Laparoscopic retrojejunal trans-mesenteric anastomosis for extended left-sided colorectal resections - a new solution to an old problem.

AIM

Following extended left-sided colorectal resection, creation of the anastomosis can be challenging due to insufficient length of the remaining proximal and distal bowel. Retroileal pull-through and the Deloyers procedure are feasible but require ligation of the middle colic vessels and additional right colonic mobilization. The aim of this study was to describe our initial experience with an alternative technique for performing tension-free anastomosis following minimally invasive left-sided resection.

METHOD

This was a retrospective case series of all patients who underwent a retrojejunal trans-mesenteric pull-through following elective laparoscopic left-sided colorectal surgery between September 2019 and September 2020. Placing the retrojejunal window 15-20 cm distal to the duodenojejunal junction allows the transverse colon to pass via the most direct route through the base of the proximal jejunal mesentery to the distal colon or rectal stump instead of passing over the small bowel, yielding additional length for the anastomosis. An accompanying video demonstrates this technique for three different case scenarios.

RESULTS

Seven consecutive patients underwent this approach following colorectal resection; three had inherently shorter left colons, two had synchronous left-sided tumours and two had inadvertent intraoperative marginal artery injury. There were no anastomotic complications or early postoperative morbidity related to the mesenteric window. The additional time taken for the procedure ranged from 5 to 35 min. The risk of complications related to extended left-sided resections may possibly be reduced, although further studies are required to evaluate this.

CONCLUSION

Retrojejunal trans-mesenteric pull-through is a novel, but straightforward, safe and useful option for reducing tension in laparoscopic left-sided colorectal anastomoses.