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. 2023 Jan 13;36(1):37–46. doi: 10.1055/s-0042-1758776

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

Herschel David Vargas 1,✉
PMCID: PMC9839430  PMID: 36643828

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.

Keywords: colorectal anastomosis, length, tension-free

Key Points

  • Collagenolysis marks the inflammatory phase of healing and jeopardizes intestinal anastomoses. While cause of anastomotic leak remains a topic of intense scrutiny, surgeons consider tension free approximation a fundamental principle of anastomotic construction.

  • Left-sided as opposed to right-sided colorectal resection requires mobilization techniques to acquire adequate mesenteric length to facilitate anastomoses.

  • Gaining length involves deliberate and thorough anatomical dissection of the colon and its mesentery achieving the ultimate goal: a straightened colon with pivot point occurring at the base of the mesentery.

  • Splenic flexure mobilization usually provides adequate length following the vast majority of left-sided colorectal resection for anastomosis. Nuances of this maneuver involve discrete steps resulting in a straightened colon and providing optimal descent of the conduit.

  • If splenic flexure mobilization fails to provide adequate length or if extended resection occurs, special techniques exist – retroileal anastomosis or derotation of the right colon – which facilitate anastomosis of the transverse colon or ascending colon to the rectum or anal canal.

From the patient perspective a healed, functional anastomosis represents a singular measure of successful treatment of the pathologic condition requiring resection. On the contrary, a failed anastomosis inflicts serious morbidity and even mortality and likely leads to prolonged hospitalization, often reoperation and disability including stoma creation and loss of continence. 1 Anastomotic failure is catastrophic.

During the inflammatory phase of healing following anastomosis, collagenolysis prevails and the integrity of the approximation depends on the tensile strength of the suture or staple line joining the two ends of bowel. 2 3 4 5 This vulnerable period of the anastomosis to breaking or dehiscence magnifies the fundamental tenet of anastomotic construction: approximation without tension. This generally does not apply to most right-sided colonic resections due to the mobility of the small bowel mesentery. Instead, the issue of mesenteric length and reach of the conduit for anastomosis almost always are related to left-sided colorectal resection where the conduit or proximal bowel must be mobilized to be brought into proximity to a fixed target, the rectum or anal canal/ anus. Given the vulnerability of the anastomosis during the early phases of healing, avoidance of tension therefore is critical and inability to achieve anastomosis without tension represents a “red line” and an indication for stoma creation.

Knowledge of various maneuvers to accomplish a tension free anastomosis therefore is critical to the operative performance and successful outcome of colorectal resection. This review focuses on such specific techniques enabling the surgeon to bridge the physical distance and achieve the desired approximation of the two bowel ends and thereby reduce undesired and often devastating consequences of anastomotic complications.

When to Anticipate Issues of Reach following Colorectal Resection?

There are specific instances where surgeons should anticipate length or reach issues. As previously stated, this scenario occurs following a left-sided colorectal operation. The issue of reach of the proximal conduit results from the relative fixity of the distal target organ, that being the rectum or anal canal, and this most commonly presents following low anterior resection requiring low pelvic or anal anastomosis. Extended resections involving the more proximal left colon or transverse colon present another occasion where mobilization and adjunct maneuvers may be necessary. The savvy surgeon knows that literally any left-sided resection may involve more mobilization and the experienced, prepared surgeon possesses the know-how to facilitate approximation. For the young or novice surgeon heightened anticipation and accordingly specific technical planning must be part of one's preoperative preparation given the inevitability of such situations.

When considering the at-risk procedure, the author considers first the left-sided nature of the colorectal resection. Certainly, low anterior resection may represent the most common indication that maneuvers to mobilize the splenic flexure may be necessary. Though necessity of routine mobilization often debated, the indication for proximal mobilization of the splenic flexure should be anticipated. 6 7 Standard anterior resection or sigmoid colectomy in an elective setting may also require splenic flexure mobilization (SFM) and obese patients with shortened mesenteries or young patient's lacking any bowel redundancy may make reach difficult.

Precise preoperative localization of the pathologic condition is critical to planning extent of resection. Caution should be advised when a neoplastic lesion is identified, and the location estimated by distance. An endoscopist endeavors to best predict the segment of colon involved but this admittedly involves “guesswork” and uncertainty. However, for the operating surgeon precise segmental location remains critical data. Tattoos placed at the time of colonoscopy may help during surgery but do not provide useful information in terms of localization for preoperative planning. CT scan can be helpful in this regard, but lesions are not always identified. This scenario should be considered analogous to any tumors of the rectosigmoid colon where a surgeon should personally confirm the level of the cancer for treatment planning to exclude a mid or low rectal cancer and whether the patient should be considered for neoadjuvant therapy. Similarly, considerable differences in operative strategies and extent of resection depending on whether the condition involves the sigmoid colon, descending colon or even more proximally. Any experienced surgeon will recount occasions where the endoscopic assessment proved markedly disparate from the operative findings. The author employs endoscopic clip placement with plain radiograph to help localize specific segment of the colon for resection if CT imaging cannot clarify this matter. Clip is placed distal to the lesion and plain film obtained to help with localization. Ideally, the clip will stay present for the staging CT scan to help plan for resection. Best practice in this regard has not been established but one which should be considered ripe for investigation and clarification.

Tumors involving the descending colon ( Fig. 1 ) therefore presents a common scenario requiring extensive mobilization as generally extended left colectomy will be necessary. 8 Splenic flexure pathology too challenges surgeons as to the ideal bowel resection necessary, subtotal colectomy with ileosigmoid anastomosis or splenic flexure resection with transverse colon to sigmoid colon anastomosis. 9 10 11 The latter may be limited by the condition of the sigmoid colon and if diseased (e.g., chronic diverticular changes) additional distal resection may be necessary resulting in the need for transverse colon to rectal anastomosis. The limited reach of the transverse colon may be rectified by full SFM, but additional length may be required even after this maneuver is executed to its maximal extent. 12

Fig. 1.

Fig. 1

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Lesion in the mid descending colon ( arrows to apple core lesion ). Planned resection with lymphadenectomy based on the inferior mesenteric artery pedicle to include the left colic artery and associated lymph nodes. For this lesion, left colectomy with extended mobilization of the splenic flexure will be necessary to restore intestinal continuity.

