Skip to main content

Advertisement

SpringerLink
Log in

Anatomical and embryological perspectives in laparoscopic complete mesocoloic excision of splenic flexure cancers

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Laparoscopic complete mesocoloic excision (CME) with central vascular ligation for splenic flexure cancer is technically challenging because of its anatomical complexity. Although embryological and anatomical consideration should be helpful to perform CME in colorectal cancer surgery, such studies on the splenic flexure are lacking.

Methods

The splenic flexure is located embryologically between the terminal portion of the midgut and the beginning of the hindgut, and is supplied by the superior mesenteric and inferior mesenteric arteries. The mesentery of the transverse and descending colon originally is a continuous sheet, although they rotate and partially fuse to each other during development. Our surgical strategy was excision of the transverse and descending mesocolon with ligation of the left colic artery and left branch of the middle colic artery, and extraction of the specimen in an intact package wrapped by the embryological planes.

Results

We performed laparoscopic surgery according to our surgical strategy in 17 patients with splenic flexure colon cancer. There were no conversions to open surgery or serious intraoperative complications. Two patients had pathological stage (pStage) I, 5 pStage II, 9 pStage III, and 1 pStage IV disease. No patient had recurrence except for 1 with pStage IV cancer, with a median follow-up of 16 months.

Conclusions

Our laparoscopic CME technique is feasible for treatment of splenic flexure cancer. Knowledge of anatomy based on embryology is essential to perform this surgery.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S (2009) Standardized surgery for colonic cancer: complete mesocoloic excision and central ligation–technical notes and outcome. Colorectal Dis 11:354–364 (discussion 364–365)

    Article  CAS  PubMed  Google Scholar 

  2. West NP, Hohenberger W, Weber K, Perrakis A, Finan PJ, Quirke P (2010) Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol 28:272–278

    Article  PubMed  Google Scholar 

  3. West NP, Kobayashi H, Takahashi K, Perrakis A, Weber K, Hohenberger W, Sugihara K, Quirke P (2012) Understanding optimal colonic cancer surgery: comparison of Japanese D3 resection and European complete mesocoloic excision with central vascular ligation. J Clin Oncol 30:1763–1769

    Article  PubMed  Google Scholar 

  4. Nakagoe T, Sawai T, Tsuji T, Jibiki M, Ohbatake M, Nanashima A, Yamaguchi H, Yasutake T, Kurosaki N, Ayabe H, Ishikawa H (2001) Surgical treatment and subsequent outcome of patients with carcinoma of the splenic flexure. Surg Today 31:204–209

    Article  CAS  PubMed  Google Scholar 

  5. Perrakis A, Weber K, Merkel S, Matzel K, Agaimy A, Gebbert C, Hohenberger W (2014) Lymph node metastasis of carcinomas of transverse colon including flexures. Consideration of the extramesocoloic lymph node stations. Int J Colorectal Dis 29:1223–1229

    Article  PubMed  Google Scholar 

  6. Pisani Ceretti A, Maroni N, Sacchi M, Bona S, Angiolini MR, Bianchi P, Opocher E, Montorsi M (2015) Laparoscopic colonic resection for splenic flexure cancer: our experience. BMC Gastroenterol 15:76

    Article  PubMed  PubMed Central  Google Scholar 

  7. Rouffet F, Hay JM, Vacher B, Fingerhut A, Elhadad A, Flamant Y, Mathon C, Gainant A (1994) Curative resection for left colonic carcinoma: hemicolectomy vs. segmental colectomy. A prospective, controlled, multicenter trial. French Association for surgical research. Dis Colon Rectum 37(7):651–659

    Article  CAS  PubMed  Google Scholar 

  8. Odermatt M, Siddiqi N, Johns R, Miskovic D, Khan O, Khan J, Parvaiz A (2014) The short- and long-term outcomes for patients with splenic flexure tumours treated by left versus extended right colectomy are comparable: a retrospective analysis. Surg Today 44(11):2045–2051

    Article  PubMed  Google Scholar 

  9. Nakashima M, Akiyoshi T, Ueno M, Fukunaga Y, Nagayama S, Fujimoto Y, Konishi T, Noaki R, Yamakawa K, Nagasue Y, Kuroyanagi H, Yamaguchi T (2011) Colon cancer in the splenic flexure: comparison of short-term outcomes of laparoscopic and open colectomy. Surg Laparosc Endosc Percutan Tech 21(6):415–418

    Article  PubMed  Google Scholar 

  10. Acar HI, Comert A, Avsar A, Celik S, Kuzu MA (2014) Dynamic article: surgical anatomical planes for complete mesocoloic excision and applied vascular anatomy of the right colon. Dis Colon Rectum 57:1169–1175

    Article  PubMed  Google Scholar 

  11. Matsuda T, Iwasaki T, Sumi Y, Yamashita K, Hasegawa H, Yamamoto M, Matsuda Y, Kanaji S, Oshikiri T, Nakamura T, Suzuki S, Kakeji Y (2017) Laparoscopic complete mesocoloic excision for right-sided colon cancer using a cranial approach: anatomical and embryological consideration. Int J Colorectal Dis 32:139–141

