Techniques and feasibility of the cranial-to-caudal approach for laparoscopic left colectomy in obstructive splenic flexure cancers: A consecutive case series (with video)

Aim Laparoscopic surgery of splenic flexure cancers (SFCs) is one of the most challenging operations among other colorectal surgical procedures. The most commonly performed and recommended laparoscopic surgical technique is the medial-to-lateral approach. On the other hand, in obstructive splenic flexure cancers (OSFCs), the medial-to-lateral approach may not be possible due to the narrowed surgical field by dilated bowel and difficulty in positioning the bowel. This study aims to present the surgical technique and feasibility of laparoscopic left colectomy with cranial-to-caudal dissection as a new alternative method in OSFCs. Method All consecutive patients who underwent laparoscopic left colectomy with cranial-to-caudal dissection for OSFC between December 2018 and February 2022 were analysed. All procedures were performed by a single surgeon experienced in laparoscopic colorectal surgery and video recorded. Result Five consecutive cases of OSFC who underwent laparoscopic surgery with a cranial-to-caudal approach were evaluated. The median operating time was 180 (165-195) min, and the length of hospital stay was nine (7-12) days. The surgical margins were tumour-free, and the median number of harvested lymph nodes was 20 (17-36). Four patients had pTNM stage 3B disease, and one patient had stage 2A disease. There were no major complications and mortality. Conclusion In this study, a new alternative surgical approach was used for OSFCs, one of the most challenging procedures in laparoscopic surgery. This technique can also be safely used not only in OSFCs but also in other left colon tumours (adhesions, obesity, etc.) that require splenic flexure mobilization and pose difficulty in a medial-to-lateral approach.