Splenectomy

In the presence of extensive omental involvement, metastatic implants occasionally involve the splenic hilum, capsule, or parenchyma and may necessitate the removal of the spleen en bloc with the omentum. Magtibay and colleagues24 described their center's experience with splenectomy as part of cytoreductive surgery in ovarian cancer and showed that splenectomy as part of primary or secondary cytoreductive surgery is associated with modest morbidity and mortality. Their data also confirmed that overall survival was substantially influenced by residual disease status after completion of primary surgical cytoreduction.

Before proceeding with the splenectomy, it is necessary to palpate the spleen and omentum to determine the extent of disease. Not infrequently one has to proceed with an en bloc resection of the omentum and spleen, since splenic involvement is often a result of direct extension from the omentum (Fig. 7-14). In such a case, a posterior approach is often preferred. The splenocolic, splenorenal, and spleno-phrenic ligamentous attachments of the spleen are first divided, allowing the spleen to be gently rotated anteriorly and medially (Fig. 7-15). The gastrosplenic ligament is then incised while carefully isolating and ligating the short gastric vessels and thus exposing the vascular supply, which can then be divided safely (Fig. 7-16). Care should be taken not to injure the tail of the pancreas. An anterior approach often limits blood loss in the event of a hilar injury or uncontrolled bleeding during the dissection. The gastrosplenic ligament is first divided and the short gastric vessels identified and ligated. The parietal peritoneum is incised, allowing the splenic vessels to be identified and secured (Fig. 7-17). The remaining attachments can then be incised and the specimen removed.

Because of the risk of postsplenectomy sepsis, patients undergoing elective sple-nectomy should be immunized against encapsulated organisms (meningococcus, pneumococcus, and Haemophilus influenzae) ideally a minimum of 10 days before surgery; alternatively, the vaccines can be given postoperatively.

Figure 7-15. Division of the lateral ligamentous attachments allows early control of the vascular supply. (From Morris M, Gershenson DM, Burke TW, et al: Splenectomy in gynecologic oncology: indications, complications, and technique. Gynecol Oncol 43:118-122, 1991, Figure 4.)

Figure 7-16. The splenic vessels may be ligated by a posterior approach. (From Morris M, Gershenson DM, Burke TW, et al: Splenectomy in gynecologic oncology: indications, complications, and technique. Gynecol Oncol 43:118-122, 1991, Figure 5.)

Figure 7-16. The splenic vessels may be ligated by a posterior approach. (From Morris M, Gershenson DM, Burke TW, et al: Splenectomy in gynecologic oncology: indications, complications, and technique. Gynecol Oncol 43:118-122, 1991, Figure 5.)

Chapter 7 Ovarian Cancer Surgery 121

Figure 7-17. An anterior approach to the splenic vessels allows early control of the vascular supply. (From Morris M, Gershenson DM, Burke TW, et al: Splenectomy in gynecologic oncology: indications, complications, and technique. Gynecol Oncol 43:118-122, 1991, Figure 3.)
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