GYNECOLOGIC ONCOLOGY 43, 118-122 (1991)

Splenectomy in Gynecologic Oncology: Indications, Complications, and Technique

MITCHELL MORRIS, M.D., DAVID M. GERSHENSON, M.D., THOMAS W. BURKE, M.D., J. TAYLOR WHARTON, M.D., LARRY J. COPELAND, M.D., AND FELIX N. RUTLEDGE, M.D.

Department of Gynecology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030

Received January 2, 1991

Although uncommonly performed in this setting, splenectomy is sometimes indicated in patients with gynecologic malignancies. From January 1970 through March 1989, 45 patients at The University of Texas M.D. Anderson Cancer Center underwent splenectomy during the course of gynecologic laparotomies. All procedures were performed by the gynecology staff and trainees. Twenty-seven patients (60%) had ovarian cancer; endometrial and cervical cancers were present in three patients each. The re- maining 11 patients had other diseases. Splenectomy was planned preoperatively in only 9 patients (20%). Thirteen patients (29%) underwent splenectopmy because of injury to the spleen. Injury was most commonly due to traction during omentectomy, re- sulting in capsular laceration. The injury was immediately rec- ognized in 12 patients; 1 patient required reexploration for hemo- peritoneum. In 24 patients (53%), splenectomy was performed for tumor reduction. Pathologic examination showed that 11 of 24 patients had capsular involvement by tumor, 7 had paren- chymal metastases, and 6 had no direct splenic involvement. Residual tumor following cytoreduction was smaller than 2 cm in 62.5% of patients. Splenectomy is a well-tolerated procedure and the operative approach can be tailored to the clinical situation and distribution of tumor. An attempt should be made to repair splenic injury when tumor involvement is not present. 0 1991

Academic F’reas, Inc.

INTRODUCTION

Splenectomy is occasionally indicated during surgery for pelvic malignancy. Several reports in the gynecologic literature document small numbers of patients who have undergone splenectomy, with the most common indica- tion being tumor reduction for epithelial carcinoma of the ovary [l-3]. Iatrogenic injury of the spleen is also a re- ported indication in the gynecologic literature [4]. Since splenic involvement with tumor or repair of splenic injury is within the scope of surgery for gynecologic malignancy, it is appropriate that gynecologists be familiar with sple-

nectomy and have knowledge of the conservative alter- natives that may exist.

The purpose of this study was to examine the indica- tions for and complications arising from splenectomy per- formed during the course of gynecologic surgery.

PATIENTS AND METHODS

Retrospective review of patient records for January 1970 through March 1989 identified 45 patients of the gynecology service at The University of Texas M. D. Anderson Cancer Center who underwent splenectomy. All procedures were performed by the gynecology staff and trainees. The mean patient age at the time of surgery was 62 years, with a range of 35 to 83 years. Sixty-four percent of patients had some form of ovarian cancer, seven percent had endometrial cancer, seven percent had cervical cancer, and twenty-seven percent had other di- agnoses (Table 1). Splenectomy was planned preopera- tively in 9 patients (20%).

Survival was calculated using the life-table analysis of Berkson and Gage. Other assessments of statistical sig- nificance were made using the Lee-Desu statistic [5].

RESULTS i”’

The splenectomy procedure was performed for tumor reduction in 24 cases (53%). The mean age of the patients who underwent splenectomy as a cytoreductive procedure was 62 years (range, 39 to 74 years). The procedure was planned preoperatively in only 3 of these 24 cases.

