Medial to Lateral Splenic Flexure Mobilization for Sigmoid Colectomy

In this video we show our technique for splenic flexure mobilization via a medial to lateral approach

This is a 64 year old gentleman with two synchronous lesion in the sigmoid colon, one proximally and one distally as shown by the two tattoed areas.
The key landmark for this approach is the inferior mesenteric vein (IMV) which is found next to the ligament of treitz.
The pancreatic tail is identified under the mesocolon.
The right wall of the aorta is shown and the inferior mesenteric vein is followed caudally where it travels together with the left colic artery down to the origin of the inferior mesenteric artery
Next to the pancreatic tail the IMV is azygous, travelling with out a paired artery.
The left colic artery in fact can be seen traveling toward the colon in the mesocolic fat.

The IMV is elevated and the peritoneum covering it is scored
A medial to lat dissection is carried out separating the mesocolon from Toldt’s fascia and the retroperitoeal structures
The vein is divided using the ligasure device

Now the mesocolon is gently elevated and the plane between it and the anterior surface of the pancreas is developed.

There are loose attachments between these two structures which can be taken down with gentle blunt or with bipolar dissection. Although this is an avascular plane, care must betaken not to injure the pancreas

The lesser sac is therefore entered from the medial side and the stomach comes into view.

After the tail of the pancreas is freed from the mesocolon the dissection continues along the gastrocoloc ligament which is divided. The lesser sac is entered again exposing the medial dissection above the pancreas.
The splenocolic ligament is divided and complete mobilization of the flexure is carried out.

Next we turn out attention to the inferior mesenteric artery and continue the dissection along the right pararectal sulcus next the the right iliac artery incising the peritoneum with monopolar cautery

The medial to lateral plane is developed here too separating the mesocolon and mesorectum from the retroperitoneum

The dissection continues rostrally meeting the previously completed dissection under the IMV/left colic artery complex

Thus the origin of the IMA is isolated and a characteristic T shaped structure is identified comprising the origin of the IMA, the left colic/IMVcomplex and the superior rectal artery

The sigmoid mobilization is completed along the white line of Toldt.

The mesorectum is divided at the level of the rectosigmoid junction and the distal bowel transected with an ENDOGIA stapler

A minilaparotomy created and the specimen exteriorized, the mesocolon divided and an anvil secured into the descending colon.

After reinsufflation an EEA anstaomosis is created and inspected colonoscopically.

This patient had an uncomplicated three day hospital stay.

Session: Podium Video Presentation

Program Number: V002

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