Synchronous pathologic conditions, either inflammatory or neoplastic may involve extended left-sided resection to include transverse and left colonic resection ( Fig. 2 ). The bowel sparing philosophy of operations for Crohn's disease necessitates consideration of avoidance of resection of any normal intestine and an uninvolved right colon should be preserved. Neoplasms of the transverse and left colon may require extended resection where maintenance of the right colon may be possible.

Fig. 2.

Fig. 2

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Image of extended left and transverse colectomy for multi-segment diverticulitis involving the sigmoid, descending colon and transverse colon.

Lastly, reoperations where prior left-sided resection occurred represent a situation where extended mobilization or an advanced maneuver beyond SFM may be necessary. One should be acutely aware of this circumstance. Redo low anterior resection certainly commands one's attention for expectation for extended mobilization and additional surgical techniques to achieve coloanal anastomosis. 13 14 However, reoperations for even surgical closure of colostomy following prior Hartmann's procedure may require advanced techniques. 12 15 16 Suffice it to say that any prior left-sided resection should alert one that mesenteric length and reach may be inadequate and additional mobilization techniques may be required.

A contingency plan to address inadequate length involves completion or total abdominal colectomy with ileorectal anastomosis. While representing a viable option, there remain disadvantages. For the patient completion colectomy sacrifices bowel length, storage function, absorption capacity, and ileocecal valve function. 17 From a physiologic and functional standpoint completion colectomy and ileocecal valve removal compromise overall bowel function as compared with segmental colectomy and potentially the quality of life for the individual. 18 In addition, one should be concerned that ileorectal anastomosis leak rates may be higher than expected compared with colorectal anastomosis. 19 Ultimately, the decision for extent of resection should first and foremost be dictated by the curative treatment of the pathologic condition and one should hesitate to perform completion colectomy as a default option simply because of surgical expediency or lack of surgeon preparation.

In summary, the importance of anticipation of issues of reach cannot be overstated. Various factors must be considered including the location of the pathologic condition dictating resection, patient anatomical factors including obesity, and prior left-sided resection. Mastery of SFM and familiarity and ability to perform advanced maneuvers such as ileal mesenteric window or derotation of the right colon represent technical skillsets possessed by the intestinal surgeon.

Splenic Flexure Mobilization

The first maneuver to gain length following left-sided colorectal resection: SFM. The necessity of routine mobilization following anterior resection may be debatable 6 7 but in the event of insufficient bowel length, SFM reliably provides in the vast majority of cases the additional reach to perform a tension free anastomosis. Mastery of this is mandatory for the intestinal surgeon.

The understanding of SFM may in the past has varied among surgeons. However, with the advent of minimally invasive technique and improved visualization surgeons can better articulate and describe for teaching or instruction purposes the elements comprising this maneuver. 20 21 22 23 24 Camera-based surgery provides better exposure of the relevant anatomy – fascial attachments, embryologic planes, and mesenteric structures – involved in the dissection and mobilization of the splenic flexure.

Various techniques developed as a result. These emphasize different aspects of the maneuver or variations but the sum of the steps regardless of order or approach should accomplish the goal. Liang described a standardized SFM technique utilizing the robotic platform. 24 This step-wise approach involves eight steps and the report suggests the feasibility and efficiency of a single dock and without the use of the laparoscope. In particular this description emphasizes entering the lesser sac ventral to the pancreas following division of the inferior mesenteric vein and moving medial to lateral along the edge of the pancreas to the splenic hilum ( Fig. 3 ). 24 The authors contend that deliberate dissection proved effective even in the case of “severe body habitus.” Garcia-Granero et al suggest the concept of a “splenic flexure box” as a teaching model. The “box” provides a geometric metaphor by which different approaches to mobilizing the splenic flexure can be understood. As a result, the authors describe five different approaches to laparoscopic SFM first using cadavers and then prospectively employing in operative cases to illustrate. 25 Approaches include an anterior approach by taking the omentum off the transverse colon, an anterior approach going through the omentum, a lateral approach from the splenic flexure, an infra-mesocolic approach just ventral to the pancreas, and a trans-mesocolic approach going through the bare area of the distal transverse colon. The model focuses on entry into the lesser sac and access to the attachments to the inferior border of the pancreas. This same group subsequently provided a description with video demonstrating seven steps of a laparoscopic SFM with emphasis on the advantages of an infra-mesocolic vein approach. 21 These examples reveal the essential aspects, regardless of the operative platform, and uniformity of the maneuver: mobilization of the descending colon, splenic flexure and transverse colon and the attached mesentery to the middle colic pedicle. These two illustrations also highlight that the SFM can vary by direction of approach (lateral to medial, medial to lateral, superior or supramesocolic, inferior to superior) or by mesenteric structure (inferior mesenteric artery first, inferior mesenteric vein first) and so on. 24 25

Fig. 3.

Fig. 3

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( A ) Attachments of the transverse colon mesentery to the inferior border of the pancreas ( red arrows ). Transverse colon is retracted caudally to divide the lateral attachments of the transverse colon to the pancreas. ( B and C ) Transverse colon mesentery is retracted cephalad during dissection of the medial aspect of the attachments to the inferior border of the pancreas to avoid injury to the fourth portion of the duodenum. (Source: Photo courtesy of W. Forrest Johnston).

The different approaches available offer unique advantages, but each may have limitations or difficulties depending on the pathologic condition, anatomical variation, and as previously mentioned the patient body habitus. Challenges of the maneuver include deliberate dissection of the complex and varied greater omentum and its embryologic attachments to the mesentery, retroperitoneum, the transverse colon, descending colon, stomach and spleen. Complete detachment of the omentum from the colon and its mesentery are often necessary for successful mobilization.

The transverse colon, splenic flexure, and descending colon based on embryologic development share a common mesentery. 26 This unit therefore must be mobilized from the retroperitoneum off Gerota's fascia and the pancreas posteriorly. Dissection posteriorly can be initiated medially along the inferior mesenteric vein (IMV), laterally, and inferiorly from either the IMA or from an inferolateral approach. In each case, the goal is to dissect toward the base of the pancreas. Entry into the lesser peritoneal sac ultimately is critical to isolate and divide the avascular attachment of the transverse colon mesentery to the inferior border of the pancreas. Each centimeter of division of the attachments to the pancreas will give 1 to 2 cm of additional length of the colon conduit. Superior attachments to the stomach, omentum, and spleen must also be addressed. This can be performed between the omentum and the transverse colon or by division of the omentum (gastrocolic ligament). 24 There are often retrogastric adhesions to the transverse colon mesentery which must be freed. Lastly lateral attachments along the colic gutter must be incised.