    Article  PubMed  Google Scholar 

  12. Stelzner S, Hohenberger W, Weber K, West NP, Witzigmann H, Wedel T (2016) Anatomy of the transverse colon revisited with respect to complete mesocoloic excision and possible pathways of aberrant lymphatic tumor spread. Int J Colorectal Dis 31:377–384

    Article  PubMed  Google Scholar 

  13. Steffen C, Bokey EL, Chapuis PH (1987) Carcinoma of the splenic flexure. Dis Colon Rectum 30(11):872–874

    Article  CAS  PubMed  Google Scholar 

  14. Sadler TW (2012) Langman’s medical embryology, 12th edn. Lippincott, Philadelphia

    Google Scholar 

  15. Standring S (2015) Gray’s anatomy-the anatomical basis of clinical practice, 41st edn. Elsevier, Philadelphia

    Google Scholar 

  16. Kanemitsu Y, Komori K, Kimura K, Kato T (2013) D3 lymph node dissection in right hemicolectomy with a no-touch isolation technique in patients with colon cancer. Dis Colon Rectum 56:815–824

    Article  PubMed  Google Scholar 

  17. Kapiteijn E, Putter H, van de Velde CJ (2002) Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg 89:1142–1149

    Article  CAS  PubMed  Google Scholar 

  18. Martling AL, Holm T, Rutqvist LE, Moran BJ, Heald RJ, Cedemark B (2000) Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet 356:93–96

    Article  CAS  PubMed  Google Scholar 

  19. Fukuoka A, Sasaki T, Tsukikawa S, Miyajima N, Ostubo T (2016) Evaluating distribution of the left branch of the middle colic artery and the left colic artery by CT angiography and colonography to classify blood supply to the splenic flexure. Asian J Endosc Surg 10:148–153

    Article  PubMed  Google Scholar 

  20. Miyamoto R, Nagai K, Kemmochi A, Inagawa S, Yamamoto M (2016) Three-dimensional reconstruction of the vascular arrangement including the inferior mesenteric artery and left colic artery in laparoscope-assisted colorectal surgery. Surg Endosc 30:4400–4404

    Article  PubMed  Google Scholar 

  21. Ogino T, Takemasa I, Horitsugi G, Furuyashiki M, Ohta K, Uemura M, Nishimura J, Hata T, Mizushima T, Yamamoto H, Doki Y, Mori M (2014) Preoperative evaluation of venous anatomy in laparoscopic complete mesocoloic excision for right colon cancer. Ann Surg Oncol 21(Suppl 3):S429–435

    Article  PubMed  Google Scholar 

  22. Rusu MC, Vlad M, Voinea LM, Curca GC, Sisu AM (2008) Detailed anatomy of a left accessory aberrant colic artery. Surg Radiol Anat 30:595–599

    Article  CAS  PubMed  Google Scholar 

  23. Watanabe J, Ota M, Suwa Y, Ishibe A, Masui H, Nagahori K (2017) Evaluation of lymph flow patterns in splenic flexural colon cancers using laparoscopic real-time indocyanine green fluorescence imaging. Int J Colorectal Dis 32:201–207

    Article  PubMed  Google Scholar 

  24. Al-Asari SF, Lim D, Min BS, Kim NK (2013) The relation between inferior mesenteric vein ligation and collateral vessels to splenic flexure: anatomical landmarks, technical precautions and clinical significance. Yonsei Med J 54:1484–1490

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-chou, Chuo-ku, Kobe, 650-0017, Japan

    Takeru Matsuda, Kimihiro Yamashita, Hiroshi Hasegawa, Masashi Yamamoto, Yoshiko Matsuda, Shingo Kanaji, Taro Oshikiri, Tetsu Nakamura, Satoshi Suzuki & Yoshihiro Kakeji

  2. Division of Minimally Invasive Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan

    Yasuo Sumi

Authors
  1. Takeru Matsuda
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yasuo Sumi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kimihiro Yamashita
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hiroshi Hasegawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Masashi Yamamoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yoshiko Matsuda
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Shingo Kanaji
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Taro Oshikiri
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Tetsu Nakamura
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Satoshi Suzuki
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Yoshihiro Kakeji
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Takeru Matsuda.

Ethics declarations

Disclosures

Takeru Matsuda, Yasuo Sumi, Kimihiro Yamashita, Hiroshi Hasegawa, Masashi Yamamoto, Yoshiko Matsuda, Shingo Kanaji, Taro Oshikiri, Tetsu Nakamura, Satoshi Suzuki, and Yoshihiro Kakeji have no conflicts of interest or financial ties to disclose.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Matsuda, T., Sumi, Y., Yamashita, K. et al. Anatomical and embryological perspectives in laparoscopic complete mesocoloic excision of splenic flexure cancers. Surg Endosc 32, 1202–1208 (2018). https://doi.org/10.1007/s00464-017-5792-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-017-5792-6

Keywords

Search

Navigation