In 13 patients (29%), the spleen was removed because of iatrogenic injury. Splenic rupture was caused by trac- tion injury in all 13 cases. This was most common during omentectomy or during mobilization of the splenic llexure of the colon. In 12 cases, the injury was noted at the time

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TABLE 1 Preoperative Diagnosis

Diagnosis N %

Ovarian cancer 27 60.0 Endometrial cancer 3 6.1 Cervical cancer 3 6.7 Other 12 26.1

Recurrent vaginal cancer 2 Colon cancer 2 Nodular lymphoma 1 Cervical lymphoma 1 Unknown primary 1 Benign pelvic mass 1 MMMT of the uterus 1 CIS of the cervix 1

of surgery and corrected by immediate splenectomy. Fol- lowing cytoreductive surgery, 1 patient required reex- ploration for hemoperitoneum and was found to have an unrecognized splenic laceration. In most cases, pressure and hemostatic agents were applied to the site of injury in an attempt to control bleeding. Formal attempts at splenic repair were not undertaken in this group of patients.

In eight patients (18%), the spleen was removed for other reasons. Indications included splenectomy for au- toimmune thrombocytopenic purpura (three patients), splenomegaly (three), and treatment and staging of lym- phoma (two). In six of these eight patients, splenectomy was planned preoperatively. In all eight cases, the primary

indication for surgery was gynecological. Polyvalent pneu- mococcal vaccine was routinely given to patients following splenectomy.

Splenectomy was well tolerated by most patients. No patient required reexploration for bleeding or abscess fol- lowing splenectomy. Red cell transfusion was required in 39 patients (87%). One patient, who underwent second- ary cytoreductive surgery for recurrent ovarian cancer, developed severe gastrointestinal bleeding and died on Postoperative Day 13.

Postoperative morbidity was seen in 13 women (29%). There were 4 instances of febrile morbidity, 2 of pneu- monia, and 2 of disseminated intravascular coagulation. Two patients each had sepsis and gastrointestinal bleed- ing. Prolonged ileus, hepatitis, and a gastrointestinal an- astomotic leak occurred in 1 patient each. There were no cases of severe thrombocytosis following splenectomy, al- though 1 patient did develop a deep venous thrombosis. No known cases of late sepsis, subphrenic abscess, or pancreatic pseudocyst occurred. Atelectasis of the left lower lung, a common finding after splenectomy, was noted in 6 patients. Since most patients did not receive chest radiographs, the true incidence of this minor com- plication is unknown. All were routinely given incentive spirometry for the first few postoperative days.

Of the 24 patients who underwent splenectomy for tu- mor reduction, the splenectomy was part of the primary operation in 9 (38%) cases. Fifteen patients (62%) had the procedure during secondary cytoreductive surgery. Twenty-two of the twenty-four patients had epithelial car-

FIG. 1. Photomicrograph showing infiltration of the splenic parenchyma by solid areas of poorly differentiated adenocarcinoma.

120 MORRIS ET AL.

FIG. 2. (A) To ensure adequate exposure, a lower-abdominal mid- line incision should be extended to the xiphoid process. (B) Extensive tumor involvement of the omentum with extension to the greater cur- vature of the stomach and to the hilum and capsule of the spleen.

cinema of the ovary, one had a recurrent granulosa cell tumor, and one had an adenocarcinoma of the endo- metrium. At the completion of cytoreductive surgery, 62% had residual tumors smaller than 2 cm. In 7 cases, the spleen was found to have parenchymal involvement by tumor (Fig. 1). Eleven patients had capsular disease, and six had no pathologic involvement by tumor. In these 6 cases, the surgeon felt that optimal cytoreduction re- quired splenectomy because of extensive hilar or peri- capsular involvement.

DISCUSSION

Splenectomy is not ordinarily associated with gyneco- logic surgery. Deppe et al. were the first to report a case

FIG. 3. An anterior approach to the splenic vessels allows early control of the vascular supply.

of splenectomy in a woman undergoing tumor reduction for ovarian cancer [l]. Five additional cases in women with ovarian cancer were reported in the Italian literature. [3]. In that series, all five women suffered severe mor- bidity. More recently, Sonnendecker et al. [4] from South Africa reported on six patients with ovarian cancer who underwent splenectomy during the course of cytoreduc- tive surgery. Tumor involved the spleen in five cases, including one case of parenchymal disease. One patient underwent splenectomy because of a traction injury. Five of six patients in this series suffered severe morbidity, including deep vein thrombosis in two patients, pulmo- nary embolism in two, and a pancratic pseudocyst in one.

