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Page 2 of 6 Ke et al. Mini-invasive Surg 2018;2:35 I http://dx.doi.org/10.20517/2574-1225.2018.46

approach for colon and rectal cancer was associated with less morbidity, enhanced recovery, and at least
[3-6]
equivalent oncological outcomes . In China Medical University Hospital (CMUH), a tertiary medical
center in Taichung City, a team of colorectal surgeons performs a high volume of cases for laparoscopic
rectal surgeries.

Left-sided CRC comprises two thirds of all colorectal malignancies. The standard surgical treatment is a
[7]
complete oncologic resection with a primary anastomosis . There were initial concerns about the potential
risk of tumor cell dissemination during laparoscopy but this has not been validated. The emergence of lap-
aroscopic colorectal surgery has not been fully embraced by most surgeons mostly because of the increased
[4]
technical laparoscopic skill requirements . This paper aims to discuss the importance of splenic flexure
mobilization (SFM) and its technical details during laparoscopic rectal surgery.

SFM
SFM is one of the essential, challenging and technically demanding step during laparoscopic rectal cancer
surgery. The use of SFM for CRC surgery remains a contentious issue [5,6,8] , but safe dissection of the splenic
flexure to fully mobilize the descending colon is mandatory not only for oncologic resection but also for
safe anastomosis [4,9-11] . The definition of SFM is different among several studies with some describing the
technique as either complete or partial mobilization [3,5,6,12] . However, it is relevant to know the procedural
aspect of SFM consisting of the division of the splenocolic, phrenicocolic, gastro colic and pancreaticome-
socolic ligaments. It is crucial to differentiate a partial splenic flexure from the complete SFM. In partial
SFM, it is limited only to the division of splenocolic and phrenicocolic ligaments while a complete SFM
includes not only the division of splenocolic and phrenicocolic ligaments (partial mobilization) but the di-
vision of gastro-colic and pancreaticomesocolic attachments. This can be technically accomplished either
through a lateral-to-medial or a medial-to-lateral approach [3,4,6,9,10] . A variety of approaches for SFM have
been used by surgeons to simplify the technique. A median to lateral approach for the complete mobiliza-
tion of the splenic flexure was commonly described in various studies [9,10,19,20] . This approach is similar to
[13]
the study of Marsden et al. , in which many surgeons favor routine mobilization of the flexure at an early
stage in the operation, particularly for low rectal cancers. It is often considered helpful to carry out this
step along with division of the inferior mesenteric artery (IMA), the inferior mesenteric vein (IMV) and
the colon before beginning the pelvic dissection. This approach allows the divided colon and small bowel
to be packed away giving good access to the pelvis for the rectal dissection [4,9,10] . This highlights the impor-
tance of a complete SFM prior to the pelvic dissection of any rectal surgery.

SFM is a crucial part in all left-sided colorectal surgeries particularly laparoscopic anterior and low an-
terior resections [4,9,10] . SFM is performed in order to achieve adequate oncological resection, create a
tension-free anastomosis with a good blood supply, and perform a pouch reconstruction if necessary [3,4,14] .
It allows to achieve a straight segment of supple and well vascularized segment of the descending colon
that can be easily anastomosed to the remnant rectum down in the pelvis in which some surgeons favor
[5]
creating a recreational pouch to decrease frequency of bowel movement . In a cadaveric study done by
[7]
Thum-umnuaysuk et al. , a greater length of colon at 17.98 ± 6.80 cm was achieved and it reached statisti-
cal significance when high ligation of IMA and IMV coupled with SFM was done. In a separate cadaveric
[11]
study by Araujo et al. , it was shown that an additional 10 to 28 cm segment of the descending colon can
[15]
be gained if SFM was carried out with or without distal transverse colon mobilization. Kye et al. cited
that as much as 30 centimeters of colon redundancy will be reached if high IMV ligation was performed as
[15]
compared to a low IMV ligation which gains 5 centimeters less. The results in the paper of Kye et al. had
comparable results to the previous cadaveric studies which considered SFM as vital in every laparoscopic
rectal surgery to come up with a lengthy colon needed to have a tension-free anastomosis. Elongation of
the colon is essential in creating a tension-free anastomosis which involves adequate mobilization of the
[16]
bowel ends particularly on the colonic side . The vascular supply of the proximal and distal margins after
resection becomes an integral part of the process [8-20] . In the process of performing a complete SFM, it is