Laparoscopic resection of splenic flexure colon cancer - a video vignette

Splenic flexure colon cancer is relatively rare. It accounts for 2%–5% of all colorectal cancers [1], and for this reason there is still no consensus about its surgical management. The controversy is mainly focused on the extent of the resection, about the surgical approach to be adopted and on the type of anastomosis to be performed. Different approaches have been proposed in the literature, varying from a right extended colectomy to a left super-extended resection, with or without splenectomy and distal pancreatectomy. We believe these are not necessary routinely except in cases of widespread lymph node metastasis and visceral involvement. The aim of this didactic video (Video S1) is to show how we perform totally laparoscopic resection of splenic flexure colon cancer, focusing on the key vascular steps but most of all on the lymph node dissection and feasibility of intracorporeal anastomosis. The wide variability of the surgical approach also arises from the fact that patients with tumours in this location have been excluded from randomized controlled trials because of the difficulty in deciding the appropriate operative procedure, as well as technical dif- ficulties with laparoscopic lymph node dissection. The lymphatic drainage at this site is variable, and the exact site of lymphatic dissection is uncertain. In their recent study, Watanabe and colleagues [2] proposed a lymph flow pattern evaluation in splenic flexure colon cancer using real-time indocyanine green fluorescence imaging. They concluded that in the case of the distal third of the transverse colon cancer a lymph node dissection of the left branch of the middle colic artery and the root of the inferior mesenteric vein should be performed; in the case of the first part of the descending colon cancer, one should perform lymph node dissection along the left colic artery and the root of the inferior mesenteric vein. Finally, in splenic flexure cancer, the lymph flow can run in various directions necessitating ligation of both the middle colic artery and left colic artery, at least in cases without widespread lymph node metastasis. It should be noted that, regardless of the type of technique and technology used, compliance with the correct oncological parameters is mandatory, and therefore there is need for clearance of tumour resection margins of 3–5 cm, isolation of the neoplasm using a ‘no-touch isolation technique’ and an adequate lymphadenectomy of at least 17 lymph nodes [3]. In conclusion, we believe lymph node dissection may be required depending on each individual case; however, it is quite difficult to determine this during surgery. An accurate preoperative study using real-time indocyanine green fluorescence imaging could be the future for a commonly accepted technique.