Splenocolic ligament and phrenicocolic ligament represent the area of greatest concern for the any surgeon performing SFM. Splenic injury during colon surgery fortunately is rare and occurred in 1.1% of over 2,300 colorectal resections in a recent single institutional study. 27 Splenic salvage (topical agents 64% and splenorrhaphy 16%) was achieved in the vast majority of cases while splenectomy was necessary in 20%. Interestingly, laparoscopic compared with open technique was associated with decreased incidence of splenic injury likely due to improved visualization of the left upper quadrant. Most commonly splenic injury is related to traction on the omentum or colon with capsular injury representing the most common type though a range of injuries can occur. 28 Interestingly, splenic injury is not necessarily limited to SFM and increased rates occur following any prior abdominal surgery. 27 Awareness of the mechanisms of injury compels precise dissection of the embryologic attachments or lienocolic and phrenicocolic ligaments and, in particular, judicious tension on the bowel and omentum in the vicinity of the spleen. 28

The matter regarding actual mesenteric release medially – or the level of vessel division (arterial and venous) – is a particularly relevant aspect of this maneuver. While some may debate the oncologic benefit of high ligation of the inferior mesenteric artery, 29 30 technically speaking high ligation of the inferior mesenteric artery and proximal ligation of the inferior mesenteric vein at the base of the pancreas provide the greatest reach of the colonic conduit. Cadaveric studies ( Fig. 4 ) 31 objectively validate this specific point as conduit reach was significantly greater – approximately 10 cm – following high tie of the inferior mesenteric artery compared with low tie and confirms what long has been observed by those who perform coloanal anastomoses. 31 32 33 That said, low ligation of the IMA combined with division of the left colic artery will result in approximately the same mesenteric length and descent of the conduit as high ligation. 31

Fig. 4.

Fig. 4

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Options for vessel ligation for left colectomy. ( A ) Mobilization of splenic flexure with high ligation of the IMA and IMV just distal to the aorta and the pancreas, respectively. Second ligation of the left colic artery is needed. ( B ) Mobilization of the splenic flexure with low ligation of the IMA below the bifurcation (at the superior rectal artery) along with ligation of the IMV below the pancreas. The left colic artery can be preserved or divided to gain length. Source: Reproduced with permission of Bonnet et al. 31

A surgeon and the patient benefit from familiarity with all options and successful mobilization often involves incorporating different aspects of the various approaches in combination. Therefore, one should be hesitant to become beholden to one approach but rather one should pursue facility with all approaches. 25 34 35 The result, however, should be consistent: a mobile bowel and its mesentery which descend straight from the ligament of Treitz, pivoting on the middle colic pedicle and providing a conduit which is well perfused based upon the marginal artery. The end of descending colon should easily reach well below the symphysis pubis for colonic J Pouch Anal Anastomosis.

Splenic Flexure Mobilization 2.0: Additional Steps to Maximizing Reach

The above describes essential aspects of splenic flexure. To gain additional length, nuances of dissection include: (1) continued medial mobilization of the transverse colon off the retroperitoneum and pancreas to the origin of the middle colic artery; (2) release of the ligament of Treitz; and (3) relaxing incision of the splenic flexure mesentery. These additional aspects of mobilization provide greater reach of the conduit for anastomosis.

In the first instance, the IMV division occurs to the left or just posterior to the ligament of Treitz. Following conventional mobilization, the pivot point occurs at the divided IMV. The distance from the IMV to the middle colic artery and SMA on average is nearly 4 cm. 36 After dividing the IMV at the inferior border of the pancreas, the transverse colon mesentery can be freed over the ligament of Treitz and the fourth portion of the duodenum to reach the left branch of the middle colic artery. This additional mobilization will change the pivot point of the bowel to over SMA and aorta rather than the ligament of Treitz. By continuing the dissection of the mesentery medial to the divided IMV to the middle colic artery, one essentially moves the pivot point to a more midline position. This procures a shorter path to the target organ and increases the reach of the colon conduit. This involves release of the ligament of Treitz to liberate the transverse colon mesentery off the retroperitoneum and more medially on the inferior border of the pancreas ( Fig. 5 ). In addition, the pivot point also becomes more caudal given the oblique positioning of the pancreas; proceeding from left to right the pancreatic head rests inferior or lower than the tail. 37 Thus, the pivot point of the mesentery moves to the midline and more caudal as well and as a result now possesses a shorter distance to the midline target organ, the distal rectum, or anal canal ( Fig. 6 ). 38

Fig. 5.

Fig. 5

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Operative photo of the ligament of Treitz ( red arrow ). Avascular tissue plane on top of the fourth portion of the duodenum can be opened extending to the patient's right until the left branch of the middle colic artery. This will effectively move the pivot point of the colon conduit to be in line with the aorta and increase conduit length. (Source: Photo courtesy of W. Forrest Johnston).

Fig. 6.

Fig. 6

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More length obtained after additional mobilization from IMV to the middle colic artery. (1) Mobilize the colon mesentery off Gerota's fascia to aorta ( green solid arrows ); (2) Mobilize attachments of the transverse colon mesentery off inferior border pancreas ( green dashed arrow ); (3) Divide IMV at the inferior border of the pancreas; (4) Dissect medially to the middle colic vessel. Source: Reproduced with permission of Vargas and Margolin. 38

Gaining maximal length of the colonic conduit also involves straightening of the splenic flexure. Often the course of the descending colon relative to the transverse colon is angled, in some cases more than 90 degrees. The relevant anatomical factors contributing to this conformation include (1) adherent omentum on the ventral surface of the bowel and (2) the conformation of the mesentery itself at the flexure which limits the opening of this angled shape. One of the final steps then is to scrutinize the bowel for vestiges of the omentum on the ventral surface and to dissect this free. Then, to address the mesentery, an incision can be made from the divided IMV toward the splenic flexure which will “relax,” or open the angle of the mesentery and serve to “un-hinge” the course of the intestine changing it from an angle to making it straighter ( Fig. 7 ). 38

Fig. 7.

