Long splenic flexure carcinoma requiring laparoscopic extended left hemicolectomy with CME and transverse-rectal anastomosis: technique for a modified partial Deloyers in 5 steps to achieve enough reach and preserving middle colic vessels

Abstract

Introduction: This How-I-Do-It article presents a modified Deloyers procedure by mean of the case of a 67-year-old female with adenocarcinoma extending for a long segment and involving the splenic flexure and proximal descending colon who underwent a laparoscopic left extended hemicolectomy (LELC) with derotation of the right colon and primary colorectal anastomosis.

Background: While laparoscopic extended right colectomy is a well-established procedure, LELC is rarely used (mainly for distal transverse or proximal descending colon carcinomas extending to the area of the splenic flexure). LELC presents several technical challenges which are demonstrated in this How-I-Do-It article.

Technique and methods: Firstly, the steps needed to mobilize the left colon and procure a safe approach to the splenic flexure are described, especially when a tumor is closely related to it. This is achieved by mobilization and resection of the descending colon, while maintaining a complete mesocolic excision to the level of the duodenojejunal ligament for the inferior mesenteric vein and flush to the aorta for the inferior mesenteric artery. Subsequently, we depict the adjuvant steps required to enable a primary anastomosis by trying to mobilize the transverse colon and release as much of the mesocolic attachments at the splenic flexure area. Finally, we present the rare instance when a laparoscopic derotation of the ascending colon is required to provide a tension-free anastomosis. The resection is completed by delivery of the fully derotated ascending colon and hepatic flexure through a suprapubic mini-Pfannenstiel incision. The primary colorectal anastomosis is subsequently fashioned in a tension-free way and provides for a quick postoperative recovery of the patient.

Results: This modified Deloyers procedure preserves the middle colic since the fully mobilized mesocolon allows for a tension-free anastomosis while maintaining better blood supply to the mobilized stump. Also, by eliminating the need for a mesenteric window and the transposition of the caecum, we allow the small bowel to rest over the anastomosis and the mobilized transverse colon and reduce the possibility of an internal herniation of the small bowel into the mesentery.

Conclusions: Laparoscopic derotation of the right colon and a partial, modified Deloyers procedure preserving the middle colic vessels are feasible techniques in experienced hands to provide primary anastomosis after LELC with improved functional outcome. Nevertheless, it is important to consider anatomical aspects of the left hemicolectomy along with oncological considerations, to provide both a safe oncological resection along with good postoperative bowel function.

Keywords: Colonic derotation; Complete mesocolic excision; Deloyers procedure; Embryology; Left extended colectomy; Splenic flexure carcinoma.

Fig. 1

Panel A—Entered lesser sac and dividing the embryologic adhesions of the TC mesentery. Panel B—Divide and open the Fredet’s fascia. Panels C and D—Toldt’s fascia is fully mobilized and the right colon is going up to reach the RUQ (visible the appendix over the duodeno-pancreatic head

Fig. 2

Specimen with IMV and IMA stump taken at their origin

Fig. 3

Specimen outside its length is demonstrated and transverse colon is exteriorized up the hepatic flexure, which is visible at the level of the wound protector (suprapubic incision)

Fig. 4

Panel A—Colorectal anastomosis already stapled, SB on the right, no internal hernia, colon lying over the aorta. Panel B—Proximal colon going down to the pelvis but still on the left of the D-J flexure and of the SB. Panel C—Proximal colon going down to the pelvis on the left of the D-J flexure and the SB is only on the right side, no internal hernia. Panel D—Middle colic pedicle and its right branch visible going down at the medial side of the colon and aorta. No SB loops are left underneath the colon

Fig. 5

Panel A—The SB loops are being pulled towards the right quadrants. Panel B—Left quadrants are then free and left without any small bowel. Panel C—The proximal colon is going down and care is taken to keep the SB on the right side. Panel D—Everything of the small bowel is on the right side. No internal hernias are left behind

Fig. 6

Panel A—Dissection of the root of transverse colon mesentery with complete skeletonization and mobilization of the middle colic vessels pedicle aiming to get more length and reach without sacrificing the middle colic vessels. Panel B—Middle colic vessels fully mobilized and preserved seen from above (lesser sac). Panel C—Detail of the origin of the stump of Middle colic vessels fully mobilized and preserved. Panel D—Here It can be appreciated how much of reach has been obtained thanks to the mobilization of the root of TC mesentery and the tortuous long segment of middle colic vessels

Fig. 7

LELC with a primary TC-rectal anastomosis achieved with a partial modified Deloyers by fully mobilizing the transverse colon, with a “middle colic vessel sparing” technique. a Laparoscopic extended left colectomy with CME and CVL. b Primary anastomosis is achieved by fully mobilizing the transverse colon, with a “middle colic vessel sparing” technique. c The fully mobilized mesocolon allows for a tension-free anastomosis while maintaining better blood supply to the mobilized stump and also by eliminating the need for a mesenteric window and the transposition of the caecum; the modified technique allows for the small bowel to rest over the colon and above the anastomosis and by keeping the mobilized transverse colon on the left of the D-J flexure and over the aortic line