Importance of the Moskowitz artery in the laparoscopic medial approach to splenic flexure mobilization: a cadaveric study

Abstract

We performed a cadaveric study on 27 human cadavers. The vascular arcades of the splenic flexure were dissected, the number of vascular arches, and the origin and localization of its terminal anastomosis were recorded. The splenic flexure avascular space (SFAS) was defined as the avascular zone in the mesocolon delimited by the VEOP, middle colic artery, ascending branch of the left colic artery and the vascular arch of the splenic flexure nearest to the VEOP and was quantified as the distance between the VEOP and the most proximal arch RESULTS: The artery of Drummond was identified in 100% of the cadavers. In 5 of 27 (18%) Riolan's arch was present, and in 3 of 27 (11%) the Moskowitz artery was found. The mean distance from the VEOP to the artery of Moskowitz was 0.3 cm (SD 0.04). This vascular arch travelled from the origin of the middle colic artery to the distal third of the ascending branch of the left colic artery. The SFAS was greater (p = 0.001) in cadavers that only presented the artery of Drummond (mean 6.8 cm; SD 1.25) than in those with Riolan's arch (mean 4.5 cm; SD 0.5) CONCLUSIONS: In the medial approach for laparoscopic mobilization of the splenic flexure, when only one of the arches is present, the avascular area is an extensive and secure territory. If the artery of Moskowitz is present, the area is nonexistent and this would contraindicate the approach due to risk of iatrogenic bleeding. A radiological preoperatory study could be essential for accurate and safe surgery in this area.

The importance of the Moskowitz artery as a lesser-known collateral pathway in the medial laparoscopic approach to splenic flexure mobilisation and its evaluation with preoperative computed tomography.

“…The most well-known among these is the Drummond marginal artery and Riolan’s arch [ 4 – 6 , 17 , 18 ]. Another little-known collateral pathway is the Moskowitz artery [ 7 – 9 ]. However, there are also some different views on the identification and naming of the Moskowitz artery.…”

“…However, there are also some different views on the identification and naming of the Moskowitz artery. For example, some argue that this artery is an expanding part of Riolan’s arch, while another view is that it is a separate anastomotic structure [ 5 – 9 ]. In our study, we observed the Moskowitz artery as a separate anastomotic structure, similar to the second opinion.…”

“…Also, Riolan’s arch was found in 18% of cases and Moskowitz’s artery in 11%. However, the relatively low number of patients and the lack of vessel diameters are noteworthy [ 9 ]. In addition, the need for a radiological preoperative study is mentioned in this field for correct and safe surgery.…”

“…The Moskowitz artery (MA) runs along the colonic mesentery floor and represents the link between the proximal segment of the middle colic artery and the ascending branch of the left colic artery. The Moskowitz artery runs through the base of the mesocolon, above the ventral edge of the pancreas [ 8 , 9 ].…”

Vascular anatomy of the splenic flexure, focusing on the accessory middle colic artery and vein

“…c). In such cases, we defined the connecting artery between the LCA and AMCA as the Moskowitz artery, which is the collateral artery that runs more centrally than Riolan’s arch . These connecting arteries are often called meandering arteries .…”