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Splenic Flexure “Box”: Illustrative diagram of the anatomy of the splenic flexure to simplify the learning and teaching of the different alternatives of mobilization. (1) Stomach, (2) Colon, (3) Pancreas, (4) Spleen, (5) Greater omentum, (6) Omental bursa, (7) Transverse mesocolon. A Box. B Box with landmarks. C Completed SF Box
Source publication
Aim
The aim of this study was to describe all the possible approaches for laparoscopic splenic flexure mobilization (SFM), each suitable for specific situations, and create an illustrated system to show SFM approaches in an easy and practical way to make it easy to learn and teach.
Methods
Two different phases. First part: Cadaver-based study of t...
Citations
... la transcavidad de los epiplones o bursa omentalis 4 y, recientemente, García-Granero et al. 5 postulan 5 abordajes posibles en función de algunas modificaciones a los anteriormente mencionados. En Uruguay, una de las principales contribuciones al conocimiento de esta región anatómica y sus implicancias en el tratamiento de la patología neoplásica fue realizada por el Dr. Luis Praderi. ...
... Siguiendo esta premisa, García-Granero et al. 5 describen todas las posibles vías de abordaje en un modelo de disección cadavérica, así como durante el curso de procedimientos quirúrgicos, determinando que existen 5 vías de acceso a la transcavidad de los epiplones (y por lo tanto de abordajes), cuya factibilidad dependerá del escenario planteado (resección vs. descenso). Dicho modelo cadavérico ha sido denominado por los autores como la "caja" del AE (splenic flexure " box"), correspondiendo dicha "caja" a la transcavidad de los epiplones, presentada como propuesta para facilitar y estandarizar la enseñanza de este procedimiento. ...
Introducción: La movilización completa del ángulo esplénico (AE) es una técnica compleja, con una lenta curva de aprendizaje. Métodos: Se realizó un estudio anatómico del ángulo esplénico así como de sus posibles vías de abordaje en modelo simulado cadavérico y se describe la técnica quirúrgica por abordaje medial laparoscópico. Resultados: Se lograron identificar 5 vías de abordaje: anterior trans-omental, anterior, lateral, medial infra-mesocólica y medial trans-mesocólica. Se describen en un modelo cadavérico las estructuras ligamentarias de fijación identificadas, la anatomía vascular del ángulo esplénico y sus principales relaciones anatómicas. Discusión: El cirujano debe conocer la anatomía, relaciones y vías de abordaje del ángulo esplénico. Mediante simulación cadavérica hemos logrado reproducir un modelo previamente validado de enseñanza y entrenamiento de la técnica para su movilización completa. Conclusiones: El modelo cadavérico de simulación para la movilización del ángulo esplénico es una herramienta útil aplicada a la práctica quirúrgica.
... In particular, the left upper abdomen has two locations that need further surgical considerations: the lesser sac and the spleen. 3 The lesser sac is a natural space, a 'box', limited dorsally by the body and tail of the pancreas, and caudally by the transversa mesocolon, where the middle colic artery runs. Ventrally, the greater omentum will cover this box, together with the posterior side of the stomach. ...
... 7 Computer-based training modules use various multimedia components such as text, graphics, animation, and videos that can theoretically facilitate the learning process. 8 Incorporating them into the training programs facilitates learning, enhances training efficacy, and also standardizes the surgical procedures. We demonstrate our novel videobased training module that was developed to teach SFM. ...
Background:
Computer-based training modules use various multimedia components such as text, graphics, animation, and videos that can theoretically facilitate the learning process. Splenic flexure mobilization (SFM) is a crucial step for tension-free colorectal/anal anastomosis that can be a technically demanding step. This study is designed to demonstrate our novel training module for SFM with high-vessel ligation during surgery and present the anatomical landmarks and embryological plans for SFM.
Materials and methods:
A step-by-step educational video was prepared to standardize and teach the technical steps of the SFM. 3D animation was prepared and cadaveric dissection was performed in a step-by-step manner similar to minimally invasive surgery. This is followed by the laparoscopic technique. Since we have started this modular training program in our department, a consecutive of 100 patients underwent laparoscopic low anterior resection and coloanal anastomosis with covering stoma. Demographics, characteristics, and postoperative outcomes were evaluated.
Results:
Surgical anatomical planes and important vascular structures/variations are both shown by 3D animation, cadaveric dissection, and laparoscopic surgery. Out of 100 consecutive cases, there were no mortality, 5 anastomotic leakages 1 of which necessitates reoperation, and 2 splenic injuries which were managed conservatively.
Conclusion:
This unique educational video module for SFM demonstrates surgical anatomical planes and important vascular structures/variations. The employment and implementation of time-independent multimedia components lead to effective training and can theoretically facilitate the learning process.
Simple Summary
Ovarian cancer (OC), the most lethal gynecological malignancy, usually presents in advanced stages. Unlike other gynecological malignancies, advanced epithelial OC often spreads through peritoneal and lymphatic dissemination to the upper abdomen. Hence, OC necessitates complex surgical procedures usually involving the upper abdomen with the aim of achieving optimal cytoreduction without visible macroscopic disease. Omitting dissection of these particular areas can compromise complete cytoreduction. Neglected anatomical areas that may harbor tumor residues include the omental bursa; Morison’s pouch; the base of the round ligament of the liver and hepatic bridge; the splenic hilum; and suprarenal, retrocrural, cardiophrenic and inguinal lymph nodes. These areas are commonly involved and should be rigorously evaluated in every patient with advanced epithelial OC as they often preclude optimal cytoreduction. This article provides a meticulous anatomical description of neglected anatomical sites concealing possible residual disease during OC surgery and describes surgical steps essential for the dissection of these “neglected” areas.
