Different approaches for complete mobilization of the splenic flexure during laparoscopic rectal cancer resection

Innovative pancreas-guided technique for splenic flexure mobilization in laparoscopic left hemicolectomy

OBJECTIVE

Splenic flexure mobilization (SFM) is a major challenge in laparoscopic left hemicolectomy. This study aims to assess the safety and effectiveness of the pancreas-guided SFM technique during laparoscopic left hemicolectomy.

METHODS

From January 2018 to December 2023, 352 patients with left-sided colon cancer underwent laparoscopic left hemicolectomy. Based on the SFM method used, the patients were divided into the pancreas-guided group (167 cases) or the "Three Approaches Roundabout"/classic group (185 cases). Clinicopathologic characteristics and intraoperative and postoperative variables were compared between the two groups.

RESULTS

The two groups had no significant differences in baseline indicators (P > 0.05). All surgeries were successful without needing to convert to laparotomy, and there were no combined organ resections involving the spleen or pancreas in either group. The mean duration of surgery was significantly lower in the pancreas-guided group than in the classic group (P < 0.01). The median volume of intraoperative blood loss in the pancreas-guided group was lower than that in the classic group (P < 0.01). Through video playback, it was found that the retro-pancreatic space had been entered during operation in 8 cases (4.3%) in the classic group, while there were no such occurrences in the pancreas-guided group. This difference was statistically significant (P < 0.05). The difference in the number of lymph nodes cleared, postoperative hospital stays, and incidence of complications were not statistically significant (all P > 0.05) between the groups.

CONCLUSION

The pancreas-guided SFM technique is a safe and feasible option for laparoscopic left hemicolectomy. Our study's findings suggest that this approach facilitates accurate access to the correct anatomic plane, potentially improving surgical efficiency.

How to do it: Splenic flexure mobilisation via medial trans-mesocolic approach

Complete splenic flexure mobilization is a critical step in left-sided colorectal resections. Surgeons use three approaches-anterior, medial, and lateral-to divide peritoneal ligaments connecting the left colon. The decision to perform mobilization varies, with minimal impact on post-operative outcomes but longer surgery times and rare complications. Pancreatic injury risk is low, though other structures, like arteries and the duodenum, may be at risk. Our video outlines the medial trans-mesocolic approach, with the patient positioned in lithotomy. We expose the duodenal-jejunal flexure, ligate the inferior mesenteric vein, and perform medial to lateral dissection, completing splenic flexure mobilization. This video vignette outlines how to perform this technique for left sided colorectal resections.

SAGES masters program: the top 10 seminal articles for the laparoscopic left and sigmoid colectomy pathway for complex disease

BACKGROUND

The SAGES University Colorectal Masters Program is a structured educational curriculum that is designed to aid practicing surgeons develop and maintain knowledge and technical skills for laparoscopic colorectal surgery. The Colorectal Pathway is based on three anchoring procedures (laparoscopic right colectomy, laparoscopic left and sigmoid colectomy for uncomplicated and complex disease, and intracorporeal anastomosis for minimally invasive right colectomy) corresponding to three levels of performance (competency, proficiency and mastery). This manuscript presents focused summaries of the top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease.

METHODS

A systematic literature search of Web of Science for the most cited articles on the topic of laparoscopic complex left/sigmoid colectomy yielded 30 citations. These articles were reviewed and ranked by the SAGES Colorectal Task Force and invited subject experts according to their citation index. The top 10 ranked articles were then reviewed and summarized, with emphasis on relevance and impact in the field, study findings, strength and limitations and conclusions.

RESULTS

The top 10 seminal articles selected for the laparoscopic left/sigmoid colectomy for complex disease anchoring procedure include advanced procedures such as minimally invasive splenic flexure mobilization techniques, laparoscopic surgery for complicated and/or diverticulitis, splenic flexure tumors, complete mesocolic excision, and other techniques (e.g., Deloyers or colonic transposition in cases with limited colonic reach after extended left-sided resection).

CONCLUSIONS

The SAGES Colorectal Masters Program top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease anchoring procedure are presented. These procedures were the most essential in the armamentarium of practicing surgeons that perform minimally invasive surgery for complex left and sigmoid colon pathology.

