissanaike and Frezza and Basso et al.[32],[33],[34],[35] all highlighted the successful use of LS when managing patients with a high Grade IV or V splenic injuries. Regarding outcomes, the literature on LS in a trauma setting is limited, but there are published reports that demonstrate successful management of trauma patients via LS. Huang et al.[18] published a report regarding 11 trauma patients managed via LS and noted similar post-operative courses compared with overall survival patient. Nasr et al.[34] reported a series of four stable patients undergoing delayed LS for blunt trauma with favourable outcomes. Recently, Shamim et al.[17] reports a series of 113 consecutive patients underwent LS for trauma with a morbidity and mortality rate of 19.4% and 14.1%, respectively. In another series of Li et al.,[19] the mortality rate was 0. According to the reports, mortality and morbidity rate remains stable during time suggesting that above all the mortality rate obtained is reflective of the overall injury burden incurred by the patient and is not attributed to the surgical intervention.[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[42] In light of these findings, as surgeons become more experienced and comfortable in laparoscopic techniques, the use of LS in trauma patients is expected to rise. From the results of this study, we advocate that in a haemodynamically stable trauma patient with splenic injury, LS should be entertained by surgeons with the appropriate skills.


In conclusion, the results of this study support the feasibility and safety of laparoscopic approach in the management of spleen injuries in stable trauma patient in whom initial NOM fails. However, further studies are needed before we can draw an objective conclusion. A well-designed, ethically sound, randomised, multicentre trial in haemodynamically stable patients in whom NOM has failed is warranted. Nevertheless, such a review may allow surgeons to acknowledge LS indications.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Feliciano DV. Abdominal trauma revisited. Am Surg 2017;83:1193-202.
2Bardes JM, Inaba K, Schellenberg M, Grabo D, Strumwasser A, Matsushima K, et al. The contemporary timing of trauma deaths. J Trauma Acute Care Surg 2018;84:893-9.
3El-Menyar A, Abdelrahman H, Al-Hassani A, Peralta R, AbdelAziz H, Latifi R, et al. Single versus multiple solid organ injuries following blunt abdominal trauma. World J Surg 2017;41:2689-96.
4Zarzaur BL, Kozar R, Myers JG, Claridge JA, Scalea TM, Neideen TA, et al. The splenic injury outcomes trial: An American Association for the Surgery of trauma multi-institutional study. J Trauma Acute Care Surg 2015;79:335-42.
5Nagata I, Abe T, Uchida M, Saitoh D, Tamiya N. Ten-year inhospital mortality trends for patients with trauma in Japan: A multicentre observational study. BMJ Open 2018;8:e018635.
6Abolfotouh MA, Hussein MA, Abolfotouh SM, Al-Marzoug A, Al-Teriqi S, Al-Suwailem A, et al. Patterns of injuries and predictors of inhospital mortality in trauma patients in Saudi Arabia. Open Access Emerg Med 2018;10:89-99.
7Pfeifer R, Schick S, Holzmann C, Graw M, Teuben M, Pape HC. Analysis of injury and mortality patterns in deceased patients with road traffic injuries: An autopsy study. World J Surg 2017;41:3111-9.
8Leppäniemi A. Nonoperative management of solid abdominal organ injuries: From past to present. Scand J Surg 2019;108:95-100.
9Yiannoullou P, Hall C, Newton K, Pearce L, Bouamra O, Jenks T, et al. A review of the management of blunt splenic trauma in England and wales: Have regional trauma networks influenced management strategies and outcomes? Ann R Coll Surg Engl 2017;99:63-9.
10Brenner M, Hicks C. Major abdominal trauma: Critical decisions and new frontiers in management. Emerg Med Clin North Am 2018;36:149-60.
11Bagaria D, Kumar A, Ratan A, Gupta A, Kumar A, Kumar S, et al. Changing aspects in the management of splenic injury patients: Experience of 129 isolated splenic injury patients at level 1 trauma center from India. J Emerg Trauma Shock 2019;12:35-9.
12Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, Guillamondegui OD, et al. Selective nonoperative management of blunt splenic injury: An Eastern Association for the Surgery of Trauma Practice Management Guideline. J Trauma Acute Care Surg 2012;73:S294-300.
13El-Matbouly M, Jabbour G, El-Menyar A, Peralta R, Abdelrahman H, Zarour A, et al. Blunt splenic trauma: Assessment, management and outcomes. Surgeon 2016;14:52-8.
14Dhillon NK, Barmparas G, Thomsen GM, Patel KA, Linaval NT, Gillette E, et al. Nonoperative management of blunt splenic trauma in patients with traumatic brain injury: Feasibility and outcomes. World J Surg 2018;42:2404-11.
15Furlan A, Tublin ME, Rees MA, Nicholas DH, Sperry JL, Alarcon LH. Delayed splenic vascular injury after nonoperative management of blunt splenic trauma. J Surg Res 2017;211:87-94.
16Swaid F, Peleg K, Alfici R, Matter I, Olsha O, Ashkenazi I, et al. Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: An analysis of a national trauma registry database. Injury 2014;45:1409-12.
