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International Surgery Journal | December 2019 | Vol 6 | Issue 12 Page 4210
International Surgery Journal
Elmeligi MH et al. Int Surg J. 2019 Dec;6(12):4210-4215
http://www.ijsurgery.com
pISSN 2349-3305 | eISSN 2349-2902
Original Research Article
Splenic flexure mobilization is an essential role in laparoscopic
low anterior resection!
Mohamed Hamed Elmeligi*, Mohamed Sabry Amar, Mohammed Nazeeh Shaker Nassar
INTRODUCTION
In Europe, colorectal cancer considered the most
common malignancy. Two thirds of all colorectal
malignancies are left-sided colorectal cancer. Complete
oncologic resection is the standard surgical treatment if
possible, with a primary anastomosis.1
In 1991, Jacobs et al was the first one who describes
laparoscopic colonic resection after that Laparoscopic
colonic surgery has been employed for the treatment of
colon cancer.2
Several studies show that treatment of colorectal cancers
can be performed by laparoscope with acceptable
outcomes, while other studies show controversy for
laparoscopic colorectal cancer surgeries.2
There is debate still exists regarding mobilization of
splenic flexure during laparoscopic rectal cancer
resection because mobilization of splenic flexure
considered difficult step either during conventional or
laparoscopic technique as it may require a more operative
time, changing the position of the patient, increasing the
length of the abdominal incision or insertion of additional
ports.3
ABSTRACT
Background:
Routine mobilization of splenic flexure whether partial or complete became an essential step in
laparoscopic low anterior resections in order to perform an oncologic resection and to achieve a safe, tension-free
anastomosis.
Methods:
60 patients with rectal cancer were operated by laparoscopic low anterior resection with high ligation of
inferior mesenteric artery in general surgery department, Menoufia university hospital between February 2016 and
January 2019. All patients were divided randomly into 2 equal groups based on the techniques used in splenic flexure
mobilization whether partial (group A) or complete (group B).
Results:
The majority of our patients were male 56.6% and 60% in both groups respectively with mean age
(54.6±8.8) years in group A and mean age (58.5±9.2) years in group B. The operative time was highly significant
lower in group A (269±17.6 minutes) than group B (304±22.4 minutes) while the conversion rate was significantly
higher in group B (26.6%) than group A (6.6%). Regarding the postoperative data there was only significantly higher
leak from the anastomosis in group A (20%) than group B (3.3%).
Conclusions:
Complete splenic flexure offer better oncological outcome and low incidence of anastomotic leak but
with higher conversion rate, prolonged operative time, more blood loss and more 30 day mortality rate. So it needs
more time to gain more experience to overcome these disadvantages.
Keywords: Splenic flexure mobilization, Laparoscopic surgery, Low anterior resection
Department of Surgery, Menoufia Faculty of Medicine, Menoufia University Hospitals, Menoufia, Egypt
Received: 18 October 2019
Accepted: 13 November 2019
*Correspondence:
Dr. Mohamed Hamed Elmeligi,
E-mail: mhamedsurg@yahoo.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2349-2902.isj20195377
Elmeligi MH et al. Int Surg J. 2019 Dec;6(12):4210-4215
International Surgery Journal | December 2019 | Vol 6 | Issue 12 Page 4211
Low anterior resection for rectal cancer in patients having
short sigmoid colon may require mobilization of the
splenic flexure to avoid tension on colonic anastomosis.4
Routine mobilization of splenic flexure have been
advised by some surgeon in order to obtain a anastomosis
without tension which obtain a good blood supply from
the middle colic vessels, in case of inferior mesenteric
artery origin ligation for oncological purposes.5,6
The aim of our study was to demonstrate the role of
splenic flexure mobilization in low anterior resection for
rectal cancer.
METHODS
This study was a prospective randomized controlled
study included 60 patients of rectal cancer who were
operated by laparoscopic low anterior resection with high
ligation of inferior mesenteric artery in general surgery
department, Menoufia university hospital between
February 2016 and January 2019. Informed consent has
been taken from all patients.
Patients were divided into two groups based on
mobilization of splenic flexure (partial or complete):
group A included 30 patients who underwent partial
mobilization of splenic flexure while group B included 30
patients who underwent complete mobilization of splenic
flexure.