Fig. 7

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Unhinging the splenic flexure. ( A ) 18-degree splenic flexure conformation – indicated by dotted white line – secondary to residual omentum on ventral surface. ( B ) 90-degree conformation persists following removal of omentum. Relaxation incision made to “un-hinge” the flexure conformation indicated by pickups. ( C ) Green dotted arrow indicates completion of relaxing incision with preservation of the marginal artery to allow perfusion distally. Source: Reproduced with permission of Vargas & Margolin. 38

Lastly, division of the left branch of the middle colic artery or an accessory branch of the middle colic artery can be divided to obtain additional length. 21 Adequate collateral flow from the right branch of the middle colic artery generally provides sufficient perfusion via the marginal artery. The Arc of Riolan present in the central mesentery should be considered and protected but this vessel is relatively uncommon. 24 This step of division of additional mesentery again may provide additional mobility of the mesentery thereby improving reach for anastomosis.

In summary, inadequate length following left-sided resections almost always can be rectified by performing SFM. Multiple approaches have been described and one should be prepared to employ aspects of each approach to achieve complete release of the transverse and left colon for gaining maximal length. Following standard SFM, additional steps assist in maximizing reach of the conduit.

Lastly, one must acknowledge that in spite of the advantages of video camera-guided surgery ultimately exposure is achieved using miniature end effectors which may prove inadequate and certain maneuvers may be difficult to replicate. The goal of a tension free anastomosis and obtaining adequate length should never be compromised because of platform-related challenges whatever this may entail. Transitioning to open laparotomy offers the most reliable assessment of reach issues restoring palpation and providing direct visualization of potential problem areas hampering full mobility of the mesentery and bowel. One should not hesitate to transition, if unable to clarify the anatomical reasons for inadequate length. At this point, if inadequate length persists salvage maneuvers are indicated such as creation of an ileal mesenteric window with retroileal anastomosis or derotation of the right colon. In fact, these aspects of optimizing SFM should be considered requisite to facilitate the next maneuver: retroileal anastomosis .

Advanced Maneuvers: Beyond Splenic Flexure Mobilization

These advanced maneuvers provide methods of anastomosis of the transverse colon to the rectum and anal canal. Ileal mesenteric window with retroileal anastomosis likely will be required for transverse colon – mid to distal – to reach the pelvis. De-rotation of the right colon should be considered for anastomosis of the hepatic flexure or ascending colon following resection of the transverse colon and left colon. As previously stated, these advanced techniques often will be necessary in cases of extended bowel resection or following prior left-sided colorectal resection where additional left-sided resection or redo low anterior resection results in a transverse colon or more proximal colonic conduit for anastomosis. 13 14 In nearly 40% of cases of redo low anterior resection, either ileal mesenteric window or derotation of the right colon was necessary to achieve anastomosis. The decision making occurs in stepwise or sequential fashion. One must execute the prior maneuver before abandonment and advancing to the next step or maneuver.

Retroileal Anastomosis via a Mesenteric Ileal Window

The concept of a mesenteric window to facilitate anastomosis was first described by Andre Toupet in 1961. Following resection of splenic flexure carcinoma, Toupet created a defect in the small bowel mesentery to bring the proximal transverse colon to the sigmoid colon. 39 40 Subsequently, in 1976, Hays published a case report of anastomosis following extended left colectomy for left colon cancer utilizing a mesenteric window to pass the transverse colon to reach the upper rectum for anastomosis. 41

The first case series in the U.S. literature authored by Rombeau and Turnbull in 1978 described a series of 11 patients at the Cleveland Clinic 42 indicating utility and safety with no major septic complications reported. The maneuver likely is infrequently necessary and may depend on the practice type in which one finds themselves. In Turnbull's series of 302 patients over a 10-year period, retroileal anastomosis was necessary 11 times or in 4% left-sided colon resections. Similarly, Ludwig reported 13 patients out of a 340-patient cohort undergoing left-sided resection, essentially 4%, who required a retroileal pelvic anastomosis. Of course, this maneuver initially was described using open technique but during the era of minimally invasive surgery several reports confirm the successful performance using laparoscopic technique. 43 44 45 46

The specific steps involved include complete SFM, detachment of the omentum, mobilization of the right colon and root of small bowel mesentery, creation of an opening in the small bowel mesentery, and passage of the transverse colon through the mesentery behind the ileum into the pelvis. The transverse colon conduit is generally based upon the right branch of the middle colic arterial supply 43 although others have reported division of the middle colic artery and use of even the hepatic flexure or ascending colon for anastomosis. 42 47

The transverse colon then descends straight from the root of the middle colic artery and as it passes through the mesenteric window the transverse colon mesentery will be oriented to the left with the colonic tube positioned to the right. The shape and volume of the mesentery should be tailored, preserving the course of the marginal artery of Drummond, and the conduit passes through a window or defect 4–5 cm in size.

The position of the mesenteric window usually is situated in an avascular area between the superior mesenteric artery and the ileocolic artery. 48 This clear space can be visually confirmed via transillumination of the mesentery. Laparoscopically, the detection of the bare area for creation of the mesenteric defect can be challenging especially in the heavier patient with obese mesentery. Utilizing the planned specimen extraction wound for access offers a solution to this issue. A midline wound allows for exteriorization of the right colon and small bowel mesentery and under direct visualization one can create the mesenteric window.

The defect should be snug reducing the risk of small bowel herniation. Fixation sutures can be performed but are not absolutely necessary. Prior to anastomosis reassessment of the perfusion of the end of transverse colon should be performed. Clinical assessment of pulsatile arterial flow in the cut marginal artery at the proximal resection site and clinical assessment of perfusion provide reliable confirmation. 49 Alternatively, adjunct methods of perfusion assessment including indocyanine green scintigraphy may provide the surgical team with assurances of viability of the conduit. 50 51

The transverse colon via this approach can reach distally to the anal canal. Again prior to moving to the next step one must be convinced that all aspects of the dissection have been thoroughly performed releasing the transverse colon from all embryologic tissue planes (omental, retroperitoneal) and that the mesentery has been dissected to the base of middle colic artery. If the conduit fails to reach the intended target, upper rectum or distally, the middle colic artery likely is the limiting anatomical factor and must be sacrificed. Division of the left branch of the middle colic artery and even the entire middle colic artery has been described as additional methods for releasing the mesentery to facilitate reach of the transverse colon, and in fact, in the description of Turnbull's technique the middle colic vessels were divided. 42 If the conduit still fails to physically reach via the mesenteric window or if the proximal transverse colon becomes ischemic following middle colic pedicle transection, the next option for anastomosis involves Deloyer's procedure, or de-rotation of the right colon.

