Abstract
Splenic flexure release (SFR) is a fundamental skill to master when performing laparoscopic colorectal surgery. Some controversy exists regarding the need to perform SFR in all patients undergoing left-sided colorectal resections. This maneuver is not infrequently required and, when properly conducted, can provide significant benefits when considering restoration of bowel continuity. Gastrointestinal anastomoses carry significant morbidity associated with leaks when they occur. SFR can minimize anastomotic complications by optimizing tension-free anastomoses and adequate blood supply. Preoperative workup is usually based on patients’ baseline diagnosis. It is important to recognize potential variations in blood supply at the splenic flexure and the potential for bowel ischemia if inadvertent ligation of critical vessels is carried out or required. Release of the splenic flexure should be considered in the beginning of the procedure. There are three main approaches to SFR: the supramesocolic, inframesocolic, and lateral to medial approach. Surgeons performing laparoscopic colectomy should become familiar with all three techniques, and judgment is required when deciding which approach should be preferentially based in a given case. In addition to bowel ischemia, potential complications of SFR include bowel and organ injury to the spleen, pancreas, kidney, and splenic vessels. Thorough knowledge of the anatomy, understanding of each surgical approach to SFR, and meticulous surgical technique are the best tools to avoid injuries.
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References
Goulder F. Bowel anastomoses: the theory, the practice and the evidence base. WJGS. 2012;4(9):208–6.
Chand M, Miskovic D, Parvaiz AC. Is splenic flexure mobilization necessary in laparoscopic anterior resection? Dis Colon Rectum. 2012;55(11):1195–7.
Brennan DJ, Moynagh M, Brannigan AE, Gleeson F, Rowland M, OʼConnell RP. Routine mobilization of the splenic flexure is not necessary during anterior resection for rectal cancer. Dis Colon Rectum. 2007;50(3):302–7.
Tortorelli A, Alfieri S, Sanchez A, Rosa F, Papa V, Di Miceli D, et al. Anastomotic leakage after anterior resection for rectal cancer with mesorectal excision: incidence, risk factors, and management. Am J Surg. 2015;81(1):41–7.
Toh JWT, Matthews R, Kim SH. Arc of Riolan-preserving splenic flexure takedown during anterior resection. Dis Colon Rectum. 2018;61(3):411–4.
Jurowich CF, Germer CT. Elective surgery for sigmoid diverticulitis – indications, techniques, and results. Visc Med. 2015;31(2):112–6.
Rullier E, Denost Q, Vendrely V, Rullier A, Laurent C. Low rectal cancer. Dis Colon Rectum. 2013;56(5):560–7.
Marks JH, Myers EA, Zeger EL, Denittis AS, Gummadi M, Marks GJ. Long-term outcomes by a transanal approach to total mesorectal excision for rectal cancer. Surg Endosc. 2017;31(12):5248–57.
Marks JH, Salem JF. From TATA to NOTES: how taTME fits into the evolutionary surgical tree. Tech Coloproctol. 2016;20(8):513–5.
Marks JH, Montenegro GA, Salem JF, Shields MV, Marks GJ. Transanal TATA/TME: a case-matched study of taTME versus laparoscopic TME surgery for rectal cancer. Tech Coloproctol. 2016;20(7):467–73.
Caycedo-Marulanda A, Ma G, Jiang HY. Transanal total mesorectal excision (taTME) in a single-surgeon setting: refinements of the technique during the learning phase. Tech Coloproctol. 2018;22(6):433–43.
Fukuoka A, Sasaki T, Tsukikawa S, Miyajima N, Ostubo T. Evaluating distribution of the left branch of the middle colic artery and the left colic artery by CT angiography and colonography to classify blood supply to the splenic flexure. Asian J Endosc Surg. 2016;10(2):148–53.
Sakorafas GH, Zouros E, Peros G. Applied vascular anatomy of the colon and rectum: clinical implications for the surgical oncologist. Surg Oncol. 2006;15(4):243–55.
