doi:10.1111/codi.12942
Clinical note
A new technique of extreme lateral positioning for laparoscopic splenic flexure mobilization S. Gonsalves, I. Brayshaw, S. Maslekar, J. Hance, P. Sagar and D. Miskovic The John Goligher Colorectal Unit, St James University Hospital, Leeds, UK Received 15 July 2014; accepted 23 December 2014; Accepted Article online 9 March 2015
Abstract Aim This aim of this study was to describe a novel positioning technique that assists in the expeditious mobilization of the splenic flexure without the need for redraping or compromise of port placement.
median time (interquartile range) for laparoscopic splenic flexure mobilisation was 10 (9–11.25).
Method A prospective case series was studied to evaluate the technique and its ability to facilitate splenic flexure mobilization.
Conclusion This novel positioning technique is safe and feasible. We include a detailed video that describes and demonstrates the requisites for its safe conduct. We also include intra-operative footage demonstrating the benefits of the patient’s position.
Results The technique was used in 12 patients. There were no adverse intra- or postoperative events. The
Keywords Splenic flexure mobilization, colonic mobilization, rectal cancer
Laparoscopic splenic flexure mobilization is considered to be a technically difficult step of anterior resection [1]. To facilitate mobilization, patients with a high flexure or adhesions from the spleen and omentum may require additional laparoscopic ports or multiple position changes of the patient. Right lateral positioning of the patient is a well-described technique that assists mobilization of the splenic flexure [2] but it usually requires intra-operative repositioning and redraping of the patient, which can be time consuming. We describe our technique of extreme lateral positioning with the patient in the modified Lloyd-Davies position. It enables improved retraction by gravity of the flexure without the need to redrape the patient during the procedure.
right side of the table, lateral to the already positioned lateral patient support (Fig. 1). A suction bean bag Vacuum Beanbag positioner - Full body - 1000mm 9 730mm, Anetic Aid, Guiseley, UK) is placed just slightly above the right lateral support, and a large patient gel pad (Azure gel pad, 1150mm 9 520mm 9 10mm, Anetic aid, Guiseley, UK) is placed just slightly above the bean bag, ensuring protection of the patient’s pressure areas whilst in the extreme lateral position (Fig. 2). Once the patient is transferred to the operating table and placed in the Lloyd-Davies position, suction is applied to the beanbag and a 30° wedge (Crawford Wedge Large; Anetic Aid) is placed underneath the beanbag on the patient’s left side (Fig. 3). A gel-padded strap is placed across the patient’s chest to provide further support whilst in the extreme position.
Positioning technique
Operative technique
The operating table is set as for placement of the patient in the modified Lloyd-Davies position, with the addition of an arm extension board secured to the
The ports are inserted in the neutral patient position, which is achieved by initially tilting the operation table 30° to the patient’s left. Mobilization of the splenic flexure requires the insertion of three ports [umbilicus 12-mm camera port, 5-mm left lateral port (at the level of the umbilicus) and a 5-mm port in the right upper quadrant]. The table is tilted fully to the right and to
Introduction
Correspondence to: Danilo Miskovic PhD FRCS, Consultant Colorectal Surgeon, Clinical Associate Professor, St James’s University Hospital, Beckett Street, Leeds, LS9 7TF, UK. E-mail:
[email protected]
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S. Gonsalves et al.
Novel position for laparoscopic splenic flexure mobilization
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Figure 1 (a) Operating table viewed from the right lateral position. A side extension board is placed lateral to the already secured lateral support. A gel pad is placed medially to the support and overlies the laparoscopic bean bag. (b) Close up of the operating table viewed from the right lateral position.
an anti-Trendelenburg position, achieving a 60–70° extreme right lateral position (Fig. 4). This provides optimal exposure of the lateral attachments of the splenic flexure. Dissection commences along the white line of Toldt in the left paracolic gutter using a diathermy hook or a Harmonic Scalpel© (Endo Surgery INC Johnson & Johnson Medical SPA, Somerville, New Jersey, USA). The mesentery of the descending colon is carefully separated from Gerota’s fascia, continuing cranially towards the splenic flexure. The lesser sac is either entered laterally or by separation of the omentum from the transverse colon/division of the gastrocolic ligament – with direct entry to the lesser sac. After lateral dissection is completed, attention is focused on the medial dissection, which is performed with the patient in the Trendelenburg position. High tie ligation of the inferior mesenteric artery and vein is performed from the medial aspect.
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Figure 2 (a–c) Different views of the laparoscopic beanbag placed onto the patient lateral support with gel pad being placed above this to protect pressure areas.
The authors have performed this technique in 12 patients and have not experienced any intra-operative or postoperative adverse events. Our median time (interquartile range) for laparoscopic splenic flexure mobilisation was 10 (9–11.25) min. After an introductory training period, the initial positioning technique can be confidently performed in less than 10 min.
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Novel position for laparoscopic splenic flexure mobilization
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Figure 4 The extreme lateral position.
Figure 3 (a,b) A 30 wedge is placed underneath the laparoscopic beanbag on the patient’s left side.
Authors Contribution Study conception and design: Simon Gonsalves, Ian Brayshaw, Danilo Miskovic. Acquisition of data: Sushil Maslekar, Julian Hance, Peter Sagar, Danilo Miskovic. Analysis and interpretation of data: not applicable. Writing manuscript: Simon Gonsalves, Ian Brayshaw, Danilo Miskovic.
resection for colorectal malignancy without splenic flexure mobilisation. Colorectal Dis 2008; 10: 165–9. 2 Frame RJ, Wahed S, Mohiuddin MK, Katory M. Right lateral position for laparoscopic splenic flexure mobilization. Colorectal Dis 2011; 13: e178–80.
Supporting Information Additional Supporting Information may be found in the online version of this article: Video S1. A novel positioning technique: extreme lateral positioning for laparoscopic splenic flexure mobilisation.
References 1 Katory M, Tang CL, Koh WL et al. A 6-year review of surgical morbidity and oncologic outcome after high anterior
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