Deloyer's Procedure or De-rotation of the Right Colon

The transverse colon often will reach the rectum or lower third of the pelvis following SFM or by traversing the mesentery via a mesenteric window. However, the mid or proximal transverse colon may be the exception and in these unusual cases the next option for colorectal or coloanal anastomosis is the Deloyer's procedure or derotation of the right colon. Variations of derotation with anastomosis of the right colon exist, and the first such description was reported in 1955 by Lillehei and Wangensteen. In this thought-provoking publication, the authors described the counterclockwise rotation of the cecum in the coronal plane and construction of a cecorectal anastomosis. 52 In 1958, Deloyer's subsequently reported a technique involving anastomosis of the ascending colon to the rectum following derotation in the sagittal plane . 53 54 These techniques preserved the ileocecal valve, and in the case of Deloyer's technique retained the ascending colon, and thereby offered patients the physiologic benefits of storage and absorptive properties of the right colon. In so doing, the patients potentially benefitted from improved postoperative function compared with total colectomy and ileorectal anastomosis. 55

Interestingly, this technique may be necessary for a variety of indications. Synchronous tumors may require extended left colectomy and involve transverse colon resection. Reoperations especially redo low anterior resection or Hartmann's colostomy closure are also occasions where derotation enabled anastomosis of the right colon to the rectum or more distally to the anal canal. 13 14 15 16 Lastly, this maneuver and the variation of anti-peristaltic cecorectal anastomosis also have been employed for surgical treatment of chronic constipation and colonic inertia. 56 57 58

This maneuver involves division of the middle colic artery, right colic artery with preservation of the ileocolic artery. The proximal transverse colon may likely be sacrificed, if the transverse colon in fact remains well-perfused via an intact marginal artery of Drummond, this may allow for anastomosis via a mesenteric window. However, if resection includes the transverse colon and hepatic flexure, a colorectal and even coloanal anastomosis can be accomplished using the distal ascending colon based upon the ileocolic artery. The appendix is removed as the cecum will be “flipped” into the right upper quadrant where the dorsal surface of the right colon now rests ventrally. Some would describe this as an “inversion” of the right colon as opposed to de-rotation. 15 The counterclockwise rotation occurs in the sagittal plane with rotation along the axis of the ileocolic pedicle. 59 The bowel can reach the pelvis and in the extreme case the anal canal facilitates a tension free anastomosis.

Technical nuances exist. Dissection to the base of the ileocolic pedicle allows for gentle rotation of the vessels and avoids potential kinking ( Fig. 8 ). A true separate right colic artery from the SMA is not commonly found 60 but when present generally needs to be divided; however, some contend this is primarily necessary for low rectal anastomosis and that the right colic artery can be preserved. 15

Fig. 8.

Fig. 8

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Deloyers maneuver. ( A )Right colon mesentery in native position. See “cut edge” of mesentery oriented cranially. ( B ) mesentery at 50% derotation in the sagittal plane. Note the “cut edge” of mesentery oriented caudally. ( C ) Mesentery following de-rotation of the right colon. The “cut edge of mesentery” oriented caudally and slightly to the left. Note the flat mesentery. Blue dotted line marks ileocolic pedicle.

Several publications report use of scintigraphy for confirmation of perfusion of the conduit following de-rotation and given the occasional use of this technique such technology may provide additional validation of the viability of the ascending colon. 50 51 61 Fecal diversion following de-rotation should be performed as clinically indicated as with any pelvic anastomosis but need not be considered mandatory. 15 16

Septic complications and in particular, anastomotic leaks are rare and likely on par with any other colorectal anastomoses. Manceau published the largest case series to date involving 48 patients. 16 Thirty-one of 38 or 64% of patients underwent fecal diversion. However, all diverting stomas were closed. No leaks occurred. Another separate report of 14 patients involved use of fecal diversion in nine out of 14 or 64% 15 Again, all stomas ultimately were closed. No patient suffered anastomotic leak or major septic complications requiring reoperation or intervention.

From a functional standpoint preservation of the ileocecal valve and right colon revealed that patients experienced fewer than three bowel movements per day in over 60% of cases in the Manceau series. 16 Kontovounisios case series of 14 patients demonstrated that 71.4% (10/14) of the patients had two bowel movements per day and 21.4% (3/14) had three per day. 15 Although the literature reflects the relative rarity of the maneuver and comparative studies are not available, the reports would suggest the safety of the technique compared with conventional colorectal anastomosis, and postoperative bowel function would argue superior function when contrasted to the function seen in a historical group undergoing the alternative of completion colectomy with ileorectal anastomosis. 18

Summary

In summary, there are few moments in intestinal surgery which induce more stress than the situation where a great distance exists between the two ends of bowel for anastomosis. A surgeon must possess the knowledge and technical skill to gain length: to fully mobilize the colon and its mesentery and in so doing preserve perfusion of the proximal bowel to achieve a tension free anastomosis during left-sided colorectal resection. Anticipation and surgeon preparation are critical. If one lacks the familiarity of these maneuvers, the reality of inadequate reach becomes a surgical nightmare, and the only true safe recourse is stoma creation. If one anticipates and prepares and possesses the familiarity of advanced maneuvers, contingency plans can be executed, and crisis averted. The likelihood or frequency necessitating such techniques may depend on the type of clinical practice in which one is engaged. For those in a referral center where one encounters more complex colorectal pathology or where one is more likely to receive referrals for reparative or re-operative surgery these techniques may be more frequently performed. However, it would be naïve to not understand that any surgeon performing intestinal surgery will be faced with such challenges of reach and the opportunities for advanced surgical mobilization techniques to achieve anastomosis.

