the left: spleen, distal pancreas, and omentum · the left: spleen, distal pancreas, and omentum...
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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
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VERBAL DISCLOSURE No disclosures or conflicts of interests.
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“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
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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
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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
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Anatomic relationships
Spleen - Anatomy
Vasculature
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• 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
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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
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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
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Splenectomy / Distal Pancreatectomy
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• 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
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Splenectomy - Posterior Approach
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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
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Splenectomy - Anterior Approach
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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
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Multi-Visceral Resection Partial Gastrectomy
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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