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Ke et al. Mini-invasive Surg 2018;2:35 I http://dx.doi.org/10.20517/2574-1225.2018.46 Page 3 of 6

Figure 1. Placement of trocars

noteworthy that only high ligation of both the IMV and IMA as well as division of the involved attach-
ments in the splenic flexure will result in a lengthy colon that would provide for a tension-free anastomosis.
[17]
Toh et al. , highlighted the presence of an important vessel known as the Arc of Riolan that provides col-
lateral mesenteric circulation in 10% of individuals and naturally found anterior to the IMV on the inferior
border of the pancreas. It is important that this vessel should be preserved during high ligation of the IMV
and splenic flexure takedown to ensure collateral supply from the SMA through the connection between
[17]
the middle colic and left colic artery . Performing a technically sound and complete SMF can have an im-
pact on the patient’s postoperative recovery although the success of the surgery is reliant on several com-
pounding factors.

Several of these studies mentioned a variety of possible risk factors owing to the technical difficulty of such
a procedure. The presence of comorbidities such as hypertension and diabetes mellitus, increased BMI,
increased American Society of Anesthesiologist score, previous neoadjuvant chemo radiotherapy have
been linked to the technical difficulty of performing SFM due to the risks that accompany it. However,
the results did not reach statistical significance leading to the conclusion that the benefits of the step in all
laparoscopic rectal surgeries far outweighs the risk [4-6,8-10,12,14-16] . One common intraoperative complication
cited in various studies is causing tears to the spleen whether it is complete or partial avulsion will be im-
material since both can cause significant bleeding [4-6,8-10,12] . This particularly happens during the process of
dividing the phrenicocolic and especially the splenocolic ligaments. There were mentions of inadvertent se-
rosal injuries to the small bowel but they were insignificant as far as the overall result of those studies were
concerned [5,12,18] . The presence of anastomotic leaks after laparoscopic rectal surgery in which SFM was
performed were cited in some of the published papers [8,12,15,16,18] . It was attributed in some cases to the pres-
ence of tension and inadequate vascularity on the involved segments but no direct links were established
between SFM and anastomotic leaks since it is considered to be multifactorial.

The team of colorectal surgeons in CMUH adopted the method of doing a mandatory SFM. Incorporating
SFM in all laparoscopic rectal surgeries will enable the team to overcome the learning curve involved in
this very technical procedure.

SURGICAL METHOD
The following part details the precise description of how a complete SFM is done in our institution. The ap-