The patient is in a prone Trendelenburg position with legs wide open. A total of five trocars are used (a 12mm trocar in the supraumbilical position for a 30º camera, two trocars – 5 mm and 12 mm respectively- at the right iliac fossa, a 5 mm trocar at the left flank, and a final trocar at the epigastrium).
The first step is the accommodation of the small bowel and then we start the dissection of the mesosigmoid. A key step during this maneuver is to perform traction of the mesosigma at the level of the inferior mesenteric vessels. The hook is used to open the peritoneum, and the pneumorectum helps by dividing the planes and improving visualization.
Step by step, the inferior mesenteric artery is identified and sectioned using a LigaSure. The left ureter must be previously recognised.
The surgery continues in a medial to lateral approach, stopping under the retroperitoneal plane. Now the inferior mesenteric vein is sectioned allowing better mobilization of the mesocolon.
Now a window is opened in the mesocolon, and the most important landmark at this time is the pancreas and Riolan’s arcade. The assistant surgeon performs traction of the transverse colon towards the pelvis allowing good exposure of the omentum while the surgeon enters the lesser sac.
Then the mesocolon is sectioned, and we continue to the retromesocolic space while respecting the arcade that runs along the top edge of the dissection. Finally we release the colon of the omentum thus completing the mobilization of the splenic flexure.
In this case we followed a lateral to medial approach. The first step of the surgery was the same as in the previous patient. The hook was used to open the peritoneum and step by step the inferior mesenteric artery was identified and sectioned using a LigaSure™.
We started lateral dissection using the hook. In this maneuver traction of the colon from lateral to medial by the surgeon and the assistant is very important. We must make a careful dissection without damaging the colon. Step by step we perform a left to right dissection releasing the colon and the mesocolon from the retroperitoneum above the pre-renal fat until the pancreas can be visualized. Finally we open the lesser sac and we release the omentum colon, thus completing splenic flexure mobilization following this approach.
Sometimes use of a gauze in the retroperitoneal plane is useful to achieve better perception of the anatomy when following a medial to lateral approach.
It also serves to assist in dissecting the correct plane.
Then we complete the lateral dissection. Gauze serves as a guide to find the plane previously dissected from the medial area. In this way we combine both approaches. As in the previous cases we release the omentum colon, thus completing the splenic flexure mobilization.