Iatrogenic spleen injury during minimally invasive left colonic flexure mobilization: the quest for evidence-based results.

INTRODUCTION: To assess the frequency, risk factors and outcomes of iatrogenic spleen injury during minimally invasive colo-rectal surgery with a particular focus on the routine splenic flexure mobilization tehcnique.

EVIDENCE ACQUISITION: Exclusion criteria: 1) topic not pertinent to the main topic of the review; 2) all case reports, editorials, conference highlights were excluded. After a title and abstract first selection and a final full-text analysis has been performed. The results of the selected articles are presented.

EVIDENCE SYNTHESIS: The iatrogenic splenic injury rate during colorectal surgery is 0.96%. The iatrogenic injuries cause around 20% of all splenectomy. Ligaments over-traction is the most frequent mechanism of damage. The routine splenic flexure mobilization is a matter of scientific debate. Risk factors - open surgery, male sex, peripheral vascular disease, malignant neoplasia, diverticulitis, emergency surgery and teaching-hospital status. There is a risk difference according to the procedure: transverse colectomy has the highest risk, followed by left colectomy and total colectomy.

CONCLUSIONS: The routine mobilization of the left colonic flexure is a debated topic. However, according to some authors (including our experience), this procedure is not a risk factor and it may be advantageous: 1) it does not excessively prolong the total operative time; 2) better surgical skills development; 3) the tension-related ischemia is avoided; 4) wider oncological dissection. Technical accuracy with cautious dissection/visualization can reduce the rate of iatrogenic splenic damage. Laparoscopy decreases the rate of splenic injury by almost 3.5 times. Robotic surgery may have the potential to further reduce this complication, but more data are needed on the topic.