Surgical Steps: Splenic Flexure Mobilization

Splenic flexure mobilization is performed with the da Vinci System in a 3-arm set-up with only instrument arms (1) and (3) docked to minimize external collisions [Figure 30].

Figure 30: Splenic flexure set-up

Instrumentation: 0^° endoscope, Fenestrated Maryland Bipolar (left (3)), Hot Shears^™ (Monopolar Curved Scissors) (right (1), alternatively Harmonic^™ Curved Shears) - if visualization is compromised, switch to a 30^° endoscope up/down for a different viewing angle
To achieve a tension-free anastomosis, the splenic flexure is mobilized in a medial approach. From the supra-umbilical endoscope port the surgeon has optimal view of the anterior surface of the pancreas and the base of the left transverse mesocolon, especially in obese patients. Anatomical overview and arm set up shown below [Figure 31 and 32].

Figure 31: Anatomy overview of procedure step 4

Figure 32: Arms (1) and (3) aligned for splenic flexure mobilization

Follow the dissection plane of the previous sigmoid colon mobilization, cephalad and anterior to Toldt's fascia
Assistant retracts the transverse colon anteriorly to expose the inferior border of the pancreas
Open the transverse mesocolon just above the body of the pancreas and enter the lesser sac
Continue dissection posteriorly towards the base of the descending colon and distal transverse colon.
Dissect the omentum in the avascular plane towards the transverse colon, starting from the middle third of the transverse colon. Transverse colon can be "rolled" caudally (as posterior dissection has already been performed) to help with tissue tension on the omentum
Finally, the lateral attachments are divided and the splenic flexure is fully mobilized

View Surgical Steps:

Next: Tips & Tricks