Gaining Mesenteric Length following Colorectal Resection: Essential Maneuvers to Avoid Anastomotic Tension

Abstract

A surgeon must possess the knowledge and technical skill to obtain length following a left-sided colorectal resection to perform a tension free anastomosis. The distal target organ – either rectum or anus – is fixed in location, and therefore requires surgeons to acquire mastery of proximal mobilization of the colonic conduit. Generally, splenic flexure mobilization (SFM) provides adequate length. Surgeons benefit from clearer understanding of the multiple steps involved in SFM as a result of improved visualization and demonstration of the relevant anatomy – adjacent organs and the attachments, embryologic planes, and mesenteric structures. Much may be attributed to laparoscopic and robotic platforms which provided improved exposure and as a result, development or refinement of novel approaches for SFM with potential advantages. Complete mobilization draws upon the sum or combination of the varied approaches to accomplish the goal. However, in the situation where extended resection is necessary or in the case of re-operative surgery sacrificing either more proximal or distal large intestine often occurs, the transverse colon or even the ascending colon represents the proximal conduit for anastomosis. This challenging situation requires familiarity with special maneuvers to achieve colorectal or coloanal anastomosis using these more proximal conduits. In such instances, operative techniques such as either ileal mesenteric window with retroileal anastomosis or de-rotation of the right colon (Deloyer's procedure) enable the intestinal surgeon to construct such anastomoses and thereby avoid stoma creation or loss of additional large intestine.

Is Delaying a Coloanal Anastomosis the Ideal Solution for Rectal Surgery?

“…The colon was sufficiently mobilized to allow its exteriorization below the anus without tension and without compromising its vascularity. Alternatively, in the case of insufficient colonic length, the transverse colon was brought down through the mesentery (Toupet procedure), or the inverted right colon was used (Deloyers maneuver) 21–24 . The exteriorized colon stump segment was wrapped with gauze at the end of the procedure.…”

“…Alternatively, in the case of insufficient colonic length, the transverse colon was brought down through the mesentery (Toupet procedure), or the inverted right colon was used (Deloyers maneuver). [21][22][23][24] The exteriorized colon stump segment was wrapped with gauze at the end of the procedure. DCAA was protected by a diverting stoma (ileostomy or colostomy) when the aim of the DCAA was to optimize the anastomosis healing in patients with a high risk of AL.…”

A commentary on ‘Short-term outcomes following intracorporeal vs. extracorporeal anastomosis after laparoscopic right and left-sided colectomy: a propensity score-matched study’

“…During laparoscopic colectomy, intracorporeal anastomosis (IA) is divided into left and right colon. Left-sided colonic anastomosis faces more complexities, but clinical research data is limited 1 . Teramura et al .…”

“…Firstly, further subgrouping on different surgical strategies is recommended for patients undergoing left-sided colectomy. Due to factors such as residual bowel length, anastomotic tension, and blood supply, left-sided colonic anastomosis faces more complexities, which affects the early healing of patients 1 . The authors concluded that IA is more favorable in some patients who have difficulty with anastomosis due to insufficient mobilization but did not clearly state the management of such anastomotic difficulties.…”