Lengthening of left colon after rectal resection: What all is adequate? A prospective cohort study

Abstract

Low tie of IMA, with splenic flexure mobilization as required results in sufficient mobilization only in 50% patients with partial sigmoid resection. Ligation of descending branch of LCA is feasible, safe and enables a tension free anastomosis and is especially beneficial when sigmoid colon is resected completely.

Complicated Diverticular Disease

“…Some studies indicate length gained with SFM, ligation of IMA, and ligation of inferior mesenteric vein (IMV) at 28 to 30 cm, 60,61 while others indicate that only 3 to 6 cm is gained when adding SFM to high-IMA ligation and complete mobilization of the descending colon to the splenic flexure. 61,62 Authors suggest more length was gained by performing high ligation of the IMA, ligation of the IMV at inferior border of the pancreas, and mobilizing the entire descending colon without SFM. Further, SFM is associated with 10 to 20% increased operative time, 60,61,63 increased use during laparoscopy, and when diverticulitis involves the descending colon.…”

The role of splenic flexure mobilization in laparoscopic rectal surgery for rectal cancer

“…The results in the paper of Kye et al [15] had comparable results to the previous cadaveric studies which considered SFM as vital in every laparoscopic rectal surgery to come up with a lengthy colon needed to have a tension-free anastomosis. Elongation of the colon is essential in creating a tension-free anastomosis which involves adequate mobilization of the bowel ends particularly on the colonic side [16] . The vascular supply of the proximal and distal margins after resection becomes an integral part of the process [8][9][10][11][12][13][14][15][16][17][18][19][20] .…”

“…Elongation of the colon is essential in creating a tension-free anastomosis which involves adequate mobilization of the bowel ends particularly on the colonic side [16] . The vascular supply of the proximal and distal margins after resection becomes an integral part of the process [8][9][10][11][12][13][14][15][16][17][18][19][20] . In the process of performing a complete SFM, it is noteworthy that only high ligation of both the IMV and IMA as well as division of the involved attachments in the splenic flexure will result in a lengthy colon that would provide for a tension-free anastomosis.…”

“…There were mentions of inadvertent serosal injuries to the small bowel but they were insignificant as far as the overall result of those studies were concerned [5,12,18] . The presence of anastomotic leaks after laparoscopic rectal surgery in which SFM was performed were cited in some of the published papers [8,12,15,16,18] . It was attributed in some cases to the presence of tension and inadequate vascularity on the involved segments but no direct links were established between SFM and anastomotic leaks since it is considered to be multifactorial.…”

The three approaches to the colonic splenic flexure mobilization – a video vignette

“…The goal remains the same, which is to avoid anastomotic tension, at the cost of a trend towards an increased rate of minor complications, and no major adverse events . When the splenic downloading is not enough, ligation of the descending branch of the left colic artery enables a tension‐free anastomosis . The operating time for this step, during the entire colorectal procedure, is influenced by the patient's characteristics (previous surgery, high splenic flexure, short mesentery etc.)…”