The Left: Spleen, Distal Pancreas,

and Omentum

Robert E. Bristow, MD, MBA

Division of Gynecologic Oncology

Department of Obstetrics and Gynecology

University of California, Irvine – Medical Center

Educational Forum VIII: Innovation Techniques for Surgical Debulking:

Essentials of Cytoreductive Surgery

VERBAL DISCLOSURE No disclosures or conflicts of interests.

“The Spleen” Job description: superhero

Class: human cursed by magic

History: as a child, The Spleen

was rude to an old Gypsy woman,

trying to pass off his own flatulence

as hers, so she cursed him, making

his emissions extremely potent

Powers: The Spleen can break wind which is so powerful

that those in the path of the gas lose consciousness and

are left completely incapacitated

Splenectomy / Distal Pancreatectomy Indications

• Surgical cytoreduction that will contribute to

optimal (≤1cm) or no gross residual disease

- primary surgery (frequency as high as 14%)

- secondary surgery (isolated splenic disease common)

• Hemorrhage control after traumatic injury to spleen

- usually occurs during omentectomy as a result of

excessive downward traction at splenic flexure

- fortunately uncommon indication

Magtibay PM et al. Gynecol Oncol 2006; 102: 369.

Chen LM et al. Gynecol Oncol 2000; 77: 362.

• Location of splenic metastasis

- Capsule: 52-63%

- Parenchyma: 16-46%

- Hilum: 52-66%

• Distal pancreas involvement

- frequency not well defined

- tail of pancreas is located only 1cm from

splenic hilum in 75% of cases

Splenectomy / Distal Pancreatectomy

Anatomic relationships

Spleen - Anatomy

Vasculature

• Positioning

- dorsal lithotomy preferred

- reverse Trendelenburg / rightward tilt

• Incision(s)

- vertical midline most versatile

- subcostal for isolated splenic disease

• Retractor

- self-retaining (upward traction on costal margin)

• Surgeon position

- patient left side or between legs

Splenectomy Procedure

Splenectomy Procedure • Evaluation of extent of disease

• Plan the operation & sequence of procedures

• Operational tasks (divide and conquer)

- splenicocolic ligament

- gastrosplenic ligament (and short gastric aa.)

- splenophrenic ligament

- splenorenal ligament

- splenic artery

- splenic vein

Splenectomy / Distal Pancreatectomy • Surgical stapler utilized for transection of pancreas

- vascular load preferred

• Suture reinforcement of transection line associated

with reduced incidence of pancreatic leak

• Elective ligation of pancreatic duct may reduce

incidence of pancreatic leak

• Drainage of LUQ

- check amylase POD#3

Splenectomy / Distal Pancreatectomy

• Use for bulky anterior disease or hilum tumor

• Divide omentum, enter lesser sac as far as possible

• Mobilize splenic flexure

• Divide splenorenal ligament, rotate spleen medially

• Isolate and divide splenic a.&v.

- individually (suture) or together (stapler)

• Distal pancreatectomy or dissect tail of pancreas

• Divide gastrosplenic ligament & short gastric aa.

- partial gastrectomy (if necessary)

Splenectomy - Posterior Approach

Splenectomy - Posterior Approach

Splenectomy - Anterior Approach • Use for bulky posterior disease or diaphragm tumor

• Divide omentum, enter lesser sac

- visualize pancreas, splenic a.&v.

• Mobilize splenic flexure

• Divide gastrosplenic ligament, short gastric aa.

- expose splenic hilum, tail of pancreas

• Isolate and divide splenic a.&v.

- individually (suture) or together (stapler)

• Divide splenorenal ligament, rotate spleen medially

- separate tail of pancreas, remaining attachments

Splenectomy - Anterior Approach

Splenectomy with Contiguous Diaphragm Disease

Strategic Approach

• Open lesser sac

• Divide gastrosplenic ligament

• Early ligation of splenic a. & v.

• Approach diaphragm disease

- peritonectomy, FT resection

• Mobilize spleen medially

• Dissect/resect tail of pancreas

Multi-Visceral Resection Partial Gastrectomy

Left Upper Quadrant Cytoreduction Summary

• Indications

- Primary and secondary cytoreduction that contributes

to an overall complete / optimal resection

- Management of traumatic splenic injury

• Technical approach

- Anterior / posterior / combined approach dictated by

extent and locale of disease

• Morbidity

- Acceptable and predictable