Inclusion criteria:
All patients with early rectal cancer included.
Exclusion criteria
Advanced stage, recurrent colorectal cancer, synchronous
malignancy in right sided colon, patients with intestinal
obstruction, immuno-compromised patients and patients
underwent abdominoperineal resection excluded.
All patients were subjected preoperatively to history
taking, examinations (general and local) and
investigations which include routine labs, CEA,
colonoscope to exclude synchronous malignancies and
take biopsy from colorectal malignancies for
histopatholigy to confirm diagnosis.
Metastatic work up include chest X ray or CT chest if
indicated, CT abdomen and pelvis with contrast (oral and
IV).
All patients underwent colonic preparation 3 days before
surgery and given low molecular weight heparin + elastic
stocking for prophylaxis against DVT. Antibiotic was
given at induction of anesthesia.
Surgical technique
A medial-to-lateral approach was followed, and high
ligation of inferior mesenteric artery was routinely
performed in our practice after ligation of inferior
mesenteric artery we dissect cephally to demonstrate
inferior mesenteric vein to be our land mark for splenic
mobilization.
The retroperitoneal dissection was continued over
Gerota’s fascia until Toldt’s fascia and the pancreas were
seen at the lateral and superior borders of the dissection,
respectively. After the dissection of Toldt’s fascia and
mobilization of the sigmoid and descending colon, the
phrenicocolic and splenocolic ligaments were sealed and
divided until the body of the spleen was clearly
demonstrated (partial mobilization)
The operation was completed via four trocars in the
partial mobilization of splenic flexure group, but we
preferred to insert an additional trocar between the
umbilicus and xiphoid process and moved the camera to
this port while performing a complete mobilization of
splenic flexure, which was more commonly performed in
recent years. In this technique, in addition to dissected
ligaments during partial mobilization of splenic flexure,
gastrocolic and pancreaticomesocolic attachments were
also divided.
Operative time and amount of blood loss were recorded
and compared between both groups. Postoperatively, all
patients encourage for early mobilization, early feeding
and proper pain control.
Follow up (end point)
All patients were followed up inpatient for hospital stay,
post-operative complications in the form of surgical site
infection, ileus, anastomotic leak, intra-abdominal
hemorrhage and reoperation.
Histopathological findings as T stage, resection margin,
lymph nodes (LN) removed, length of specimen were
compared between both groups.
Statistical analysis
The collected data were organized, tabulated and
statistically analyzed using SPSS software (Statistical
Package for the Social Sciences, version 21, SPSS Inc.
USA). Data were described using mean and standard
deviation (SD) and frequencies according to the type of
the data (quantitative or categorical respectively). Chi-
square and fisher exact test were used for comparison of
qualitative variables. We used one way ANOVA test to
compare between means of categorical and numerical
data. Significance level (p value) was adopted, i.e. p<0.05
for interpretation of results of tests of significance.
Elmeligi MH et al. Int Surg J. 2019 Dec;6(12):4210-4215
International Surgery Journal | December 2019 | Vol 6 | Issue 12 Page 4212
RESULTS
60 patients with early rectal cancer were operated by
laparoscopic low anterior resection in general surgery
department, Menoufia university hospital during
February 2016 to January 2019. All patients were divided
randomly to 2 groups based on splenic flexure
mobilization where partial or complete.
The majority of our patients were male 56.6% and 60%
in both groups respectively with mean age (54.6±8.8)
years in group A and mean age (58.5±9.2) years in group
B. There was no significant difference regarding age and
sex between both groups (Table 1).
The number of patients subjected to neoadjuvant were 18
(60%) and 19 (63.3%) in both groups respectively with
no significant difference between both groups (Table 1).
The operative time was highly significant lower in group
A (269±17.6 minutes) than group B (304±22.4 minutes)
while the conversion rate was significantly higher in
group B (26.6%) than group A (6.6%) (Table 1).
Table 1: Demographics and perioperative data.