17Shamim AA, Zafar SN, Nizam W, Zeineddin A, Ortega G, Fullum TM, et al. Laparoscopic splenectomy for trauma. JSLS 2018;22. pii: e2018.00050.
18Huang GS, Chance EA, Hileman BM, Emerick ES, Gianetti EA. Laparoscopic splenectomy in hemodynamically stable blunt trauma. JSLS 2017;21. pii: e2017.00013.
19Li H, Wei Y, Peng B, Li B, Liu F. Feasibility and safety of emergency laparoscopic partial splenectomy: A retrospective analysis. Medicine (Baltimore) 2017;96:e6450.
20Trejo-Ávila ME, Valenzuela-Salazar C, Betancourt-Ferreyra J, Fernández-Enríquez E, Romero-Loera S, Moreno-Portillo M. Laparoscopic versus open surgery for abdominal trauma: A case-matched study. J Laparoendosc Adv Surg Tech A 2017;27:383-7.
21Birindelli A, Segalini E, Affinita A, Tugnoli G, Di Saverio S. Laparoscopic splenectomy with selective intra-corporeal ligation of splenic hilar vessels for high grade splenic injury-video vignette. Colorectal Dis 2017. doi: 10.1111/codi.13988.
22Ermolov AS, Tlibekova MA, Yartsev PA, Guliaev AA, Rogal MM, Samsonov VT, et al. Laparoscopic splenectomy in patients with spleen injuries. Surg Laparosc Endosc Percutan Tech 2015;25:483-6.
23Morsi M, Wael M, Yahia Z. Use of laparoscopy in the management of abdominal trauma: a center experience. Egypt J Surg 2015;4:11-6.
24Khubutiya MS, Yartsev PA, Guliaev AA, Levitsky VD, Tlibekova MA. Laparoscopy in blunt and penetrating abdominal trauma. Surg Laparosc Endosc Percutan Tech 2013;23:507-12.
25Fan Y, Wu SD, Siwo EA. Emergency transumbilical single-incision laparoscopic splenectomy for the treatment of traumatic rupture of the spleen: Report of the first case and literature review. Surg Innov 2011;18:185-8.
26Carobbi A, Romagnani F, Antonelli G, Bianchini M. Laparoscopic splenectomy for severe blunt trauma: Initial experience of ten consecutive cases with a fast hemostatic technique. Surg Endosc 2010;24:1325-30.
27Rolton DJ, Lovegrove RE, Dehn TC. Laparoscopic splenectomy and diaphragmatic rupture repair in a 27-week pregnant trauma patient. Surg Laparosc Endosc Percutan Tech 2009;19:e159-60.
28Ransom KJ, Kavic MS. Laparoscopic splenectomy following embolization for blunt trauma. JSLS 2008;12:202-5.
29Agarwal N. Laparoscopic splenectomy in a case of blunt abdominal trauma. J Minim Access Surg 2009;5:78-81.
30Ayiomamitis GD, Alkari B, Owera A, Ammori BJ. Emergency laparoscopic splenectomy for splenic trauma in a Jehovah's witness patient. Surg Laparosc Endosc Percutan Tech 2008;18:626-30.
31Pucci E, Brody F, Zemon H, Ponsky T, Venbrux A. Laparoscopic splenectomy for delayed splenic rupture after embolization. J Trauma 2007;63:687-90.
32Dissanaike S, Frezza EE. Laparoscopic splenectomy in blunt trauma. JSLS 2006;10:499-503.
33Huscher CG, Mingoli A, Sgarzini G, Brachini G, Ponzano C, Di Paola M, et al. Laparoscopic treatment of blunt splenic injuries: Initial experience with 11 patients. Surg Endosc 2006;20:1423-6.
34Nasr WI, Collins CL, Kelly JJ. Feasibility of laparoscopic splenectomy in stable blunt trauma: A case series. J Trauma 2004;57:887-9.
35Basso N, Silecchia G, Raparelli L, Pizzuto G, Picconi T. Laparoscopic splenectomy for ruptured spleen: Lessons learned from a case. J Laparoendosc Adv Surg Tech A 2003;13:109-12.
36Di Saverio S, Birindelli A, Podda M, Segalini E, Piccinini A, Coniglio C, et al. Trauma laparoscopy and the six w's: Why, where, who, when, what, and how? J Trauma Acute Care Surg 2019;86:344-67.
37Cirocchi R, Birindelli A, Inaba K, Mandrioli M, Piccinini A, Tabola R, et al. Laparoscopy for trauma and the changes in its use from 1990 to 2016: A current systematic review and meta-analysis. Surg Laparosc Endosc Percutan Tech 2018;28:1-2.
38Matsevych OY, Koto MZ, Motilall SR, Kumar N. The role of laparoscopy in management of stable patients with penetrating abdominal trauma and organ evisceration. J Trauma Acute Care Surg 2016;81:307-11.
39Teuben M, Spijkerman R, Pfeifer R, Blokhuis T, Huige J, Pape HC, et al. Selective non-operative management for penetrating splenic trauma: A systematic review. Eur J Trauma Emerg Surg 2019. doi: 10.1007/s00068-019-01117-1. [Epub ahead of print].
