Classification of the colonic splenic flexure based on three-dimensional CT analysis

Background Mobilization of the splenic flexure can be a challenging surgical step in colorectal surgery. This study aimed to classify the splenic flexure based on the three-dimensional (3D) coordinates of the splenic hilum and left renal hilum. This classification was used to compare splenic flexure mobilization during colorectal resection. Methods CT images of patients with colorectal cancer treated between April 2018 and December 2019 were analysed retrospectively. 3D mutual positioning of the splenic flexure from the ligament of Treitz to the splenic hilum or the left renal hilum was used to classify patients into three groups using cluster analysis. The difference in the procedure time between groups was also analysed in a subset of patients undergoing laparoscopic colectomy with complete splenic flexure mobilization. Results Of 515 patients reviewed, 319 with colorectal cancers were included in the study and categorized based on the 3D coordinates of the splenic hilum and left renal hilum as caudal (100 patients), cranial (118) and lateral (101) positions. Male sex (P < 0.001), older age (P = 0.004) and increased bodyweight (P = 0.043) were independent characteristics of the lateral group in multiple logistic regression analysis. Thirty-four patients underwent complete splenic flexure mobilization during the study period; this took significantly longer (mean 78.7 min) in the lateral group than in the caudal and cranial groups (41.8 and 43.2 min respectively; P = 0.006). Conclusion Locating the splenic flexure using 3D coordinates could be helpful in predicting a longer duration for mobilization of the splenic flexure.

Laparoscopic Approaches to Splenic Flexure Mobilization Tailored According to Disease- and Patient-Related Factors

Early in the 1990s, minimally invasive surgery manifested in laparoscopic surgery found its way to the field of colorectal surgery. Since then, a rising trend in utilizing laparoscopic approach in colorectal surgery, either for benign or malignant disease, is being noticed. In laparoscopic colorectal surgery, the most difficult and challenging step for colorectal surgeons is the mobilization of the splenic flexure. Laparoscopic mobilization of the splenic flexure is an area of debate, with no universally accepted gold standard approach. Multiple approaches have been described in the medical literature and no approach is considered the standard approach. Hence, colorectal surgeons should be familiar with all the different approaches and they should have the ability of utilizing a tailored splenic flexure mobilization approach modified according to patient- and disease-related factors. Herein, we review the different surgical approaches to laparoscopic splenic flexure mobilization that can be tailored to the surgeons needs according to patient- and disease-related factors.