Parenchymal splenic metastases from ovarian cancer have been rarely reported [4-71. The 7 cases noted here bring the total reported cases to 10.

The technique of splenectomy in patients with meta- static disease in and around the spleen must be tailored to the clinical situation and the distribution of tumor. Splenic involvement with ovarian cancer is often a result of direct extension from the omentum, and separation of the omentum from the spleen may not be possible (Fig. 2). Tumor plaque involving the spleen or parenchymal lesions is less common.

To perform splenectomy, many surgeons prefer an an- terior approach to the blood supply with ligation of the splenic vessels adjacent to the superior border of the pancreas (Fig. 3). This technique will limit the blood loss should any hilar injury occur during the dissection. The gastrosplenic ligament is initially divided with ligation of the vasa brevia. The parietal peritoneum is incised and the splenic artery is identified along the superior border of the pancreas. Following this artery’s ligation, the re- maining vasa brevia are divided, as is the splenocolic ligament. The remaining ligamentous attachments, which are usually avascular, are then cut. The hilar vessels in- cluding the short gastric vessels are then identified and ligated, and the specimen is removed en bloc.

It is not unusual for anterior surgical access to be lim- ited by the distribution of tumor. In these cases, sple- nectomy is best approached by first dividing the peritoneal attachments of the spleen and then rotating it medially and anteriorly (Fig. 4). The vascular supply may then be divided safely through a posterior approach (Fig. 5). Care should be taken to avoid inadvertent damage to the tail of the pancreas, which could result in pancreatic pseu- docyst formation. The splenic bed need not be routinely drained. The decision to use intraabdominal drainage should be based on the other surgical procedures that were performed.

The most common cause of iatrogenic injury to the spleen during abdominal surgery is traction injury. There is a significant potential for this injury during omentec- tomy, especially when the omentum is involved with tu-

SPLENECTOMY 121

FIG. 4. Division of the lateral ligamentous attachments allows early control of the vascular supply.

mor and has lost some of its flexibility. Injury may also occur during mobilization of the splenic flexure or from improper retractor placement.

Although still incompletely understood, the immuno- logic function of the spleen has been recognized as being important in the adult. Most surgeons advocate repair of all but the most severe splenic ruptures in order to pre- serve splenic function [8-101. In reported series from trauma centers, the majority of splenic ruptures are re- paired. When compared with damage from auto acci- dents, stabbings, and gunshot wounds, the splenic lac- erations due to intraoperative injury are relatively minor.

When repair is attempted, splenorrhaphy should be carried out with adequate exposure, with a midline in- cision extended to the xiphoid process. The spleen should be mobilized by division of its ligamentous attachments and brought into the operative field. Hemorrhage may be immediately controlled by manual compression of the splenic pedicle. Small capsular lacerations may sometimes be controlled with pressure and the application of a he- mostatic agent such as oxidized cellulose. The use of a portion of omentum sutured onto the bleeding site may provide hemostasis. If sutures are required, simple mat- tress sutures tied over the same hemostatic materials may suffice. The argon beam coagulator has also proved useful in these situations. More extensive injuries may require resection of a segment. The raw surface may then be repaired in a similar manner using through-and-through mattress sutures. Successful use of stapling devices for repair has also been reported [ 111. Very extensive injuries or those involving the hilar region are best managed by splenectomy. If the spleen cannot be saved, some sur- geons have advocated implantation of splenic fragments

in the omentum since these fragments frequently achieve viability. It is felt by most, however, that these implants do not have sufficient blood flow and function to clear the encapsulated bacteria implicated in postsplenectomy sepsis.