Kawamoto A, Inoue Y, Okigami M, Yasuda H, Okugawa Y, Hiro J, et al. Preoperative assessment of vascular anatomy by multidetector computed tomography before laparoscopic colectomy for transverse colon cancer: report of a case. Int Surg. 2015;100(2):208–12.
McDermott S, Deipolyi A, Walker T, Ganguli S, Wicky S, Oklu R. The role of preoperative angiogram in colon interposition surgery. Diagn Interv Radiol. 2012;18(3):314–8.
Takeru M, Takeshi I, Kenro H, Daisuke T, Yutaka S, Yasuo S, et al. A three-step method for laparoscopic mobilization of the splenic flexure. Ann Surg Oncol. 2015;22(s335):1–1.
Garcia-Granero A, Sánchez-Guillén L, Carreño O, Sancho Muriel J, Alvarez Sarrado E, Fletcher Sanfeliu D, et al. Importance of the Moskowitz artery in the laparoscopic medial approach to splenic flexure mobilization: a cadaveric study. Tech Coloproctol. 2017;21(7):567–72.
Blanco-Colino R, Espin-Basany E. Intraoperative use of ICG fluorescence imaging to reduce the risk of anastomotic leakage in colorectal surgery: a systematic review and meta-analysis. Tech Coloproctol. 2017;22(1):15–23.
Merchea A, Dozois EJ, Wang JK, Larson DW. Anatomic mechanisms for splenic injury during colorectal surgery. Clin Anat. 2011;25(2):212–7.
Benseler V, Hornung M, Iesalnieks I, Breitenbuch von P, Glockzin G, Schlitt HJ, et al. Different approaches for complete mobilization of the splenic flexure during laparoscopic rectal cancer resection. Int J Color Dis. 2012;27(11):1521–9.
Bibliography
Atallah S, Albert M, Monson JRT. Critical concepts and important anatomic landmarks encountered during transanal total mesorectal excision (taTME): toward the mastery of a new operation for rectal cancer surgery. Tech Coloproctol. 2016;20(7):483–94.
Deijen CL, Tsai A, Koedam TWA, Veltcamp Helbach M, Sietses C, Lacy AM, et al. Clinical outcomes and case volume effect of transanal total mesorectal excision for rectal cancer: a systematic review. Tech Coloproctol. 2016;20(12):811–24.
Koedam TWA, van Ramshorst GH, Deijen CL, Elfrink AKE, Meijerink WJHJ, Bonjer HJ, et al. Transanal total mesorectal excision (TaTME) for rectal cancer: effects on patient-reported quality of life and functional outcome. Tech Coloproctol. 2017;21(1):25–33.
Lee L, De Lacy B, Gomez Ruiz M, Liberman AS, Albert MR, Monson JRT, et al. A multicenter matched comparison of transanal and robotic total mesorectal excision for mid and low-rectal adenocarcinoma. Ann Surg. 2018; https://doi.org/10.1097/SLA.0000000000002862. [Epub ahead of print]
Pasam RT, Trejo DE, Murray A, Lee-Kong S, Feingold D, Kiran RP. PTU-223 Conversion to open surgery from laparoscopy: to ‘try and fail’ or ‘not try at all’? Gut. 2015;64(Suppl 1):A161.1–A161.
Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc. 2010;24(5):1205–10.
Wong-Chong N, Caycedo-Marulanda A. Transanal total mesorectal excision with retroileal colorectal anastomosis: combining old and new techniques. Color Dis. 2018;20(7):642–3.
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© 2020 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)
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Caycedo-Marulanda, A., Marks, J.H. (2020). Master Program Colorectal Pathway: Laparoscopic Splenic Flexure Release (Tips and Tricks). In: Sylla, P., Kaiser, A., Popowich, D. (eds) The SAGES Manual of Colorectal Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-24812-3_4
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DOI: https://doi.org/10.1007/978-3-030-24812-3_4
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