The Difficult Splenic Flexure
Sherief Shawki
Perioperative Considerations
To adequately mobilize the splenic flexure, the omental, splenic, lateral, and retroperitoneal (pancreatic-colic) attachments must all be dissected free.
The splenic flexure takedown may be the most difficult part of the procedure.
Performing this step as the initial step of the operation minimizes incision size if conversion were needed later.
The splenic flexure often needs to be approached from several directions for successful, adequate mobilization.
Position changes from Trendelenburg to reverse Trendelenburg during the dissection will assist successful completion and help move the bowel out of the way.
Visualization is often better with minimally invasive approaches than open.
Excess tension on the attachments to the spleen can lead to tearing of the capsule and bleeding and needs to be avoided.
Patient Positioning
Modified lithotomy
Arms tucked
Joints in physiologic position and bony parts well padded
Body well secured to operative table to avoid slippage
Aim is to expose base of transverse colon mesentery, ligament of Treitz, and inferior mesenteric vein (IMV). Usually, the table can be tilted to the right (left side upward) and with mild reverse Trendelenburg (Fig. 24-1).
 FIGURE 24-1 ▪ In this image, the gastrocolic ligament has been taken down, lesser sac accessed, the transverse colon was stapled, and its mesocolon was divided. It shows the plane to be traversed in order to enter the lesser sac and dissect the base of transverse mesocolon of the body and tail of the pancreas. |
Instruments and Equipment
Hasson port (12-mm diameter)
10-mm 30-degree laparoscope
At least two 5-mm operating ports
Two 5-mm laparoscopic bowel graspers (atraumatic)
5-mm laparoscopic curved scissors with attachment for electrocautery
5-mm vessel sealing device
Technique
Camera port at the umbilicus
Working ports: right upper and right lower quadrant ports
Assistant port: left lower quadrant
The greater omentum is placed in the upper abdomen, and the transverse colon is exposed. The small bowel is placed in the right side of the abdomen. The IMV is identified, the assistant retracts the small bowel away from harm.
Elevate the IMV and incise the overlying peritoneum just medial to the IMV at the embryologic fusion plan between midgut and hindgut. Allow the CO2 to infiltrate and dissipate between tissue planes (Fig. 24-2A).
Enter the plane between the descending mesocolon, below the IMV, and Gerota fascia (Fig. 24-2B).
FIGURE 24-2 ▪ Incising the peritoneum overlying and just medial to the inferior mesenteric vein (IMV) entering the plane between IMV and Gerota fascia. A. Incising the peritoneum overlying and just medial to the inferior mesenteric vein (IMV) and B. entering the plane between the IMV and Gerota’s fascia.
Extend the peritoneal incision along the medial aspect of the IMV to obtain better accessibility and visualization.
Avoid tunneling and achieve maximum medial-to-lateral dissection (Fig. 24-3A and B).
Medial-to-lateral dissection is then carried out. The borders of dissection are:
Laterally: ideally as far as the lateral abdominal wall underneath proximal portion of descending colon (Fig. 24-4A and B).
Caudate: dissection is continued until the maximum extent of dissection is achieved (Fig. 24-5).
Cephalad: the inferior border of the pancreas is identified (Fig. 24-6).Related posts:
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