First and foremost, this requires mastering complete SFM and straightening of the transverse and left colon. In specific instances where extended left-sided resection occurs and anastomosis involves the more proximal transverse colon and the rectum distally, creation of a mesenteric window facilitates a direct path to the pelvis for the conduit and its mesentery. Similarly, when resection leaves only the ascending colon or hepatic flexure to serve as the proximal bowel conduit for anastomosis, de-rotation of the right colon offers a technique for tension free anastomotic construction. These maneuvers reduce the need for end stoma creation or anastomotic failure, preserve bowel length and physiologic function, and potentially impact the postoperative result for patients by many measures. As a result, a surgeon can achieve anastomotic construction and healing following colorectal resection thus restoring a patient to a sense of health and well-being.

Footnotes

Conflict of Interest None declared.

References

  • 1.Midura E F, Hanseman D, Davis B R. Risk factors and consequences of anastomotic leak after colectomy: a national analysis. Dis Colon Rectum. 2015;58(03):333–338. doi: 10.1097/DCR.0000000000000249. [DOI] [PubMed] [Google Scholar]
  • 2.Thompson S K, Chang E Y, Jobe B A. Clinical review: healing in gastrointestinal anastomoses, part I. Microsurgery. 2006;26(03):131–136. doi: 10.1002/micr.20197. [DOI] [PubMed] [Google Scholar]
  • 3.Slieker J C, Daams F, Mulder I M, Jeekel J, Lange J F. Systematic review of the technique of colorectal anastomosis. JAMA Surg. 2013;148(02):190–201. doi: 10.1001/2013.jamasurg.33. [DOI] [PubMed] [Google Scholar]
  • 4.Rosendorf J, Klicova M, Herrmann I. Intestinal anastomotic healing: what do we know about processes behind anastomotic complications. Front Surg. 2022;9:904810. doi: 10.3389/fsurg.2022.904810. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Thornton F J, Barbul A. Healing in the gastrointestinal tract. Surg Clin North Am. 1997;77(03):549–573. doi: 10.1016/s0039-6109(05)70568-5. [DOI] [PubMed] [Google Scholar]
  • 6.Chand M, Miskovic D, Parvaiz A C. Is splenic flexure mobilization necessary in laparoscopic anterior resection? Dis Colon Rectum. 2012;55(11):1195–1197. doi: 10.1097/DCR.0b013e3182687f10. [DOI] [PubMed] [Google Scholar]
  • 7.Ludwig K A, Kosinski L. Is splenic flexure mobilization necessary in laparoscopic anterior resection? Another view. Dis Colon Rectum. 2012;55(11):1198–1200. doi: 10.1097/DCR.0b013e3182688011. [DOI] [PubMed] [Google Scholar]
  • 8.Kalady EHCaMF Colon cancer surgical treatment: principles of colectomy 4th ed.Springer; 2022455–462.:chap 25 [Google Scholar]
  • 9.Pang A J, Marinescu D, Morin N, Vasilevsky C A, Boutros M. Segmental resection of splenic flexure colon cancers provides an adequate lymph node harvest and is a safe operative approach – an analysis of the ACS-NSQIP database. Surg Endosc. 2022;36(08):5652–5659. doi: 10.1007/s00464-021-08926-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Horsey M L, Sparks A D, Lai D, Herur-Raman A, Ng M, Obias V. Surgical management of splenic flexure colon cancer: a retrospective propensity-matched study comparing open and minimally invasive approaches using the national cancer database. Int J Colorectal Dis. 2021;36(12):2739–2747. doi: 10.1007/s00384-021-04029-y. [DOI] [PubMed] [Google Scholar]
  • 11.and Members of the Italian Society of Surgical Oncology Colorectal Cancer Network (SICO-CCN) Collaborative Group [A listing of all authors appears at the end of the article] . Degiuli M, Reddavid R, Ricceri F. Segmental colonic resection is a safe and effective treatment option for colon cancer of the splenic flexure: a nationwide retrospective study of the Italian Society of Surgical Oncology-Colorectal Cancer Network Collaborative Group. Dis Colon Rectum. 2020;63(10):1372–1382. doi: 10.1097/DCR.0000000000001743. [DOI] [PubMed] [Google Scholar]
  • 12.Chen Y C, Fingerhut A, Shen M Y. Colorectal anastomosis after laparoscopic extended left colectomy: techniques and outcome. Colorectal Dis. 2020;22(09):1189–1194. doi: 10.1111/codi.15018. [DOI] [PubMed] [Google Scholar]
  • 13.Pitel S, Lefèvre J H, Tiret E, Chafai N, Parc Y.Redo coloanal anastomosis: a retrospective study of 66 patients Ann Surg 201225605806–810., discussion 810–811 [DOI] [PubMed] [Google Scholar]
  • 14.Lefevre J H, Bretagnol F, Maggiori L, Ferron M, Alves A, Panis Y. Redo surgery for failed colorectal or coloanal anastomosis: a valuable surgical challenge. Surgery. 2011;149(01):65–71. doi: 10.1016/j.surg.2010.03.017. [DOI] [PubMed] [Google Scholar]
  • 15.Kontovounisios C, Baloyiannis Y, Kinross J, Tan E, Rasheed S, Tekkis P. Modified right colon inversion technique as a salvage procedure for colorectal or coloanal anastomosis. Colorectal Dis. 2014;16(12):971–975. doi: 10.1111/codi.12784. [DOI] [PubMed] [Google Scholar]
  • 16.Manceau G, Karoui M, Breton S. Right colon to rectal anastomosis (Deloyers procedure) as a salvage technique for low colorectal or coloanal anastomosis: postoperative and long-term outcomes. Dis Colon Rectum. 2012;55(03):363–368. doi: 10.1097/DCR.0b013e3182423f83. [DOI] [PubMed] [Google Scholar]
  • 17.Beatty GTAaJS Colonic physiology 4th ed.Springer Nature; 202229–40.:chap 2 [Google Scholar]
