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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 5 of 6

The patient is placed in a Trendelenburg and a semi-right lateral decubitus position. The patient is prepped
in a conventional manner and a conventional 5-trocar placement is instituted. A 12-mm trocar is inserted
at the umbilicus employing the Hasson’s technique (entering the abdomen under direct visualization) as
well as at the right lower quadrant of the abdomen. Additional 5 mm trocars are placed each at the right
and left paraumbilical area (5-6 cm from the umbilicus) as well as on the right upper quadrant of the abdo-
men along the mid-clavicular line [Figure 1].

After a thorough inspection of the abdominal cavity, the small bowel is carefully placed to the right side
of the abdomen using atraumatic bowel graspers and exposing the ligament of Treitz where the root of the
IMV is also located. The inferior border of the pancreas is likewise identified and the mesentery is carefully
grasped and sharp dissection is initiated using monopolar electro cautery to enter the lesser sac. This is fol-
lowed by incising the paraaortic peritoneum and the IMV is ligated at its root and divided using Ligasure.
The retroperitoneal dissection is carried out over the Gerota’s fascia by carefully separating the Toldt’s fas-
cia aided by sharp dissection until the mesentery of the descending colon can be lifted up to form a tent.
The pancreaticomesocolic attachments along the tail of the pancreas is carefully divided using Ligasure to
render visible the splenic hilum [Figure 2A-D].

The IMA is identified and isolated at its take off from the abdominal aorta. The IMA is ligated at around
1-1.5 cm distal to the aorta and carefully divided using Ligasure. Posterior dissection is continued caudally
while preserving all identified retroperitoneal structures along the dissection until the presacral space is
reached. Sharp dissection is carried out laterally until reaching the left paracolic gutter where the parietal
peritoneum commences. The sigmoid and descending colon is now mobilized by dividing the parietal peri-
toneum from the pelvis until the hilum of the spleen is visible. SFM is completed by detaching the omen-
tum from the transverse colon and dividing the splenocolic and gastro colic ligaments [Figure 2E-H].

In the pelvic phase of all laparoscopic rectal surgeries, an additional 5-mm trocar can be inserted in the left
lower quadrant of the abdomen that can be used by the assistant surgeon during this phase of the dissec-
tion. This is particularly done especially in low lying rectal tumors where a laparoscopic low anterior resec-
tion or transanal total mesorectal excision will be performed.

CONCLUSION
In our perspective, SFM is an integral step in performing laparoscopic surgery for rectal cancer. This will
enable the surgeon to achieve a tension-free anastomosis from an adequate redundant colon and have good
vascularity on both the proximal and distal ends of the segment. There is a learning curve involved in such
procedure and it can easily be overcome in high volume centers such as our institution where the steps can
be readily performed.

DECLARATIONS
Authors’ contributions
Performed the operations: Ke TW, Geniales CR, Chen WTL
Participated in the data and patients collection, wrote the manuscript: Ke TW, Geniales CR
Supervised this study: Chen WTL

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.