A video guide of five access methods to the splenic flexure: the concept of the splenic flexure box

Aim: The aim of this study was to describe all the possible approaches for laparoscopic splenic flexure mobilization (SFM), each suitable for specific situations, and create an illustrated system to show SFM approaches in an easy and practical way to make it easy to learn and teach. Methods: Two different phases. First part: Cadaver-based study of the colonic splenic flexure anatomy. In order to demonstrate the different approaches, a balloon was placed through the colonic hepatic flexure in the lesser sac without sectioning any of the fixing ligaments of the splenic flexure. Second part: A real case series of laparoscopic SFM. Results: First part: 11 cadavers were dissected. Five potential approaches to SFM were found: anterior, trans-omentum, lateral, medial infra-mesocolic, and medial trans-mesocolic. The illustrative system developed was named: Splenic Flexure “Box”(SFBox). Second part: One of the types of SFM described in first part was used in five patients with colorectal cancer. Each laparoscopic approach to the splenic flexure was illustrated in a video accompanied by illustration aids delineating the access. Conclusion: With the cadaver dissection and subsequent demonstration in real-life laparoscopic surgery, we have shown five types of laparoscopic splenic flexure mobilization. The Splenic Flexure “Box” is a useful way to learn and teach this surgical maneuver

"Near-TME" : proposed standardisation of the technique for proctectomy in male patients with ulcerative colitis

The aim of the present study was to describe in detail an approach to proctectomy in ulcerative colitis (UC), which can be standardized; near-total mesorectal excision (near-TME), to prevent injuries to autonomic pelvic nerves and subsequent sexual dysfunction. We demonstrate the technique ex vivo on a cadaver from a male patient in lithotomy position and on a sagittal section of a male pelvis. We also demonstrate the technique in vivo in two male patients diagnosed with UC, with no history of sexual dysfunction or bowel neoplasia. The study was performed at the Human Embryology and Anatomy Department. University of Valencia, Spain. The posterolateral dissection during a near-TME is similar to that of an oncologic TME, whereas the anterolateral is similar to that of a close rectal dissection. The near-TME technique preserves the superior hypogastric plexus, the hypogastric nerves, the nervi erigentes, the inferior hypogastric plexus, the pelvic plexus and the cavernous nerves. The near-TME technique is the standardisation of the technique for proctectomy in male patients with ulcerative colitis. Near-TME requires experience in pelvic surgery and an exhaustive knowledge of the embryological development and of the surgical anatomy of the pelvis. The online version contains supplementary material available at 10.1007/s10151-022-02579-

The fusion fascia of Fredet: an important embryological landmark for complete mesocolic excision and D3-lymphadenectomy in right colon cancer

Background: The fusion fascia of Toldt is a well-known landmark used by colorectal surgeons. On the contrary, the fusion fascia of Fredet (the plane between the ascending mesocolon and the visceral duodenal-pancreatic peritoneum) still remains a neglected embryological structure. Aim of this study was to provide an anatomic description of this fascia and its application to minimally invasive D3-lymphadenectomy (D3-L) and complete mesocolic excision (CME) for right colon cancer. Methods: First phase: Cadaveric dissection and anatomic description of the fascia of Fredet. Second phase: prospective evaluation of its surgical application in a consecutive series of laparoscopic right hemicolectomies with CME and D3-L at a tertiary hospital. Results: The fascia of Fredet was identified and dissected in one fresh and two formalin-fixed cadavers. The trunk of Henle and the medial border of the superior mesenteric vein defined the medial limit of this embryologic plane. Seventeen patients were operated on. Laparoscopic dissection of the fascia of Fredet was possible in every patient. Median operative time was 210 (120–380) min. There were no major postoperative complications. All cases were adenocarcinomas, except one adenomatous polyp. T stage was Tis in three, T2 in two, T3 in seven, and T4 in five patients. Median number of harvested lymph nodes was 24 (9–39). Lymphatic invasion was found in six patients. All resections were classified as satisfactory mesocolic excision and R0. Median postoperative length of stay was 6 (4–20) days. Median follow-up time was 28 (16–41) months. Local and distal recurrence rate was 0. Conclusion: The fusion fascia of Fredet is useful to achieve CME and D3-L in right colon cancers with reduced risk of intraoperative complications. This structure is particularly suitable for minimally invasive surgery; therefore, we encourage awareness of the fascia of Fredet by colorectal surgeons

Inequalities in screening policies and perioperative protection for patients with acute appendicitis during the pandemic: Subanalysis of the ACIE Appy study

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