Splenic flexure segmental colectomy for colon cancer

Abstract

Introduction

Splenic flexure colon cancer allows for different surgical options, ranging from organ sparing techniques - such as splenic flexure resection - to more radical procedures as an extended right colectomy or a left colectomy.

Description 

We present the clinical case of a 58-year-old woman, with a chronic platelet deficiency, and a positive faecal occult blood testing. She underwent a colonoscopy, revealing a 40-50 mm polyp located at the splenic flexure with a IV-V Kudo pattern, and a central depression which does not rise after submucosal injection.

Pathologic study confirms a moderately differentiated adenocarcinoma.

Staging was completed with a CT scan of the thorax, abdomen and pelvis, that showed a thickening of the colonic wall located at the vertical portion of the splenic flexure. There were no enlarged lymph nodes or distant metastases.

We decided upon a splenic flexure resection.

The patient is set in a Trendelemburg position, and the operating table tilted to the right.

We commence by sectioning the falciform ligament, which allows us to position the transverse colon and greater omentum above the liver, improving the surgical field exposure. We apply traction to the transverse mesocolon, exposing the duodenojejunal angle and the inferior mesenteric vein (IMV) as it reaches the pancreas. Left Toldt fascia is approached medially, starting just below the IMV, and its dissection is continued laterally, in a blunt manner, with care not to injure the retroperitoneum.

The IMV is then clipped and divided. The transverse mesocolon is detached from the anterior surface of the pancreas towards the splenic flexure. The left colic artery is identified and divided at its origin, the phrenocolic ligament is sectioned as well as the left colon lateral attachments.

Transverse mesocolon and left mesocolon are sectioned. The transverse and left colon are sectioned with a 60mm endo-stapler, and the enterocolotomy was closed with a two-plane barbed suture.

The specimen was extracted through a infraumbilical midline incision.

Conclusions

Splenic flexure resection is an oncologically safe procedure, specially for early onset cancer, as it results in a lower number of daily and nocturnal bowel movements when compared to classic colectomies, therefore improving patient´s quality of life.

We present a video of a splenic flexure segmental colectomy, describing the major technical steps in order to perform an adequate surgical technique.