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Splenic flexure mobilization in Robotic Colorectal Surgery: how to approach it ?

Alberto Mangano, MD, Federico Gheza, MD, Roberto E Bustos, MD, Gabriela Aguiluz, MD, Eleonora M Minerva, MD, Pier Cristoforo Giulianotti, MD, FACS, Professor of Surgery. UIC Departement of Surgery. Division of Minimally Invasive

Introduction: the routine mobilization of the left colonic flexure in colorectal surgery is still a matter of debate.We present our surgical approach with data.This technique may increases the surgical expertise/confidence when the surgical maneuver is necessary.Up to 40 % of all splenectomies are for surgery-related injuries;80% of those splenic injuries are treated by splenectomy.The iatrogenic splenic injury rate during colorectal surgery is 0.96%. Iatrogenic splenic injuries create: increased risk of mortality/morbidity, extended operative time/patient in-hospital stay and increased healthcare costs.Risk factors for iatrogenic splenic injury are: advanced age, adhesions,underlying pathology.Obesity is not a risk factor. It is debated if the left colonic flexure mobilization is a risk factor for splenic injury.The ligament over-traction  is the most frequent damage mechanism.The most dangerous surgical manuever is the spleno-colic ligament surgical dissection.Moreover, laparoscopy descreases by almost 3,5 times the splenic injury risk. Some surgeons are reluctant to routinely take down the splenic flexure.

Materials and procedures:129 robotic left colonic/rectal cases  with  routine splenic flexure mobilization technique have been performed: left colectomy(n=74), rectal surgery(n=45), transverse-colectomy(n=6) and pancolectomy(n=4). Conversion rate 1,6%,EBL <100ml,1 postop-leak(0.8%) and 0% iatrogenic splenic injuries.

Results: In our approach, there are 4 pathways that need to be mastered for the splenic flexure mobilization:a)medial to lateral dissection (underneath the inferior mesenteric vein); b)lateral to medial (from the lateral peritoneal reflection); c)access to the lesser sac with omental detachment from the transverse colon; d)access to the lesser sac with the gastrocolic opening, following the inferior border of the pancreas.The dissection should be closer to the colon rather than to the spleen. In our experience the routine mobilization of the splenic flexure may have some advantages:a) Better (without tension) distal anastomosis formation;b)Better perfusion of the proxiaml stump;c)Wider oncological dissection;d)No need of going back to the flexure when the proximal stump is too short;e)mastering a surgical manuver useful in other procedures (e.g.distal pancreasectomy). The theoretical drawbacks of routine splenic flexure mobilization can be:a)longer operative time, which is on average increased by 35 minutes;b)Risk of splenic injuries, in our experience, no splenic injuries have been registered.    

Conclusions: technical accuracy with cautious dissection/visualization can reduce iatrogenic splenic damages rate.Laparoscopy decreases splenic injury rate.Robotic surgery may have the potential to further reduce this complications. Our data suggest that the routine mobilization of the splenic flexure, has more advantages than drawbacks and it can reduce the iatrogenic splenic injury rate.More trials are needed in order confirm our findings.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 88117

Program Number: P198

Presentation Session: iPoster Session (Non CME)

Presentation Type: Poster

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