V41 - Minimally Invasive Splenic Flexure Resection with Side-to-End Anastomosis

CME Eligible

Purpose/Background: Splenic flexure oncological resections are considered challenging operations for colorectal surgeons in regards to both the surgical resection technique, given the proximity to other organs, and the creation of anastomosis due to location of the mass within the colon. Various surgical approaches have been advocated using both open and minimally invasive side-to-side, functional end-to-end anastomotic techniques or hand-sewn techniques among others. We present a minimally invasive side-to-end colo-colonic anastomosis using a circular stapler.

Methods/Interventions: We present two patients with splenic flexure masses, biopsy proven adenocarcinomas with no distant metastases on the staging work up.

A 38-year-old female who presented to the emergency department with symptomatic anemia (Hgb-7) and abdominal pain. Diagnostic work up including CT A/P demonstrated a large splenic flexure mass. Colonoscopy confirmed the large, ulcerated mass in the splenic flexure, with biopsy proven moderately differentiated adenocarcinoma with mucinous features and no metastatic disease. The second patient is a 62 yo M with symptomatic anemia (Hgb-6). The diagnostic work up included CT A/P which demonstrated large splenic flexure mass with intussusception. Colonoscopy confirmed a nearly obstructing large splenic flexure mass, biopsy proven moderately differentiated adenocarcinoma with no metastatic disease on staging work up.

Both patients underwent laparoscopic splenic flexure resection with side-to-end anastomosis using a circular stapler. The technique involves completely mobilizing the splenic flexure up to the middle colic vessels medially to ensure tension-free anastomosis. The distal colon is transected, and the anvil is placed and secured with a pursue-string suture. The proximal transection point is chosen. A 5 cm transverse colon colotomy is made and a circular stapler is passed, and a side-to-end anastomosis is performed at least 5 cm proximal to the mass. The colotomy is resected and removed with a specimen using a linear stapler and oversewn with absorbable suture.

Results/Outcomes: Both patients were treated with the alignment of enhanced recovery after surgery protocols, had uncomplicated post-operative course and were discharged home on post-operative day 4. The final pathology demonstrated adequate lymph node harvest (5/23 positive lymph nodes, 2/38 positive lymph nodes, respectively) and negative resection margins.

Conclusion/Discussion: This technique demonstrates a minimally invasive approach to splenic flexure resection and utilization of a circular stapler to perform an side-to-end anastomosis to re-create the natural angle of the splenic flexure and perform a successful oncological splenic flexure resection.