Gaining Mesenteric Length following Colorectal Resection: Essential Maneuvers to Avoid Anastomotic Tension

A surgeon must possess the knowledge and technical skill to obtain length following a left-sided colorectal resection to perform a tension free anastomosis. The distal target organ - either rectum or anus - is fixed in location, and therefore requires surgeons to acquire mastery of proximal mobilization of the colonic conduit. Generally, splenic flexure mobilization (SFM) provides adequate length. Surgeons benefit from clearer understanding of the multiple steps involved in SFM as a result of improved visualization and demonstration of the relevant anatomy - adjacent organs and the attachments, embryologic planes, and mesenteric structures. Much may be attributed to laparoscopic and robotic platforms which provided improved exposure and as a result, development or refinement of novel approaches for SFM with potential advantages. Complete mobilization draws upon the sum or combination of the varied approaches to accomplish the goal. However, in the situation where extended resection is necessary or in the case of re-operative surgery sacrificing either more proximal or distal large intestine often occurs, the transverse colon or even the ascending colon represents the proximal conduit for anastomosis. This challenging situation requires familiarity with special maneuvers to achieve colorectal or coloanal anastomosis using these more proximal conduits. In such instances, operative techniques such as either ileal mesenteric window with retroileal anastomosis or de-rotation of the right colon (Deloyer's procedure) enable the intestinal surgeon to construct such anastomoses and thereby avoid stoma creation or loss of additional large intestine.

Pancreatic injuries following laparoscopic splenic flexure mobilization

PURPOSE

To call awareness to pancreatic injury occurring following laparoscopic splenic flexure mobilization (LSFM) and to discuss the mechanisms which led to such an injury.

METHODS

Retrospective review of patients who underwent LSFM as part of their colectomy procedure and sustained pancreatic injuries at a colorectal surgery referral center during 2014-2021.

RESULTS

Of 1022 (0.6%) LSFM performed during the study period, six (0.6%) patients were identified in which clinically significant injuries to the pancreas occurred. Two patients had partial transection of the tail of the pancreas and underwent laparoscopic distal pancreatectomy during the index operation. Three patients developed a post-operative pancreatic fistula after their pancreatic injury went undiagnosed during surgery and required percutaneous drainage, one of whom eventually required a distal pancreatectomy for a persistent pancreatic fistula. Another patient developed a peripancreatic fluid collection which resolved with conservative treatment.

CONCLUSIONS

Pancreatic injury is rare and a potentially major complication of LSFM. Anatomical misperception, retroperitoneal bleeding, a large bulky splenic flexure tumor, and a "difficult flexure" were recognized as possible mechanisms of such injury.

Single-Incision Laparoscopic Complete Mesocolic Excision With Central Vascular Ligation for Descending Colon Cancer

Background

Single-incision laparoscopic complete mesocolic excision with central vascular ligation for descending colon cancer is technically challenging. Standardization of the surgical procedures is therefore needed.

Methods

In a Trendelenburg position with left side elevated, the sigmoid mesocolon is mobilized using a medial-to-lateral approach, and the left colic artery and inferior mesenteric vein (IMV) are divided after radical lymphadenectomy along the inferior mesenteric artery, preserving the superior rectal artery. The descending mesocolon is mobilized from the retroperitoneal planes up to the dorsal surface of the pancreas using medial and lateral approaches. Next, changing the surgical position to a reverse Trendelenburg position with left side elevated, the omental bursa is opened, and the transverse mesocolon is separated from the inferior border of the pancreas. The splenocolic ligament and lateral attachment are then divided, matching the previous medial dissection of the retroperitoneum, and the splenic flexure is fully mobilized. The IMV is divided again at the inferior border of the pancreas. The left branch of the middle colic artery is also divided.

Results

Forty-seven consecutive patients with DCC underwent single-incision laparoscopic CME with CVL. One patient required an additional port. Median operative time, blood loss, and number of harvested lymph nodes were 240 min (interquartile range [IQR], 195-257 min), 5 mL (IQR, 5-52 mL), and 21 (IQR, 13-29), respectively. Morbidity rate was 5.9%. Median duration of hospitalization was 9 days (IQR, 7-11 days).