Contraindications to splenorrhaphy include hemody- namic instability, coagulation defect, splenic pathology such as involvement with tumor, or major hilar injury. Since one or more of these factors are frequently present in patients with advanced ovarian cancer, opportunities for splenorrhaphy may be limited. The risks of splenor- rhaphy include increased blood loss with resultant in- creased need for blood transfusion. Reoperation for bleeding, while not likely, may be necessary.

Although the reported incidence of postsplenectomy sepsis in adults is very small, it is recommended that all patients receive vaccination with the polyvalent pneu- mococcal vaccine (Pneumovax) and a vaccine against Haemophilus influenzae. Ideally, these are given 7 to 10 days before surgery since the level of immunization that is conferred after splenectomy may not be as high. The majority of patients in our group, however, underwent unplanned splenectomy.

In conclusion, splenectomy is occasionally indicated during surgery for gynecologic cancer and, if the surgeon is familiar with the regional anatomy and technique, is safe and relatively straightforward. The procedure may be indicated during the course of cytoreductive surgery for ovarian cancer; however, prior to performing sple- nectomy for this indication, the surgeon should be sure that significant tumor bulk elsewhere is potentially re- sectable. It is difficult to justify splenectomy when the patient has more than 2 cm of residual tumor at other sites. The increasing use of devices such as the ultrasonic

FIG. 5. The splenic vessels may be ligated by a posterior approach.

122 MORRIS ET AL.

aspirator may allow satisfactory cytoreduction with 5. splenic conservation. For patients with iatrogenic splenic rupture, strong consideration should be given to sple- ‘. norrhaphy unless contraindicated.

7. REFERENCES

Deppe, G., Zbella, E. A., Skogerson, K., and Dumitru, I. The 8. rare indication for splenectomy as part of cytoreductive surgery in ovarian cancer, Gynecol. Oncol. 16, 282-287 (1983). 9. Malfetano, J. H. Splenectomy for optimal cytoreduction in ovarian cancer, Gynecol. Oncol. 24, 392-394 (1986). Scarabelli, E., Campagnutta, E., Perin, A., Sopracordevole, F., 10. Scarpa, A., Nenzi, F., and Miotto, E. La splenectomia nel trat- tamento chirurgico radicale de1 carcinoma ovarico, Minerva Gine- col. 37, 37-41 (1985). 11. Sonnendecker, E. W., Guidozzi, F., and Margolius, K. A. Sple- nectomy during primary maximal cytoreductive surgery for epithe- lial ovarian cancer, Gynecol. Oncol. 35, 301-306 (1988).

SPSS-X. Statistical package for the social sciences, 3rd ed., McGraw- Hill, New York (1988). Glezerman, M., Yanai-Inbar, I., Charuzi, I., Katz, M., Glasner, M., and Piura, B. Involvement of the spleen in ovarian adeno- squamous carcinoma, Gynecol. Oncol. 74, 143-148 (1988). Anjou, E., Chollat, I., Bret, P. M., Bretagnolle, M., Valette, P.tJ., and Piox, D., Apport de la tomodensilometrie dans la patologie splenique focalissee, Ann. Radiol. 26, 275-283 (1983). Gourevitch, D., and Hadley, G. P. Splenic conservation after trauma in children, Surg. Gynecol. Obstet. 163, 536-568 (1986). Lally, K. P., Rosario, V., Mahour, G. H., and Woolley, M. M. Evolution in the management of splenic injury in children, Surg. Gynecol. Obstet. 170, 245-248 (1990). Rappaport, W., McIntyre, K. E. J., and Carmona, R. The man- agement of splenic trauma in the adult patient with blunt multiple injuries, Surg. Gynecol. Obstet. 170, 204-208 (1990). Raschbaum, G., Harnar, T. J., and Canizaro, P. C. The use of a stapler in splenic salvage as an alternative to the sutured partial splenectomy or splenorrhaphy, Surg. Gynecol. Obstet. 166, 179- 180 (1988).