Characteristics
Group A partial (n=30)
Group B complete (n=30)
𝑥2 value
P value
Number
Frequency
(%)
Number
Frequency
(%)
Gender (male%)
17
56.60
18
60
0.6 NS
Neoadjuvant chemoradiotherapy
18
60
19
63.30
0.071
0.5 NS
Conversion rate
2
6.60
8
26.60
1.66
0.04 S
Age (years)
54.6±8.8
58.5±9.2
0.08 NS
Operative time (minutes)
269±17.6
304±22.4
0.001 HS
Blood loss (mL)
343.5±26.4
373.5±22.3
0.08 NS
HS: highly significant, S: significant, NS: not significant.
Table 2: Postoperative data.
Characteristics
Group A partial (n=30)
Group B complete (n=30)
𝑥2 value
P value
Number
Frequency
(%)
Number
Frequency
(%)
Blood transfusion
6
20
8
26.60
0.371
0.3 NS
SSI
3
10.00
5
16.60
0.351
0.3 NS
Ileus
2
6.60
3
10
0.218
0.5 NS
Anastomosis leak
6
20
1
3.30
4.75
0.05 S
Non-surgical
1
3.30
3
10.00
0.351
0.4 NS
Intra-abdominal Hemorrhage
3
10.00
5
16.60
0.351
0.3 NS
Reoperation
1
3.30
3
10.00
0.351
0.4 NS
30 days mortality
1
3.30
3
10.00
0.351
0.4 NS
Length of hospital stay (days)
8.6±2.6
8.3±2.4
0.09 NS
HS: highly significant, S: significant, NS: not significant.
Table 3: Postoperative histopathology.
Characteristics
Group A partial (n=30)
Group B complete (n=30)
𝑥2 value
P value
Number
Frequency
(%)
Number
Frequency
(%)
T stage
0.58
0.9 NS
0 (%)
0
0
0
0
1 (%)
1
3.30
2
6.60
2 (%)
7
23.30
6
20
3 (%)
19
63.30
18
60
4 (%)
3
10
4
13.30
Positive radial margin
1
3.30
0
0
1.017
0.5 NS
Harvested lymph nodes
17.9±3.5
22.5±4.4
0.01 S
Distal margin (cm)
4.1±1.7
5.9±2.2
0.01 S
Length of the specimen (cm)
25±5.2
26.9±5.2
0.16 NS
HS: highly significant, S: significant, NS: not significant.
Elmeligi MH et al. Int Surg J. 2019 Dec;6(12):4210-4215
International Surgery Journal | December 2019 | Vol 6 | Issue 12 Page 4213
Regarding postoperative data there was only significantly
higher leak from the anastomosis in group A (20%) than
group B (3.3%) (Table 2).
Figure 1: Creation of the optimum avascular plane
between the mesentery and tolds fascia.
Figure 2: Inferior mesenteric vein is a very important
land mark in laparoscopic low anterior resection
(IMV).
Figure 3: Dissection of phrencocolic ligament by
harmonic scalpel.
Histopathology reveals no significant difference between
both groups in T stage and radial margin while there were
a significantly higher number of harvested lymph nodes
in group B (22.5±4.4) than group A (17.9±3.5). Although
the distal margin was significantly longer in group B
(5.9±2.2 cm) than group A (4.1±1.7 cm) (Table 3).
DISCUSSION
Routine mobilization of splenic flexure is considered to
be an essential part of low anterior resections in order to
perform an oncologic resection and to achieve a safe,
tension free anastomosis especially with wide use of
laparoscope in colonic surgery.6-10
A recent review has revealed that mobilization of splenic
flexure decrease the anastomotic leak especially in
patients underwent low anterior resection for rectal
cancer which is agreed to our study as anastomotic leak is
significantly higher in partial splenic flexure mobilization
than in complete splenic flexure mobilization 20% of
patients in partial mobilization but in complete
mobilization 3.3% of patients.6-10
In contrast, mobilization of splenic flexure is a difficult
step; especially complete splenic flexure mobilization
may lengthen the operation time, and may be associated
with some complications, including extended incision, or
additional port insertion and injury of the spleen.8,10 This
is agreed to our study in which operation time is
prolonged in complete splenic flexure mobilization (304
minutes) and show highly significant difference than
partial mobilization.
