Anatomical basis of laparoscopic medial‐to‐lateral mobilization of the descending colon

Abstract

In laparoscopic colorectal resection, the medial-to-lateral approach has been largely adopted. This approach can be initiated by the division of either the inferior mesenteric artery (IMA) or the inferior mesenteric vein (IMV). This cadaveric study aimed to establish the feasibility of IMV dissection as the initial landmark of medial-to-lateral left colonic mobilization for evaluating the size of the peritoneal window between the IMV at the lower part of the pancreas and the origin of the IMA (IMA-IMV distance) and the point of origin of the IMA compared to the lower edge of the third part of the duodenum (IMA-D3 distance). These distances were recorded on 30 fresh cadavers. The IMA-D3 distance was 0.4 ± 2.2 cm (mean ± SD). The IMA originated from the aorta at the level of or below the D3 in 21 cases (70%). The IMA-IMV distance was 5.5 ± 1.8 cm and was greater or equal to 5 cm (large window) in 21 cases (70%). IMA-IMV distance was correlated with IMA-D3 showing that a large window was inversely correlated with a low IMA origin (P < 0.001). IMA-D3 distance was not correlated with weight, height and sex. IMA-IMV distance was largerin male (6.7 ± 0.9 vs. 4.9 ± 1.8, P = 0.001) and correlated with weight, (r = 0.60, 95%CI = 0.03-0.10, P < 0.001) and height (r = 0.54, 95%CI = 0.05-0.21, P = 0.002). IMV can be used as the initial landmark for laparoscopic medial-to-lateral dissection in two-thirds of cases. A too-small window can require first IMA division. The choice between the two different medial-to-lateral approaches could be made by evaluating the anatomical relationship between IMA, IMV, and D3.

Technical difficulties of left colic artery preservation during left colectomy for colon cancer

“…There is still some debate as to the expertise that is required to perform a laparoscopic LT, especially in the case of a fatty mesocolon [1]. Good anatomical knowledge of this area is mandatory to preserve the colic artery via the LT technique for tumors in the sigmoid colon and rectum [2,3,6]. During an LT procedure, the LCA may be damaged at its root during the dissection of the IMA.…”

Exploring Central Vascular Anatomy With Axial Computed Tomography During Surgery for Sigmoid Colon and Rectal Cancer: New Insights Into the Anatomical Relationship Between the Inferior Mesenteric Artery and the Duodenum

“…The anatomy of the IMA has been reported in previous studies and in anatomy textbooks. However, to our knowledge, the relationship between the IMA origin and the lower edge of the duodenum has only been reported in one study in recent decades ( 3 ). The authors measured IMA–D distance in 30 fresh cadavers and concluded that the IMA origin was located above the lower edge of the duodenum in 30% of cases, which is consistent with the results of the present study (27.69%).…”

“…253 lymph nodes, and the aorta is not routinely exposed to avoid autonomic nerve injury. However, the anatomical relationship between the root of the IMA and the duodenum is variable ( 3 ). In some patients, the IMA originates from the aorta above the lower edge of the duodenum, and the root of the IMA may not be adequately exposed without mobilising the third segment of the duodenum.…”

A critical view of safety in left colectomy surgery: A case of renal artery injury

“…Some authors choose between the first and the second approach based on the extent of the vascular window between the IMV and IMA. When the window is wide enough, they start from above; when it is less than 5 cm the dissection starts from the bottom instead [ 3 ]. However, this technique does not take into account any potential anatomical variation that may be responsible for errors in the identification of the IMA.…”