Laparoscopic Oncologic Splenic Flexure Resection: A Complete Mesocolic Excision with Concomitant Inferior Mesenteric...

Recently, in patients who underwent left hemicolectomy with inferior mesenteric artery (IMA) preservation for distal transverse and descending colon cancers and presented with a long remnant sigmoid colon after dissection, a significant inferior rate of intestinal complications (i.e., anastomotic ulcer, stricture, venous engorgement, and colitis) of the remnant distal colon has been observed in cases of concomitant preservation of the inferior mesenteric vein (IMV) compared with its ligation.^1-3 METHODS AND SURGICAL TECHNIQUE: This video shows a step-by-step minimally-invasive approach following oncological principles to achieve the concomitant IMA and IMV preservation for left-sided colonic cancer around the splenic flexure area. Procedure started with peritoneal incision running from the IMA axilla to the Treitz ligament. The medial-to-lateral dissection below the IMV over the Gerota fascia was developed. The left colic artery was ligated at its origin from the IMA, that was preserved. The IMV was then dissected and preserved up to the pancreatic body. Next, colo-epiploic dissection, section of the root of the transverse mesocolon from the pancreas and lateral mobilization allowed a full splenic flexure mobilization. The lymphadenectomy at the origin of the middle colic artery completed the dissecting phase (Figs. 1, 2, 3, 4, 5, 6 and 7). An intracorporeal anastomosis was performed. The patient was discharged on the fourth postoperative day with no complications. A total of 24 lymphnodes were harvested within the specimen. Fig. 1 Trocar positions Fig. 2 Initial peritoneal incision. IMA inferior mesenteric artery Fig. 3 Medial-to-lateral dissection. IMV inferior mesenteric vein, IMA inferior mesenteric artery, LCA left colic artery Fig. 4 Transverse mesocolon root detachment Fig. 5 Middle colic artery root lymphadenectomy. MC middle colic, MCA middle colic artery, SMA superior mesenteric artery, IMV inferior mesenteric vein Fig. 6 Surgical field after the dissection phase with preservation of the IMV. IMV inferior mesenteric vein, IMA inferior mesenteric artery, LCA left colic artery Fig. 7 Surgical specimen. MCA middle colic artery, LCA left colic artery CONCLUSIONS: The concomitant IMV preservation in minimally-invasive splenic flexure resections with preservation of IMA is feasible in experienced hands and may reduce complications in the distal descending colon without any prejudice to the oncological results.