The Left: Spleen, Distal Pancreas, and Omentum · The Left: Spleen, Distal Pancreas, and Omentum...

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Transcript of The Left: Spleen, Distal Pancreas, and Omentum · The Left: Spleen, Distal Pancreas, and Omentum...

  • 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