  • 18.You Y N, Chua H K, Nelson H, Hassan I, Barnes S A, Harrington J. Segmental vs. extended colectomy: measurable differences in morbidity, function, and quality of life. Dis Colon Rectum. 2008;51(07):1036–1043. doi: 10.1007/s10350-008-9325-1. [DOI] [PubMed] [Google Scholar]
  • 19.Hyman N, Manchester T L, Osler T, Burns B, Cataldo P A. Anastomotic leaks after intestinal anastomosis: it's later than you think. Ann Surg. 2007;245(02):254–258. doi: 10.1097/01.sla.0000225083.27182.85. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Isik O, Benlice C, Gorgun E. A novel approach for robotic mobilization of the splenic flexure. Tech Coloproctol. 2017;21(01):53–57. doi: 10.1007/s10151-016-1572-x. [DOI] [PubMed] [Google Scholar]
  • 21.Jeri-McFarlane S, García-Granero Á, Frasson M, Gonzalez-Argente F X. Surgical steps for splenic flexure mobilization by inframesocolic medial approach. Cir Esp (Engl Ed) 2022;100(06):370. doi: 10.1016/j.cireng.2022.04.019. [DOI] [PubMed] [Google Scholar]
  • 22.Kumamoto T, Shinohara H, Tomizawa K. Inferior pancreatic approach for laparoscopic splenic flexure mobilization. Tech Coloproctol. 2018;22(01):71–72. doi: 10.1007/s10151-017-1741-6. [DOI] [PubMed] [Google Scholar]
  • 23.Lee Y S. Three surgical approaches of laparoscopic splenic flexure mobilization. J Minim Invasive Surg. 2019;22(02):85–86. doi: 10.7602/jmis.2019.22.2.85. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Liang J T, Huang J, Chen T C. Standardize the surgical technique and clarify the relevant anatomic concept for complete mobilization of colonic splenic flexure using da Vinci Xi ® robotic system . World J Surg. 2019;43(04):1129–1136. doi: 10.1007/s00268-018-04882-z. [DOI] [PubMed] [Google Scholar]
  • 25.Garcia-Granero A, Primo Romaguera V, Millan M. A video guide of five access methods to the splenic flexure: the concept of the splenic flexure box. Surg Endosc. 2020;34(06):2763–2772. doi: 10.1007/s00464-020-07423-9. [DOI] [PubMed] [Google Scholar]
  • 26.Matsuda T, Sumi Y, Yamashita K. Anatomical and embryological perspectives in laparoscopic complete mesocoloic excision of splenic flexure cancers. Surg Endosc. 2018;32(03):1202–1208. doi: 10.1007/s00464-017-5792-6. [DOI] [PubMed] [Google Scholar]
  • 27.Isik O, Sapci I, Aytac E. Laparoscopy reduces iatrogenic splenic injuries during colorectal surgery. Tech Coloproctol. 2018;22(10):767–771. doi: 10.1007/s10151-018-1861-7. [DOI] [PubMed] [Google Scholar]
  • 28.Merchea A, Dozois E J, Wang J K, Larson D W. Anatomic mechanisms for splenic injury during colorectal surgery. Clin Anat. 2012;25(02):212–217. doi: 10.1002/ca.21221. [DOI] [PubMed] [Google Scholar]
  • 29.Boström P, Hultberg D K, Häggström J. Oncological impact of high vascular tie after surgery for rectal cancer: a nationwide cohort study. Ann Surg. 2021;274(03):e236–e244. doi: 10.1097/SLA.0000000000003663. [DOI] [PubMed] [Google Scholar]
  • 30.Yang Y, Wang G, He J, Zhang J, Xi J, Wang F. High tie versus low tie of the inferior mesenteric artery in colorectal cancer: a meta-analysis. Int J Surg. 2018;52:20–24. doi: 10.1016/j.ijsu.2017.12.030. [DOI] [PubMed] [Google Scholar]
  • 31.Bonnet S, Berger A, Hentati N. High tie versus low tie vascular ligation of the inferior mesenteric artery in colorectal cancer surgery: impact on the gain in colon length and implications on the feasibility of anastomoses. Dis Colon Rectum. 2012;55(05):515–521. doi: 10.1097/DCR.0b013e318246f1a2. [DOI] [PubMed] [Google Scholar]
  • 32.Araujo S E, Seid V E, Kim N J, Bertoncini A B, Nahas S C, Cecconello I. Assessing the extent of colon lengthening due to splenic flexure mobilization techniques: a cadaver study. Arq Gastroenterol. 2012;49(03):219–222. doi: 10.1590/s0004-28032012000300010. [DOI] [PubMed] [Google Scholar]
  • 33.Kye B H, Kim H J, Kim H S, Kim J G, Cho H M. How much colonic redundancy could be obtained by splenic flexure mobilization in laparoscopic anterior or low anterior resection? Int J Med Sci. 2014;11(09):857–862. doi: 10.7150/ijms.8874. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Benseler V, Hornung M, Iesalnieks I. Different approaches for complete mobilization of the splenic flexure during laparoscopic rectal cancer resection. Int J Colorectal Dis. 2012;27(11):1521–1529. doi: 10.1007/s00384-012-1495-6. [DOI] [PubMed] [Google Scholar]
  • 35.Kim H J, Kim C H, Lim S W, Huh J W, Kim Y J, Kim H R. An extended medial to lateral approach to mobilize the splenic flexure during laparoscopic low anterior resection. Colorectal Dis. 2013;15(02):e93–e98. doi: 10.1111/codi.12056. [DOI] [PubMed] [Google Scholar]
  • 36.Andersen B T, Stimec B V, Edwin B, Kazaryan A M, Maziarz P J, Ignjatovic D. Re-interpreting mesenteric vascular anatomy on 3D virtual and/or physical models: positioning the middle colic artery bifurcation and its relevance to surgeons operating colon cancer. Surg Endosc. 2022;36(01):100–108. doi: 10.1007/s00464-020-08242-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Sugarbaker P H. Progressive release of the left colon for a tension-free colorectal or coloanal anastomosis. Cancer Treat Res. 1996;82:255–261. doi: 10.1007/978-1-4613-1247-5_16. [DOI] [PubMed] [Google Scholar]
  • 38.Vargas H D, Margolin D A. Springer International Publishing; 2022. Anastomotic construction; pp. 157–187. [Google Scholar]