Thus, many advocate that mobilization of splenic flexure
may be omitted in most of the patients without worsening
the surgical and oncological outcome and not to be a rigid
step in laparoscopic low anterior resection.4, 10-12
In contrast to the previous studies, current data disproved
an increase in operation time and intraoperative bleeding
in patients receiving a complete mobilization of splenic
flexure.13 This was disagreed with our study in intra
operative bleeding is more in complete mobilization
about 373.5 ml than partial mobilization (343.5 ml) with
no significant difference.
The major problem is the lack of a precise definition for
splenic flexure mobilization, because most analyses did
not determine the clear border of the mobilization. The
splenic flexure and the transverse colon are fixed to the
spleen with the phrenicocolic ligament, which does not
always exist but lies as an extension of Toldt's fascia, and
with the splenocolic ligament. Dissection of these fascias
promotes partial splenic flexure mobilization; however,
further dissection through the gastrocolic attachments is
required, which are the actual connection between the
omentum and transverse colon. In addition, the
peritoneum located anterior to the pancreas connects the
pancreas and mesocolon. So dissection of pancreatico-
Elmeligi MH et al. Int Surg J. 2019 Dec;6(12):4210-4215
International Surgery Journal | December 2019 | Vol 6 | Issue 12 Page 4214
mesocolic attachment through the inferior border of the
pancreas result in complete mobilization of splenic
flexure and sometimes inferior mesenteric vein ligation
may be required at this level.3
Partial splenic flexure mobilization was preferred to be
performed via during the initial years of our laparoscopic
colorectal surgery practice by dissecting phrenicocolic
and splenocolic ligaments; however, recently we have
preferred to gastrocolic and pancreatico-mesocolic
attachments dissection (complete mobilization of splenic
flexure) via an extra port in addition to the previous
attachments that have been dissected in partial splenic
flexure mobilization.3
In a case-matched study, multivariate analysis reveals
splenic injury as a result splenic flexure mobilization.14
This was disagreed with our study as there is no splenic
injury.
The hospital stay length was similar between the groups.
However, postoperative outcomes had the paramount
significance, and previous studies have revealed that
mobilization of splenic flexure does not decrease the rates
of complications, or re-operations and 30-day
mortality.10, 11 Correspondingly, these parameters were
more in complete group than partial splenic flexure
mobilization without significant difference in our study.
In addition, complete mobilization of splenic flexure does
not produce an extended volume of the specimen because
there was no difference between the groups regarding the
number of harvested lymph nodes, the length of speci-
men, and distal margin.11 This was disagreed to our study
in which harvested lymph nodes were significantly more
in complete mobilization (22.5 LN) than partial
mobilization in which harvested lymph nodes about were
17.5 LN.
Also distal margin in complete group is 5.9 cm which is
significantly longer than partial group which was about
4.1cm while the length of specimens were 25 cm and
26.9 cm in both groups respectively without significant
difference.
Finally, our study showed significantly high conversion
rate especially in complete mobilization of splenic
flexure and this is explained by our early experience in
laparoscopic low anterior resection which needs more
and more experience to achieve the best results.
CONCLUSION
Splenic flexure mobilization is considered as an essential
role in laparoscopic low anterior resection but we should
know the difference between partial and complete
mobilization to do the optimum technique.
In our study, blood loss and 30 day mortality rate were
more in complete splenic flexure mobilization group
without significant difference while the anastomotic leak
was significantly higher in partial splenic flexure
mobilization group. On the other hand, the lymph node
harvested and distal margin were significantly more in
complete mobilization group which offers better
oncological outcome while the operative time was
prolonged in complete mobilization group with highly
significant difference than partial mobilization group,
also the conversion rate was significantly higher in
complete mobilization group. So standardization of
complete mobilization of splenic flexure is mandatory in
low anterior resection to achieve better outcome but it
needs more time to gain more experience to overcome
these disadvantages regarding conversion rate, operative
time, blood loss and 30 day mortality rate.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the by
Menoufia University-Faculty of Medicine`s Ethics
Committee
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Cite this article as: Elmeligi MH, Amar MS, Nassar
MNS. Splenic flexure mobilization is an essential
role in laparoscopic low anterior resection!. Int Surg J
2019;6:4210-5.