Conclusions

Single-incision laparoscopic CME with CVL is safe and feasible for DCC.

The importance of the Moskowitz artery as a lesser-known collateral pathway in the medial laparoscopic approach to splenic flexure mobilisation and its evaluation with preoperative computed tomography

INTRODUCTION

The collateral pathways between the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) play an important role in colonic surgery. The most well-known are the Drummond marginal artery and Riolan's arch. The Moskowitz artery, also known as the meandering mesenteric artery, is a lesser-known collateral pathway and represents another link between SMA and IMA. The Moskowitz artery runs along the colonic mesentery floor and represents the link between the proximal segment of the middle colic artery and the ascending branch of the left colic artery.

AIM

To comprehend the presence and importance of the Moskowitz artery (meandering mesenteric artery) in preoperative patients by using computed tomography (CT) studies.

MATERIAL AND METHODS

We retrospectively reviewed all abdominal CT images performed using intravenous contrast for any reason at the Radiology Department of Yeditepe University Hospital between April 2015 and September 2018. Patients older than 18 years with intravenous contrast (arterial and venous phases with a cross-section thickness of 0.625 mm), who underwent abdominal CT scan, and patients without any abdominal surgery were included in the study. As a result of the screening, 109 CT scans with eligibility criteria were included in this study.

RESULTS

There were 109 cases in this study; 50 (45.9%) of them were male and 59 (54.1%) were female. Moskowitz artery was found in 18 (16.5%) cases; 8 were males and 10 were females. Riolan's arch was present in 30 cases, of whom 15 were male and 15 were female. In our study Moskowitz artery and Riolan's arch were monitored as separate vascular structures, and in all cases with Moskowitz artery, Riolan's arch was also present. There was a statistically significant difference (p < 0.05) between the combined MCA emerging type and the presence of MA, and 12 cases with combined branch and 6 cases with single branch had Moskowitz artery. There was a statistically significant difference (p < 0.05) between LCA types and the presence of MA, and the Moskowitz artery was the most common seen at type 1 LCA.

CONCLUSIONS

Knowledge of the relationship between Riolan's arch and the Moskowitz artery is valuable, and preoperative evaluation of this artery may be beneficial in the presence of Riolan's arch. In addition, preoperative radiological evaluation and its importance are prominent in minimising intraoperative bleeding during splenic flexure mobilisation with a medial laparoscopic approach and reducing the risk of colorectal anastomosis leakage.

Evaluation of Operative Notes for Splenic Flexure Mobilization: Are the Key Aspects Being Reported?

Background: Given the importance of operative documentation, we reviewed operative notes for surgeries that required splenic flexure mobilization (SFM) to determine their accuracy. Materials and Methods: We performed a retrospective review of 51 operative notes for complete SFMs performed at a single institution from January 2015 to June 2020. Results: None of the operative notes reported a rationale for performing SFM, use of preoperative imaging to guide technical approach, reasoning for the operative method and mobilization approach used, or specific steps taken to ensure that SFM was done safely. Most reports did not include technical details, with one-third of the notes merely reporting that "the splenic flexure was mobilized." Conclusions: Increased awareness about the lack of operative documentation of the critical aspects of the SFM could stimulate initiatives to standardize the SFM method and improve the quality of operative notes for SFM.

Intraoperative complications during laparoscopic total mesorectal excision

Intraoperative complication during laparoscopic mesorectal excision for rectal cancer is a common complication occurring in 11% to 15% of the cases. They are probably underestimated because not systematically reported. The most frequent intraoperative complications are haemorrhage (3-7%), tumour perforation (1-4%), bowel injury (1-3%), ureter injury (1%), urogenital injury (2%), other organ injury (<1%), and anastomotic complications (1%). The mechanisms, management and prevention of vascular port injury, inferior mesenteric artery bleeding, small bowel and colon perforation, ureteral and urethral injury, pelvic nerve damage, tumour perforation and anastomotic failure are described. This review underlines the necessity to prevent intraoperative complication to avoid operative death and severe side-effects.