  • 39.Toupet A. Intermediate colectomy with transmesenteric angulo-sigmoid anastomosis. Presse Med. 1961;69:2693–2694. [PubMed] [Google Scholar]
  • 40.Toupet A. Colonectomies with transmesenteric anastomosis. Mem Acad Chir (Paris) 1963;89:628–630. [PubMed] [Google Scholar]
  • 41.Hays L V, Davis D R. A technic for restoring intestinal continuity after left hemicolectomy for cancer of the distal colon and rectum. Am J Surg. 1976;131(03):390–391. doi: 10.1016/0002-9610(76)90143-4. [DOI] [PubMed] [Google Scholar]
  • 42.Rombeau J L, Collins J P, Turnbull R B., Jr Left-sided colectomy with retroileal colorectal anastomosis. Arch Surg. 1978;113(08):1004–1005. doi: 10.1001/archsurg.1978.01370200098020. [DOI] [PubMed] [Google Scholar]
  • 43.Campanati R G, Hanan B, Gomes da Silva R. Laparoscopic retroileal pull-through colorectal anastomosis technique. Dis Colon Rectum. 2022;65(04):e239. doi: 10.1097/DCR.0000000000002232. [DOI] [PubMed] [Google Scholar]
  • 44.Sakamoto Y, Tokunaga R, Miyamoto Y. Retroileal colorectal anastomosis after extended left colectomy: application for laparoscopic surgery. Surg Today. 2016;46(12):1476–1478. doi: 10.1007/s00595-016-1313-9. [DOI] [PubMed] [Google Scholar]
  • 45.Dunlavy P, Allan L, Raman S. Totally laparoscopic retroileal transverse colon to rectal anastomosis following extended left colectomy. Dis Colon Rectum. 2017;60(11):1224. doi: 10.1097/DCR.0000000000000898. [DOI] [PubMed] [Google Scholar]
  • 46.Blank J J, Gibson E K, Peterson C Y, Ridolfi T J, Ludwig K A. Retroileal anastomosis in hand-assisted laparoscopic left colectomy: experience at a single institution. Surg Endosc. 2020;34(08):3408–3413. doi: 10.1007/s00464-019-07116-y. [DOI] [PubMed] [Google Scholar]
  • 47.Le T H, Gathright J B., Jr Reconstitution of intestinal continuity after extended left colectomy. Dis Colon Rectum. 1993;36(02):197–198. doi: 10.1007/BF02051181. [DOI] [PubMed] [Google Scholar]
  • 48.Kent I, Gilshtein H, Wexner S D. The retro-ileal pull-through technique for colorectal and coloanal anastomosis. Tech Coloproctol. 2020;24(09):943–946. doi: 10.1007/s10151-020-02244-3. [DOI] [PubMed] [Google Scholar]
  • 49.Kream J, Ludwig K A, Ridolfi T J, Peterson C Y. Achieving low anastomotic leak rates utilizing clinical perfusion assessment. Surgery. 2016;160(04):960–967. doi: 10.1016/j.surg.2016.06.007. [DOI] [PubMed] [Google Scholar]
  • 50.Hayami S, Matsuda K, Iwamoto H. Visualization and quantification of anastomotic perfusion in colorectal surgery using near-infrared fluorescence. Tech Coloproctol. 2019;23(10):973–980. doi: 10.1007/s10151-019-02089-5. [DOI] [PubMed] [Google Scholar]
  • 51.Impellizzeri H G, Pulvirenti A, Inama M. Near-infrared fluorescence angiography for colorectal surgery is associated with a reduction of anastomotic leak rate. Updates Surg. 2020;72(04):991–998. doi: 10.1007/s13304-020-00758-x. [DOI] [PubMed] [Google Scholar]
  • 52.Lillehei R C, Wangensteen O H. Bowel function after colectomy for cancer, polyps, and diverticulitis. J Am Med Assoc. 1955;159(03):163–170. doi: 10.1001/jama.1955.02960200009003. [DOI] [PubMed] [Google Scholar]
  • 53.Deloyers L. Technic permitting the easy assurance of continuity of the colon & conservation of sphincter after excision of the left transverse hemicolon & entire left colon; possible inclusion of rectum. J Chir (Paris) 1958;75(02):147–155. [PubMed] [Google Scholar]
  • 54.Reversal of the right hemicolon in surgery of the left colon & rectum Mem Acad Chir (Paris) 195884(28-29):878–879. [PubMed] [Google Scholar]
  • 55.Deloyers L. Suspension of the right colon permits without exception preservation of the anal sphincter after extensive colectomy of the transverse and left colon (including rectum). Technic -indications- immediate and late results. Lyon Chir. 1964;60:404–413. [PubMed] [Google Scholar]
  • 56.Costalat G, Garrigues J M, Didelot J M, Yousfi A, Boccasanta P. Subtotal colectomy with ceco-rectal anastomosis (Deloyers) for severe idiopathic constipation: an alternative to total colectomy reducing risks of digestive sequelae. Ann Chir. 1997;51(03):248–255. [PubMed] [Google Scholar]
  • 57.Marchesi F, Sarli L, Percalli L. Subtotal colectomy with antiperistaltic cecorectal anastomosis in the treatment of slow-transit constipation: long-term impact on quality of life. World J Surg. 2007;31(08):1658–1664. doi: 10.1007/s00268-007-9111-6. [DOI] [PubMed] [Google Scholar]
  • 58.Roncoroni L, Sarli L, Costi R, Violi V. Caecal-rectal antiperistaltic anastomosis without torsion of the vascular pedicle. Ann Chir. 2000;125(09):871–873. doi: 10.1016/s0003-3944(00)00010-9. [DOI] [PubMed] [Google Scholar]
  • 59.Jouvin I, Pocard M, Najah H. Deloyers procedure. J Visc Surg. 2018;155(06):493–501. doi: 10.1016/j.jviscsurg.2018.10.001. [DOI] [PubMed] [Google Scholar]
  • 60.Garćia-Ruiz A, Milsom J W, Ludwig K A, Marchesa P. Right colonic arterial anatomy. Implications for laparoscopic surgery. Dis Colon Rectum. 1996;39(08):906–911. doi: 10.1007/BF02053990. [DOI] [PubMed] [Google Scholar]
  • 61.Okamoto K, Emoto S, Sasaki K. Extended left colectomy with coloanal anastomosis by indocyanine green-guided deloyers procedure: a case report. J Anus Rectum Colon. 2021;5(02):202–206. doi: 10.23922/jarc.2020-097. [DOI] [PMC free article] [PubMed] [Google Scholar]

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