Abstract
Background: According to traditional textbooks on surgery, splenic flexure mobilization is suggested as a mandatory part of open rectal resection. However, its use in minimally invasive access seems to be limited. This stage of the procedure is considered difficult in the laparoscopic approach. The aim of this study was to systematically review literature on flexure mobilization and perform meta-analysis. Methods: A systematic review of the literature was performed using the Medline, Embase and Scopus databases to identify all eligible studies that compared patients undergoing rectal or sigmoid resection with or without splenic flexure mobilization. Inclusion criteria: (1) comparison of groups of patients with and without mobilization and (2) reports on overall morbidity, anastomotic leakage, operative time, length of specimen, number of harvested lymph nodes, or length of hospital stay. The outcomes of interest were: operative time, conversion rate, number of lymph nodes harvested, overall morbidity, mortality, leakage rate, reoperation rate, and length of stay. Results: Initial search yielded 2282 studies. In the end, we included 10 studies in the meta-analysis. Splenic flexure is associated with longer operative time (95% confidence interval (CI) 23.61–41.25; p < 0.001) and higher rate of anastomotic leakage (risk ratios (RR): 1.02; 95% CI 1.10–3.35; p = 0.02), however the length of hospital stay is shorter by 0.42 days. There were no differences in remaining outcomes. Conclusions: Not mobilizing the splenic flexure results in a significantly shorter operative time and a longer length of stay. Further research is required to establish whether flexure mobilization is required in minimally invasive surgery.
Highlights
According to traditional textbooks on surgery, splenic flexure mobilization (SFM) is suggested as an essential part of open rectal resection [1]
It is important to note that the leakage rate was higher, and the length of hospital stay was shorter in patients with SFM
Our meta-analysis demonstrated no differences in this outcome—the number of lymph nodes harvested was similar regardless of SFM
Summary
According to traditional textbooks on surgery, splenic flexure mobilization (SFM) is suggested as an essential part of open rectal resection [1]. An international questionnaire among laparoscopic colorectal surgeons showed that SFM was no longer considered mandatory—only 70% routinely mobilized the splenic flexure [2] This stage of the procedure is considered difficult in the laparoscopic approach [3]. The question arises whether the recommendation to perform SFM routinely during each operation of the rectum is still relevant in the evidence-based surgery era To answer this question, we have conducted a systematic review of the available literature in order to assess the outcomes of colorectal resection with and without SFM. Splenic flexure is associated with longer operative time (95% confidence interval (CI) 23.61–41.25; p < 0.001) and higher rate of anastomotic leakage (risk ratios (RR): 1.02; 95% CI 1.10–3.35; p = 0.02), the length of hospital stay is shorter by 0.42 days. Further research is required to establish whether flexure mobilization is required in minimally invasive surgery
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