A video guide of five access methods to the splenic flexure: the concept of the splenic flexure box

AIM

The aim of this study was to describe all the possible approaches for laparoscopic splenic flexure mobilization (SFM), each suitable for specific situations, and create an illustrated system to show SFM approaches in an easy and practical way to make it easy to learn and teach.

METHODS

Two different phases. First part: Cadaver-based study of the colonic splenic flexure anatomy. In order to demonstrate the different approaches, a balloon was placed through the colonic hepatic flexure in the lesser sac without sectioning any of the fixing ligaments of the splenic flexure. Second part: A real case series of laparoscopic SFM.

RESULTS

First part: 11 cadavers were dissected. Five potential approaches to SFM were found: anterior, trans-omentum, lateral, medial infra-mesocolic, and medial trans-mesocolic. The illustrative system developed was named: Splenic Flexure "Box"(SFBox). Second part: One of the types of SFM described in first part was used in five patients with colorectal cancer. Each laparoscopic approach to the splenic flexure was illustrated in a video accompanied by illustration aids delineating the access.

CONCLUSION

With the cadaver dissection and subsequent demonstration in real-life laparoscopic surgery, we have shown five types of laparoscopic splenic flexure mobilization. The Splenic Flexure "Box" is a useful way to learn and teach this surgical maneuver.

[Splenic flexure mobilization in surgery for rectal cancer]

Nowadays, the issue of splenic flexure mobilization (SFM) in anterior and low anterior rectal resection for rectal cancer is still debatable. This stage is important because dissection results tension-free anastomosis and excision of specimen of enough length with adequate number of harvested lymph nodes. However, literature review confirmed the absence of agreement regarding reduced incidence of colorectal anastomotic leakage and improved long-term oncologic outcomes after SFM. Opinion about selective approach to this procedure is becoming more common. Therefore, randomized trials are necessary to determine a need for routine SFM or indications for selective approach to SFM in anterior rectal resection for rectal cancer.

[Assessment of the efficiency and safety of the modified combined approach for laparoscopic splenic flexure mobilization]

AIM

To evaluate the efficacy and safety of the proposed modified combined approach for laparoscopic splenic flexure mobilization (SFM).

MATERIAL AND METHODS

A multicenter non-randomized comparative study was conducted. The main group consisted of 12 patients who underwent laparoscopic modified combined SFM from December 2018 to May 2019, the control group consisted of 12 patients who underwent laparoscopic traditional combined SFM from 2013 to 2018. The following aspects were evaluated: total duration of the operation, duration of the SFM, blood loss, rate of conversions, intraoperative complications, postoperative complications, duration of the postoperative period.

RESULTS

Significant differences were obtained for the average duration of the SFM. The duration of the procedure was calculated during watching a video of operation. The average duration of the SFM in the main group was 37.4±12.2 min, in the control group 59.5±19.1 min (p=0.03). The average blood loss in the main group was 52.5±12.3 ml, in the control group - 115.6±20.7 ml (p=0.02). In the main group there were no intraoperative complications, while in the comparison group 1 case of the spleen damage was noted, requiring conversion, and 1 case of the pancreas damage. These differences are not significant due to the small sample.

CONCLUSION

The use of the proposed modified combined approach for the laparoscopic SFM significantly reduces the duration of the operation and is accompanied by a decrease in the frequency of intraoperative complications. However, further randomized studies with a larger sample are needed.

Standardize the Surgical Technique and Clarify the Relevant Anatomic Concept for Complete Mobilization of Colonic Splenic Flexure Using da Vinci Xi® Robotic System

BACKGROUND

The present study is to set up a standardized approach for complete mobilization of colonic splenic flexure using da Vinci Xi^® robotic system, based on clarification of the mesenteric structures of distal transverse colon.

METHODS

The surgical outcomes and relevant anatomic structures of 104 consecutive patients undergoing robotic resection of primary colorectal cancer with the intent of complete mobilization of colonic splenic flexure using da Vinci Xi^® robotic system were retrospectively reviewed.

