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Mobilization of the splenic flexure: medial route during left colectomy

This video highlights the critical steps in mobilization of the splenic flexure of the colon using the medial approach. The author carries out the division of the left colic vessels and gains entry to the lesser sac. The tail of the pancreas, mesocolon, stomach, and posterior aspect of splenic flexure provide landmarks. The author completes the dissection laterally and division of posterior attachment before commencing the freeing of the lateral structures. This provides access to the posterior dissection completed earlier.

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Mobilization of the splenic flexure: medial route during left colectomy

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摘要

This video highlights the critical steps in mobilization of the splenic flexure of the colon using the medial approach.

The author carries out the division of the left colic vessels and gains entry to the lesser sac. The tail of the pancreas, mesocolon, stomach, and posterior aspect of splenic flexure provide landmarks.

The author completes the dissection laterally and division of posterior attachment before commencing the freeing of the lateral structures. This provides access to the posterior dissection completed earlier.

關鍵字

splenic flexure, colon, medial approach

媒體類型

手術影片

期間

08'30''

刊物

2007-03

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Mar 2007;7(03).
URL: http://www.websurg.com/doi-vd01en2077.htm

Mobilization of the splenic flexure: medial route during left colectomy

1. Division of left colic vessels 00'21''

I do the division now, cut with scissors and you will push that in the pelvis. We will do the division of the posterior attachment of the transverse mesocolon, splenic flexure using a medial approach. To do that, we have a trocar introduced in the right subcostal area to lift the transverse mesocolon, and I will ask my assistant to catch the inferior aspect of the mesocolon, not too close from the root, not the vessels too because these are the marginal vessels as you can see. We lift anteriorly in order to gain exposure. I have retracted the small bowel on the right and we see the duodenojejunal junction; sometimes it’s necessary to use the retractor in order to do that. The IMV is visible here. We have divided it. We have the left colic running here and we will divide the vessels so this is the left colic branch; there was the left colic artery running along. Using the Ligasure or monopolar scissors, I will divide the peritoneum only either anteriorly to the IMV if I keep it or laterally to it, not dividing too deeply because you see the pancreas is coming just behind.

2. Entering the lesser sac 02'25''

The goal is to open the lesser sac and keeping the pancreas posteriorly, keeping the vascularisation of the descending colon or respecting the mid-colic vessels. We see the pancreas. We will keep this landmark to respect the anatomy. I will use scissors. The goal is to stay anterior to Toldt’s fascia. If you are too posterior, you will go behind the pancreas. It’s a vascular-free plane and as you see the lifting helps us to do the dissection. The pancreatic tail is here. The danger is to go too anterior towards the mesocolon, and in the mesocolon and we will have a risk of vascular injury of the marginal vessels. This is the tail of the pancreas. This is the stomach and posterior aspect of the splenic flexure. We do as much as we can. Normally we can’t do it, and we have to complete the dissection laterally.

3. Freeing of lateral attachments 04'35''

We’ve done the division of the posterior attachment medially. Now we’re doing the lateral freeing. And finally we’ll reach the posterior dissection we did before. We have to open the lesser sac. In this case, we guess that we’ll have the same plane rapidly. It’s not always easy to do the complete mobilization by a medial posterior approach, except to divide the attachment of the transverse mesocolon medially.

4. Detachment of greater omentum 05'32''

At this moment, you can see that we have some difficulty to understand where we will go. Now I prefer to go between the omentum and we have to free this. We’re doing the division of the colo-omental attachment. The omentum is fixed to the colon. It’s not always necessary to do a large mobilization of the splenic flexure, particularly if we only do a sigmoidectomy. We only have to free laterally this way. And finally we’re continuing the dissection from down to up, but it’s correct that we can do a rapid opening of the lesser sac. If we want it, we can come back. You will retract like this. I will complete the posterior freeing this way. These are the omental vessels. If I have enough length, I will do the anastomosis on the compliant part of the colon. At the beginning of my experience, I always began with the freeing of the splenic flexure because I thought that if I had to convert, it would be useful to have a part done by laparoscopy and a part done in open surgery. So now I don’t begin with the freeing of the splenic flexure, I finish with it. And it’s not always necessary to free and mobilize largely the splenic flexure even when doing rectal surgery. This is a good mobilization.

5. Freeing of colonic adhesions 08'05''

We have now to clean this. We have to free this adhesion. We have to respect the vascularisation. It’s enough because we have sufficient length and we have to respect the marginal vessels.