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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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colon (Fig. 23-13).
FIGURE 23-12 Detachment of greater omentum from the transverse colon.
FIGURE 23-13 Entry into the lesser sac can be accomplished by division of the
gastrocolic ligament immediately inferior to gastroepiploic vessels or by division of the
greater omentum just superior to the transverse colon.
Left-Sided Medial-to-Lateral Dissection Approach to the
Transverse Colon
The left hemicolon is retracted medially and inferiorly, exposing the
lateral attachments at the splenic flexure (Fig. 23-14).
FIGURE 23-14 Takedown of lateral attachments at splenic flexure with medial
traction on descending colon. (Courtesy of Dr. Conor Delaney.)
These attachments are divided avoiding Gerota fascia of the left kidney
and minimizing tension on the spleen (Fig. 23-15).
FIGURE 23-15 Division of splenocolic ligament.
Then, the lesser sac is entered by dividing the greater omentum from the
transverse colon.
The omentum is retracted anteriorly and superiorly, while the
transverse colon is retracted inferiorly. This will expose a window
through which access to the lesser sac can be attained (Fig. 23-16).
FIGURE 23-16 Entry into lesser sac by division of greater omentum.
Mesenteric Approach to the Transverse Colon
The operating table is positioned to the right with reverse Trendelenburg.
The distal transverse colon mesentery is retracted anteriorly, exposing the
inferior mesenteric vein (IMV) and duodenojejunal junction (Fig. 23-17).
FIGURE 23-17 Identification of sub–inferior mesenteric vein (IMV) avascular plane
requires initiation of dissection slightly posterior to IMV at the level of the duodenojejunal
junction.
The avascular plane between the IMV and jejunum is opened.
Dissection continues laterally and superiorly, taking care to continue the
dissection anterior to the tail of the pancreas until the lesser sac is entered.
This approach will allow complete division of the mesentery of the
splenic flexure and can be followed with the previously described
division of superior and lateral attachments to the transverse and
descending colon.
Superior Approach to the Transverse Colon
Begin with entry into the lesser sac.
Elevate the omentum superiorly and anteriorly while retracting the
transverse colon inferiorly.
The omentum is then divided from the transverse colon gaining entry to
the lesser sac (Fig. 23-12).
Dissection then continues to the right or left based on the planned
operation.
PEARLS AND PITFALLS
Liberal use of operating table manipulation will aid exposure. Ensure
the patient is well secured to the operating table to optimize this tool.
Plan to move around the table as progress is made across the transverse
colon. Moving from the patients left, to between the legs, to the
patient’s right (for a right-to-left dissection) can provide improved
access, with less surgeon muscle fatigue.
Consider whether preservation of the omentum is valuable for the
clinical setting. It is often easier to leave it attached to the transverse
colon.
The gallbladder can be densely adherent to the omentum, transverse
colon or gastrocolic ligament. Take the time to identify it to avoid
injury.
There is rarely a straight line of dissection across the transverse colon
mesentery. Be cautious to avoid stomach or colon injury when nearing
the splenic flexure.
Not a lot of traction is necessary to cause a splenic capsule tear. Keep
the spleen in view during the left-sided mobilization. If it is moving,
there is too much tension.
Postoperative Care
We follow our published standardized enhanced recovery perioperative
care plan.
Orogastric tubes are removed prior to extubation, intravenous fluids are
minimized, diet is given day 0,
and urinary catheters are removed day 1.
Opioids are minimized, and patient-controlled analgesia is avoided.
Nonsteroidal anti-inflammatories are permitted and combined with oral
acetaminophen.
Subcutaneous heparin and intermittent pneumatic compression are
continued following surgery for deep vein thrombosis prophylaxis.
Suggested Readings
Rivadeneira D, Steele SR. Transverse colectomy: laparoscopic approach. In: Bardakcioglu O, ed.
Advanced Techniques in Minimally Invasive and Robotic Surgery. New York, NY: Springer;
2015:99-105.
Sonoda T. Laparoscopic sigmoidectomy/left colectomy. In: Ross HM, Lee SW, Mutch MG,
Rivadeneira DE, Steele SR, eds. Minimally Invasive Approaches to Colon and Rectal Disease
Technique and Best Practices. New York, NY: Springer; 2015:71-80.
Chapter 24
The Difficult Splenic Flexure
SHERIEF SHAWKI
Perioperative Considerations
To adequately mobilize the splenic flexure, the omental, splenic, lateral,
and retroperitoneal (pancreatic–colic) attachments must all be dissected
free.
The splenic flexure takedown may be the most difficult part of the
procedure.
Performing this step as the initial step of the operation minimizes incision
size if conversion were needed later.
The splenic flexure often needs to be approached from several directions
for successful, adequate mobilization.
Position changes from Trendelenburg to reverse Trendelenburg during the
dissection will assist successful completion and help move the bowel out
of the way.
Visualization is often better with minimally invasive approaches than
open.
Excess tension on the attachments to the spleen can lead to tearing of the
capsule and bleeding and needs to be avoided.
Patient Positioning
Modified lithotomy
Arms tucked
Joints in physiologic position and bony parts well padded
Body well secured to operative table to avoid slippage
Aim is to expose base of transverse colon mesentery, ligament of Treitz,
and inferior mesenteric vein (IMV). Usually, the table can be tilted to the
right (left side upward) and with mild reverse Trendelenburg (Fig. 24-1).
FIGURE 24-1 In this image, the gastrocolic ligament has been taken down, lesser sac
accessed, the transverse colon was stapled, and its mesocolon was divided. It shows the
plane to be traversed in order to enter the lesser sac and dissect the base of transverse
mesocolon of the body and tail of the pancreas.
Instruments and Equipment
Hasson port (12-mm diameter)
10-mm 30-degree laparoscope
At least two 5-mm operating ports
Two 5-mm laparoscopic bowel graspers (atraumatic)
5-mm laparoscopic curved scissors with attachment for electrocautery
5-mm vessel sealing device
Technique
Port placement: consistent with left-sided operations (see Chapter 21 and 23)
Camera port at the umbilicus
Working ports: right upper and right lower quadrant ports
Assistant port: left lower quadrant
The greater omentum is placed in the upper abdomen, and the transverse
colon is exposed. The small bowel is placed in the right side of the
abdomen. The IMV is identified, the assistant retracts the small bowel
away from harm.
Elevate the IMV and incise the overlying peritoneum just medial to the
IMV at the embryologic fusion plan between midgut and hindgut. Allow
the CO2 to infiltrate and dissipate between tissue planes (Fig. 24-2A).
FIGURE 24-2 Incising the peritoneum overlying and just medial to the inferior
mesenteric vein (IMV) entering the plane between IMV and Gerota fascia. A. Incising the
peritoneum overlying and just medial to the inferior mesenteric vein (IMV) and B. entering
the plane between the IMV and Gerota’s fascia.
Enter the plane between the descending mesocolon, below the IMV, and
Gerota fascia (Fig. 24-2B).
Extend the peritoneal incision along the medial aspect of the IMV to
obtain better accessibility and visualization.
Avoid tunneling and achieve maximum medial-to-lateral dissection
(Fig. 24-3A and B).
FIGURE 24-3 A and B. Extension of peritoneal cut edge inferiorly along the
inferior mesenteric vein (IMV) (A). This can lead to the origin of the inferior mesenteric
artery (B).
Medial-to-lateral dissection is then carried out. The borders of dissection
are:
Laterally: ideally as far as the lateral abdominal wall underneath
proximal portion of descending colon (Fig. 24-4A and B).
FIGURE 24-4 A and B. Extent of lateral dissection. A. Lateral abdominal wall
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