RESULTS

Complete mobilization of colonic splenic flexure can be efficiently performed by the Xi^® robotic system, as demonstrated by short operation time, minimal intra-operative blood loss, and few surgical complications. Xi^® robotic system has overcome the drawbacks of Si^® robotic system for the mobilization of colonic splenic flexure. The present study defined the following anatomic hallmarks for the colonic splenic flexure: (1) The transverse mesocolon distal to the inferior mesenteric vein adheres to the low border of pancreas by the avascular fibrous connective tissues, which have been inappropriately named as "mesenteric root"; (2) The colonic splenic flexure abuts closely to spleen with an acute angle in 78.85% (n = 82/104); (3) Only a minority of patients presented with the Riolan branch (15.38%, n = 16/104) or the Moskowitz artery (8.65%, n = 9/104).

CONCLUSION

With increased maneuverability of Xi^® robotic arms and the clarification of relevant anatomic concept, the surgical technique for the complete mobilization of colonic splenic flexure can be standardized; and the standardization of surgical technique is the first step toward the enhanced automation in the rapidly evolving robotic systems.

Effect of splenic flexure mobilization performed via medial-to-lateral and superior-to-inferior approach on early clinical outcomes in elective laparoscopic resection of rectal cancer

Introduction

Whether complete splenic flexure mobilization (SFM) is required remains a controversial issue and there are numerous approaches regarding the performance of this procedure.

Aim

To investigate the effect of SFM performed with a medial-to-lateral and superior-to-inferior approach on early clinical outcomes in laparoscopic resection of rectal cancer.

Material and methods

The SFM procedure was initiated by the ligation of the inferior mesenteric vein followed by dissection extending from the upper border of the pancreas to the splenic hilum through the gastrocolic space. The mesocolon was dissected in a superior-to-inferior and medial-to-lateral fashion and the presacral space was entered by dividing the inferior mesenteric artery. The procedure was completed by dividing all the splenocolic, phrenicocolic, gastrocolic, and pancreaticomesocolic ligaments.

Results

A total of 43 patients were included in the study, comprising 26 (60.5%) men and 17 (39.5%) women with a mean age of 58.2 ±13.9 (range: 30–87) years. Of the 43 patients, 21 (48.8%) underwent neoadjuvant chemotherapy and a diversion stoma was performed in 37 (86%) patients. No adjacent organ injury occurred intraoperatively. Mean operative time was 271 ±50 min and mean blood loss was 144 ±83 ml. One (2.3%) patient might have developed anastomotic leakage secondary to bevacizumab therapy postoperatively and developed no anastomotic stenosis in the follow-up period. Mean length of hospital stay was 9.3 ±4.3 days and no mortality occurred in any patient.

Conclusions

Splenic flexure mobilization performed via the superior-to-inferior and medial-to-lateral approach appears to be a safe and feasible procedure.

A randomized clinical trial comparing the initial vascular approach to the inferior mesenteric vein versus the inferior mesenteric artery in laparoscopic surgery of rectal cancer and sigmoid colon cancer

BACKGROUND

The inferior mesenteric artery approach with a selective lateral splenic flexure mobilization is the most widely used initial step in laparoscopic rectal and left colon surgery. Surgery started through the inferior mesenteric vein (IMV) with systematic medial mobilization (MM) has some theoretical advantages that have never been analyzed in a clinical trial. The aim of this study was to compare the two techniques with regards to surgical technique variables (conversion, surgical time, bleeding, morbidity, and mortality) and pathological outcomes.

METHODS

A single-blinded, randomized, controlled trial of patients operated electively by laparoscopic with curative intention for rectal or sigmoid cancer was performed at a single, specialized colorectal surgery department from April 2016 to October 2017.

RESULTS

49 patients were included in each group. There were no statistical differences in patient demographics between the two approaches. Pathological outcomes did not differ between the two groups. Intra-operative characteristics showed a higher conversion rate in patients in which the inferior mesenteric artery was dissected first (p = 0.031). The artery approach also increased intra-operative bleeding (p = 0.049), but there were no differences regarding operative time. On multivariate analysis, the artery approach was associated with a higher risk of conversion (OR 8.68; p = 0.050). Post-operatory complications did not differ between artery and vein dissection.