Abstract
Ovarian cancer (OC), the most lethal gynecological malignancy, usually presents in advanced stages. Characterized by peritoneal and lymphatic dissemination, OC necessitates a complex surgical approach usually involving the upper abdomen with the aim of achieving optimal cytoreduction without visible macroscopic disease (R0). Failures in optimal cytoreduction, essential for prognosis, often stem from overlooking anatomical neglected sites that harbor residual tumor. Concealed OC metastases may be found in anatomical locations such as the omental bursa; Morison’s pouch; the base of the round ligament and hepatic bridge; the splenic hilum; and suprarenal, retrocrural, cardiophrenic and inguinal lymph nodes. Hence, mastery of anatomy is crucial, given the necessity for maneuvers like liver mobilization, diaphragmatic peritonectomy and splenectomy, as well as dissection of suprarenal, celiac, and cardiophrenic lymph nodes in most cases. This article provides a meticulous anatomical description of neglected anatomical areas during OC surgery and describes surgical steps essential for the dissection of these “neglected” areas. This knowledge should equip clinicians with the tools needed for safe and complete cytoreduction in OC patients.
A surgeon must possess the knowledge and technical skill to obtain length following a left-sided colorectal resection to perform a tension free anastomosis. The distal target organ – either rectum or anus – is fixed in location, and therefore requires surgeons to acquire mastery of proximal mobilization of the colonic conduit. Generally, splenic flexure mobilization (SFM) provides adequate length. Surgeons benefit from clearer understanding of the multiple steps involved in SFM as a result of improved visualization and demonstration of the relevant anatomy – adjacent organs and the attachments, embryologic planes, and mesenteric structures. Much may be attributed to laparoscopic and robotic platforms which provided improved exposure and as a result, development or refinement of novel approaches for SFM with potential advantages. Complete mobilization draws upon the sum or combination of the varied approaches to accomplish the goal. However, in the situation where extended resection is necessary or in the case of re-operative surgery sacrificing either more proximal or distal large intestine often occurs, the transverse colon or even the ascending colon represents the proximal conduit for anastomosis. This challenging situation requires familiarity with special maneuvers to achieve colorectal or coloanal anastomosis using these more proximal conduits. In such instances, operative techniques such as either ileal mesenteric window with retroileal anastomosis or de-rotation of the right colon (Deloyer's procedure) enable the intestinal surgeon to construct such anastomoses and thereby avoid stoma creation or loss of additional large intestine.
Robotic surgery is the preferred minimally invasive approach for rectal cancer at Memorial Sloan Kettering Cancer Center. In this chapter, we describe our proposed technique for low anterior resection in a step-by-step fashion.
Oncological adequacy in rectal cancer surgery mandates not only a clear distal and circumferential resection margin but also resection of the entire ontogenetic mesorectal package. Incomplete removal of the mesentery is one of the commonest causes of local recurrences. The completeness of the resection is not only determined by tumor and patient related factors but also by the patient-tailored treatment selected by the multidisciplinary team. This is performed in the context of the technical ability and experience of the surgeon to ensure an optimal total mesorectal excision (TME). In TME, popularized by Professor Heald in the early 1980s as a sharp dissection through the avascular embryologic plane, the midline pedicle of tumor and mesorectum is separated from the surrounding, mostly paired structures of the retroperitoneum. Although TME significantly improved the oncological and functional results of rectal cancer surgery, the difficulty of the procedure is still mainly dependent on and determined by the dissection of the most distal part of the rectum and mesorectum. To overcome some of the limitations of working in the narrowest part of the pelvis, robotic and transanal surgery have been shown to improve the access and quality of resection in minimally invasive techniques. Whatever technique is chosen to perform a TME, embryologically derived planes and anatomical points of reference should be identified to guide the surgery. Standardization of the chosen technique, widespread education, and training of surgeons, as well as caseloads per surgeon, are important factors to optimize outcomes. In this article, we discuss the introduction of transanal TME, with emphasis on the mesentery, relevant anatomy, standard procedural steps, and importance of a training pathway.
Splenic flexure mobilization (SFM) is one of the most difficult steps in laparoscopic colorectal surgery and its role is harshly debated. Some surgeons considered it routinely necessary to obtain a safe anastomosis and to respect oncologic criteria; for others SFM is frequently unnecessary, not ensuring the aspects mentioned above and increasing the risk of morbidity (splenic, bowel and vessels injury, lengthened procedure). We performed a systematic review and a comprehensive meta-analysis, without any language restriction, about the peri-operative and post-operative outcomes (anastomotic leakage, intra-operative complication, conversion rate, operative time, post-operative bleeding, intra-abdominal collection, prolonged ileus, wound infection, anastomotic stricture, overall complications, hospital stay, re-operation, post-operative mortality, R0 margin resection, local recurrence) in patients undergoing elective anterior rectal resection (ARR) with or without SFM, both in laparotomic (LT) and laparoscopic (LS) approach. Fourteen studies were meta-analyzed with a total amount of 42,221 patients. The comprehensive meta-analysis shows that the mobilization or the preservation (SFP) of the splenic flexure does not statistically influence the incidence of colorectal anastomotic leakage, conversion rate, post-operative bleeding, intra-abdominal collection, prolonged ileus, wound infection, anastomotic stricture, overall complications, hospital stay, re-operation, R0 margin resection, and local recurrence results. The operative time is significantly longer in every group of patients undergoing SFM. The incidence of intra-operative complication is statistically increased in overall patients and also in the LS subgroup of patients undergoing SFM, in which also higher incidence of wound infection and re-operation is shown. The meta-analysis shows that SFM may be considered not necessary to ensure better peri-operative and post-operative outcomes in both LT and LS ARR.
