V32 - Laparoscopic splenic flexure colectomy: A didactic 10-step technique

CME Eligible

Purpose/Background: Laparoscopic splenic flexure colectomy is technically demanding due to complex anatomical relationships involving spleen, pancreas, and major vessels. Representing only 2-3% of colorectal cancers, limited comparative studies exist and standardized minimally invasive techniques are lacking. Technical challenges include dual vascular supply, proximity to pancreatic tail and splenic hilum, and extensive mobilization requirements. These contribute to increased operative time, higher conversion rates, and complications including splenic injury, pancreatic trauma, and vascular injury. This video presents a structured, reproducible 10-step technique addressing these challenges to enhance training and improve outcomes.

Methods/Interventions: This video demonstrates a standardized 10-step multi-port laparoscopic technique with high-definition footage and clear anatomical landmarks. Step 1: Retroperitoneal approach below inferior mesenteric vein establishing correct plane for early vascular identification. Step 2: Opening transverse mesocolon for lesser sac access. Step 3: Ligation of inferior mesenteric vein and left middle colic vessel branches for vascular control. Step 4: Pancreatic plateau dissection separating mesocolon from pancreas. Step 5: Omental resection and splenic flexure mobilization via gastrocolic ligament division. Step 6: Left colic artery dissection and ligation completing vascular isolation. Step 7: Left paracolic gutter mobilization connecting dissection planes. Step 8: Distal colon division beyond lesion. Step 9: Proximal colon division. Step 10: Tension-free colo-colic anastomosis construction.

Results/Outcomes: This standardized technique provides systematic, efficient approach addressing anatomical and technical challenges. Sequential steps reduce decision-making uncertainty. Early landmark identification minimizes injury risk to spleen, pancreas, and vessels. Systematic vascular control reduces bleeding. Structured format ensures reproducibility across teams and institutions, valuable for training programs. The technique maintains oncological principles including appropriate vascular ligation, adequate margins, and complete mesocolic excision. Predetermined sequence reduces cognitive burden and operative fatigue. This approach potentially reduces operative time, conversion rates, and complications including splenic injury (1-3%) and pancreatic injury while improving anastomotic outcomes.

Conclusion/Discussion: Standardization of laparoscopic splenic flexure colectomy is crucial for safety, efficiency, and training. The splenic flexure's complex anatomy and technical demands have historically challenged surgeons. This 10-step method provides clear, reproducible pathway completing the procedure. Each step systematically guides surgeons through anatomical complexities maintaining key principles: early vascular identification, systematic mobilization, structure preservation, and tension-free anastomosis. This approach provides common teaching framework, accommodates various experience levels, and establishes quality improvement baseline. Video format allows visualization difficult to convey otherwise. This guide significantly contributes to colorectal surgical education, helping master technical challenges and improve patient care while expanding minimally invasive treatment access for splenic flexure tumors.