CONCLUSIONS

In our study, the initial approach by the IMV with a systematic MM of the splenic flexure has allowed us to reduce the conversion rate without increasing complications or the surgical time. No differences were observed in the pathological results. Both approaches seem to be safe and effective and well-trained laparoscopic surgeons should have the two techniques available to them for use as needed.

Importance of the Moskowitz artery in the laparoscopic medial approach to splenic flexure mobilization: a cadaveric study

BACKGROUND

The medial approach in laparoscopic splenic flexure mobilization is based on the entrance to the lesser sac just above the ventral edge of the pancreas (VEOP). The artery of Moskowitz runs through the base of the mesocolon, just above the VEOP. The aim of this study was to assess the incidence of the artery of Moskowitz, its route and its distance from the VEOP.

METHODS

We performed a cadaveric study on 27 human cadavers. The vascular arcades of the splenic flexure were dissected, the number of vascular arches, and the origin and localization of its terminal anastomosis were recorded. The splenic flexure avascular space (SFAS) was defined as the avascular zone in the mesocolon delimited by the VEOP, middle colic artery, ascending branch of the left colic artery and the vascular arch of the splenic flexure nearest to the VEOP and was quantified as the distance between the VEOP and the most proximal arch RESULTS: The artery of Drummond was identified in 100% of the cadavers. In 5 of 27 (18%) Riolan's arch was present, and in 3 of 27 (11%) the Moskowitz artery was found. The mean distance from the VEOP to the artery of Moskowitz was 0.3 cm (SD 0.04). This vascular arch travelled from the origin of the middle colic artery to the distal third of the ascending branch of the left colic artery. The SFAS was greater (p = 0.001) in cadavers that only presented the artery of Drummond (mean 6.8 cm; SD 1.25) than in those with Riolan's arch (mean 4.5 cm; SD 0.5) CONCLUSIONS: In the medial approach for laparoscopic mobilization of the splenic flexure, when only one of the arches is present, the avascular area is an extensive and secure territory. If the artery of Moskowitz is present, the area is nonexistent and this would contraindicate the approach due to risk of iatrogenic bleeding. A radiological preoperatory study could be essential for accurate and safe surgery in this area.

Long-term oncologic outcomes of laparoscopic surgery for splenic flexure colon cancer are comparable to conventional open surgery

Purpose

Few studies about laparoscopic surgery for splenic flexure colon cancer have been published. This study aims to compare the short- and long-term outcomes of laparoscopic surgery for splenic flexure colon cancer with those of conventional open surgery.

Methods

From January 2004 to December 2010, 51 consecutive patients who underwent curative resection for stages I–III splenic flexure colon cancer were enrolled. Thirty-three patients underwent laparoscopy-assisted colectomy, while 18 patients underwent conventional open colectomy. Short- and long-term outcomes of the 2 groups were compared.

Results

There were no differences in baseline characteristics, intra- and postoperative complications. The laparoscopy group showed longer operation time (median [interquartile range, IQR]: 295.0 [255.0–362.5] minutes vs. 180.0 [168.8–206.3] minutes, P < 0.001). In the laparoscopy group, return of bowel function was faster (median [IQR]: 3 [2–4] vs. 4 [3–5], P = 0.007) and postoperative hospital stay was shorter (median [IQR]: 9 [8–11] vs. 10.5 [9–19], P = 0.026). There were no statistically significant differences in overall survival rate (84.3% vs. 76.0%, P = 0.560) or disease-free survival rate (93.8% vs. 74.5%, P = 0.078) between the 2 groups.

Conclusion

Laparoscopic surgery for splenic flexure colon cancer has better short-term outcomes than open surgery, as well as acceptable long-term outcomes. Laparoscopic surgery can be a safe and feasible alternative to conventional open surgery for splenic flexure colon cancer.

Laparoscopic Colorectal Surgery for Cancer: What Is the Role of Complete Mesocolic Excision and Splenic Flexure Mobilization?

