How is the splenic flexure mobilized during laparoscopic left hemicolectomy?

Updated: Apr 13, 2020
  • Author: David B Stewart, Sr, MD, FACS, FASCRS; Chief Editor: Vikram Kate, MBBS, MS, PhD, FRCS, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed)  more...
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Answer

Although mobilization of the splenic flexure (see the videos below) is not always necessary, it is sometimes mandated for a tension-free anastomosis. This is a more complex maneuver because of the close proximity of the stomach, spleen, and pancreas, as well as the need to avoid inadvertently transecting the transverse mesocolon, which potentially devascularizes the large intestine to be used for the anastomosis.

Laparoscopic left colectomy. Mobilization of splenic flexure: part 1.
Laparoscopic left colectomy. Mobilization of splenic flexure: part 2.
Laparoscopic left colectomy. Mobilization of splenic flexure: part 3.
Laparoscopic left colectomy. Mobilization of splenic flexure: part 4.

Splenic flexure mobilization may not be rigorously defined, and the term may be used in various ways by different surgeons. As a rule, however, the term splenic flexure mobilization should not be used to refer to incising the line of Toldt to the level of the splenic flexure but should be reserved for some degree of transection of the distal transverse mesocolon for the purpose of relocating the splenic flexure away from the spleen.

The MTL approach preferred by the author involves placing the patient in maximal reverse Trendelenburg positioning with continued right lateral decubitus tilt. The midpoint of the gastrocolic ligament is transected, allowing entry into the lesser sac. The remaining gastrocolic ligament is transected to the level of the inferior pole of the spleen, and this point of view allows the surgeon to avoid getting lost and ending up near the splenic hilum—an easy mistake to make in a patient with more visceral obesity.

The stomach is then reflected cephalad so as to expose the posterior gastric wall, which can be easily and inadvertently injured during splenic flexure mobilization. This also exposes the pancreas, which is important in that the level of mesenteric transection is several centimeters caudal to the inferior border of the pancreas. This is to preserve collateral arterial blood flow, as well as to maximize colonic length.

By this time, avascular mesenteric windows on either side of the left branch of the middle colic vessel have been further developed and exposed through the previous descending colon mobilization. These windows can then be easily identified and opened, allowing proximal transection of the left branch of the middle colic artery near the inferior border of the pancreas.

The splenic flexure proper can then be transected in an MTL direction, with the inferior pole of the spleen, the pancreas, and the transverse mesocolon clearly delineated. With the patient in reverse Trendelenburg, the colon naturally moves away from the spleen, allowing further exposure of the spleen without retraction. The previous transection of the gastrocolic and splenocolic ligaments prior to the mesenteric resection allows the colon to be safely retracted caudally without tearing of the splenic capsule; the spleen and colon are no longer attached.

The transverse colon can be mobilized to the midline of the peritoneal cavity, and the main branch of the middle colic artery and the marginal artery are preserved, with the latter now serving as the main tributary to nourish the descending colon. This places the distal half of the transverse colon and the descending colon in the midline of the peritoneal cavity, in a straight line toward the pelvis, and provides adequate length for virtually every colorectal anastomosis.

Splenic flexure mobilization is arguably the most dangerous maneuver that colorectal surgeons perform. With a proximal transection of the transverse mesocolon, a bleeding vessel can potentially retract into a retropancreatic position, continuing to bleed but not visible without pancreatic mobilization.


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