Kunihiko Nagakari, MD, Masaki Fukunaga, Tetsu Fukunaga, Seiichiro Yoshikawa, Masakazu Ouchi, Gotaro Katsuno, Yoshinori Hirasaki, Shintaro Kohama. Juntendo Univ. Urayasu Hosp.
Background and Objective
Recently, Hohenberger demonstrated complete mesocolic excision (CME) for colon cancer surgery. But the laparoscopic treatment of colon cancer located in splenic flexure is not standardized because of difficulties.
The reason are 1 ) complex of vascularity, 2 ) adjacent to vital organs at risk for damage, and 3) extensive dissection and mobilization.
It is important that we confirm anatomical position to accomplish a precise operation. We can be operated while securing safe space by approaching it from caudal and cranial side with understanding the structure of the layer in order to avoid the risk of the damage.
Subjects and Methods
Since 1993, we have performed 2300 laparoscopic colectomies, and at present, the indication is all colon cancer.
From 1994 to 2015 laparoscopic splenic flexure resection were performed in 38 patients (25 cases of transverse colon 192 cases, 13 cases of descending colon cancer 105 were necessary dissection of the MCA and the IMA of the area). These 38 cases were retrospectively investigated.
Preoperative localization of colon cancer and its blood supply are always important, it is imperative by using 3D-CT scan.
- Step1: The inferior mesenteric pedicle is identified. Medial–to-lateral approach is used. Retroperitoneal mobilization of descending colon mesentery up to pancreas. The dissection of the IMA roots is performed and LCA and IMV are divided.
- Step2: Division of lateral attachments of sigmoid and descending colon to splenic flexure.
- Step3: The avascular plane between the greater omentum and the transverse colon is divided. The dissection of the Middle colic artery(MCA) roots is performed and Lt branch of MCA is divided. The colon at the flexure is retracted caudally, and any remaining restraining attachments are divided.
- Step4: Exteriorization and anastomosis through median incision
2 conversions to open surgery were registered. All cases achieved an adequate number of lymph nodes harvested (19.6 ± 9.7). Postoperative complication rate according to the Clavien–Dindo system was 15.8 %, but only 1 complication reported was grade III.
(Wound infection 2, Paralysis 1, Bowel obstruction 1, Leakage 1 stenosis 1)
As to long-term prognosis, 5year cancer-specific survival rate for stage I to IIIa R0 resection were Stage I 100%, Stage II 81.3% and Stage IIIa 87.5% in Japanese Classification of cancer treatment.
This technique for splenic flexure colon cancer is a feasible and reproducible technique and allow to perform an oncological safe and functionally effective treatment.