40Martin MJ, Brown CV, Shatz DV, Alam HB, Brasel KJ, Hauser CJ, et al. Evaluation and management of abdominal stab wounds: A Western trauma association critical decisions algorithm. J Trauma Acute Care Surg 2018;85:1007-15.
41Schnüriger B, Lam L, Inaba K, Kobayashi L, Barbarino R, Demetriades D. Negative laparotomy in trauma: Are we getting better? Am Surg 2012;78:1219-23.
42Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: A prospective study of morbidity. J Trauma 1995;38:350-6.
43Weigelt JA, Kingman RG. Complications of negative laparotomy for trauma. Am J Surg 1988;156:544-7.
44Di Saverio S. Emergency laparoscopy: A new emerging discipline for treating abdominal emergencies attempting to minimize costs and invasiveness and maximize outcomes and patients' comfort. J Trauma Acute Care Surg 2014;77:338-50.
45Harvin JA, Kao LS, Liang MK, Adams SD, McNutt MK, Love JD, et al. Decreasing the use of damage control laparotomy in trauma: A quality improvement project. J Am Coll Surg 2017;225:200-9.
46Trust MD, Teixeira PG, Brown LH, Ali S, Coopwood B, Aydelotte JD, et al. Is it safe? Nonoperative management of blunt splenic injuries in geriatric trauma patients. J Trauma Acute Care Surg 2018;84:123-7.
47Leeper WR, Leeper TJ, Ouellette D, Moffat B, Sivakumaran T, Charyk-Stewart T, et al. Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma: Early screening leads to a decrease in failure rate. J Trauma Acute Care Surg 2014;76:1349-53.
48Aiolfi A, Inaba K, Strumwasser A, Matsushima K, Grabo D, Benjamin E, et al. Splenic artery embolization versus splenectomy: Analysis for early in-hospital infectious complications and outcomes. J Emerg Trauma Shock 2019;12:35-9.
49Justin V, Fingerhut A, Uranues S. Laparoscopy in blunt abdominal trauma: For whom? When? and why? Curr Trauma Rep 2017;3:43-50.
50Koto MZ, Matsevych OY, Mosai F, Patel S, Aldous C, Balabyeki M. Laparoscopy for blunt abdominal trauma: A challenging endeavor. Scand J Surg 2018:1457496918816927. doi: 10.1177/1457496918816927. [Epub ahead of print].
51Matsevych O, Koto M, Balabyeki M, Aldous C. Trauma laparoscopy: When to start and when to convert? Surg Endosc 2018;32:1344-52.
52Koto MZ, Matsevych OY, Mosai F, Balabyeki M, Aldous C. Laparoscopic management of retroperitoneal injuries from penetrating abdominal trauma in haemodynamically stable patients. J Minim Access Surg 2019;15:25-30.
53Sosa JL, Arrillaga A, Puente I, Sleeman D, Ginzburg E, Martin L. Laparoscopy in 121 consecutive patients with abdominal gunshot wounds. J Trauma 1995;39:501-4.
54Smith SR, Morris L, Spreadborough S, Al-Obaydi W, D'Auria M, White H, et al. Management of blunt splenic injury in a UK major trauma centre and predicting the failure of non-operative management: A retrospective, cross-sectional study. Eur J Trauma Emerg Surg 2018;44:397-406.
55Olthof DC, Joosse P, van der Vlies CH, de Haan RJ, Goslings JC. Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: A systematic review. J Trauma Acute Care Surg 2013;74:546-57.
56Olufajo OA, Rios-Diaz A, Peetz AB, Williams KJ, Havens JM, Cooper ZR, et al. Comparing readmissions and infectious complications of blunt splenic injuries using a statewide database. Surg Infect (Larchmt) 2016;17:191-7.
57Zarzaur BL, Dunn JA, Leininger B, Lauerman M, Shanmuganathan K, Kaups K, et al. Natural history of splenic vascular abnormalities after blunt injury: A Western Trauma Association multicenter trial. J Trauma Acute Care Surg 2017;83:999-1005.
58Fair KA, Connelly CR, Hart KD, Schreiber MA, Watters JM. Splenectomy is associated with higher infection and pneumonia rates among trauma laparotomy patients. Am J Surg 2017;213:856-61.
59Stockinger Z, Grabo D, Benov A, Tien H, Seery J, Humphries A. Blunt abdominal trauma, splenectomy, and post-splenectomy vaccination. Mil Med 2018;183:98-100.
60Samaiya A. To drain or not to drain after colorectal cancer surgery. Indian J Surg 2015;77:1363-8.
61Messager M, Sabbagh C, Denost Q, Regimbeau JM, Laurent C, Rullier E, et al. Is there still a need for prophylactic intra-abdominal drainage in elective major gastro-intestinal surgery? J Visc Surg 2015;152:305-13.
62Fransvea P, Costa G, Massa G, Frezza B, Mercantini P, BaIducci G. Non-operative management of blunt splenic injury: Is it really so extensively feasible? a critical appraisal of a single-center experience. Pan Afr Med J 2019;32:52. doi: 10.11604/pamj.2019.32.52.15022. eCollection 2019.