Laparoscopic colorectal surgery for cancer is nowadays routinely performed worldwide. After the introduction by Heald of total mesorectal excision for rectal cancer, also a complete mesocolic excision has been advocated as an essential surgical step to improve oncologic results in patients with colon cancer. The complete removal of mesocolon with high ligation of the main mesenteric arteries and veins and the mobilization of splenic flexure are well-known but still debated in western surgical society. The authors reviewed the literature and outlined the rationale and the results of splenic flexure mobilization and complete mesocolic excision in laparoscopic surgery for colorectal cancer.

Laparoscopic right colectomy: Miles away or just around the corner?

BACKGROUND:

Despite the drive toward centralization of surgery in high-volume centers, the majority of colectomies are still performed by low- or medium-volume surgeons.

MATERIALS AND METHODS:

A modification of the technique of laparoscopic right colectomy (LRC) originally described by Young-Fadok and Nelson was developed. The key points of that technique were maintained, but a different port-site layout and a counterclockwise approach were adopted, to warrant better trocar triangulation, to reduce the need of right colon manipulation and to avoid dissection along false planes. This modified technique was applied in 82 patients by 16 surgeons with no previous experience in LRC.

RESULTS:

Average operative time was 125 ± 35 min. Conversion occurred in 10 cases (12.2%). Grade III postoperative complications occurred in 3 patients (3.6%). No postoperative mortality was observed. Average number of lymph nodes retrieved was 19 ± 6. Average length of stay was 7 ± 4 days.

CONCLUSION:

Providing low-volume surgeons with simplified and easy-to-learn surgical techniques could improve outcomes and lead to an increased use of laparoscopy.

A Three-Step Method for Laparoscopic Mobilization of the Splenic Flexure

BACKGROUND

Splenic flexure mobilization (SFM) is sometimes required for secure and tension-free anastomosis during laparoscopic colorectal surgery. Although several approaches have been used for laparoscopic SFM,1 it is still considered complicated and troublesome because of the lack of a standardized technique. We propose a three-step method for laparoscopic SFM, aimed at providing a simplified and standardized method, which is presented in the video.

METHOD

First, the mesocolon of the transverse and descending colon is dissected from the retroperitoneal tissue using a medial approach. The appropriate plane for dissection can be recognized just beneath the inferior mesenteric vein, and the gauze should be placed in the dissected space. Second, the transverse colon and transverse mesocolon are detached from the pancreas and spleen by means of an anterior approach. The lesser sac is opened, and the attachment to the pancreas or spleen is cut using the inserted gauze as a landmark. Third, the lateral attachment of the descending colon to the left abdominal wall is dissected cranially or caudally.

RESULTS

Using this method, we performed laparoscopic SFM for 13 patients with colorectal cancer with no conversion to another approach or to open surgery. No intraoperative complications were reported, including bleeding from the spleen and injury of the pancreas. The mean time for SFM was 55 min.

CONCLUSIONS

We consider this three-step method as being useful, and it might help the standardization of laparoscopic SFM.

How much colonic redundancy could be obtained by splenic flexure mobilization in laparoscopic anterior or low anterior resection?

BACKGROUND AND OBJECTIVES

Splenic flexure mobilization (SFM) is performed to ensure a tension free anastomosis with an adequate resection margin in laparoscopic anterior resection (AR) or low anterior resection (LAR). This retrospective study was performed to determine the amount of colonic redundancy that can be expected by SFM.

METHODS

Retrospective review of medical record for a total of 203 patients who underwent SFM during laparoscopic AR or LAR for the treatment of sigmoid colon or rectal cancer was performed.

RESULTS

The obtained redundancy of the colon by SFM was 27.81 ± 7.29 cm from the sacral promontory. The redundancy of the colon by SFM with high ligation of the inferior mesenteric vein (IMV) (29.54 ± 7.17 cm from the sacral promontory) was greater than that with low ligation of the IMV (24.94 ± 6.07 cm from the sacral promontory, P < 0.0001). It took about 9.82% of the total operation time to perform SFM. There was no intraoperative complication during SFM.

CONCLUSIONS

SFM during laparoscopic AR or LAR is a safe and feasible option. Based on the result of this study, one can gain about 27.81 cm redundancy of the colon by SFM.