Level of arterial ligation in total mesorectal excision (TME): an anatomical study

Abstract

Introduction High-tie ligation is a common practice in rectal cancer surgery. However, it compromises perfusion of the proximal limb of the anastomosis. This anatomical study was designed to assess the value of low-tie ligation in order to obtain a tension-free anastomosis. Materials and methods Consecutive high-and low-tie resections were performed on 15 formalin-fixed specimens, with or without splenic flexure mobilization. If the proximal colon limb could reach the superior aspect of the symphysis pubis with more than 3 cm, the limb would be long enough for a tension-free colorectal anastomosis. Results In 80% of cases, it was not necessary to perform high-tie ligation as sufficient length was gained with low-tie ligation. The descending branch of the left colic artery was the limiting factor in the other 20% of cases. Resecting half the sigmoid resulted in four times as many tension-free anastomoses after low-tie resection. Conclusion In the majority of cases, it was not necessary to perform high-tie ligation in order to create a tension-free anastomosis. Low-tie ligation was applicable in 80% of cases and might prevent anastomotic leakage due to insufficient blood supply of the proximal colon limb.

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

“…With the growing incidence of elderly and/or atherosclerosis patients, the LT technique has regained interest as a way to conserve the LCA and preserve the vascularization of the proximal colon limb. Some studies have demonstrated a gain in colon length during LT procedures [3,5]. Nevertheless, LCA preservation remains a controversial subject because oncological advantages in the HT technique and the vascular benefits of the LT technique have not been demonstrated.…”

Oncological Outcomes following Rectal Cancer Surgery with High or Low Ligation of the Inferior Mesenteric Artery

“…Tension-free anastomosis is required to avoid anastomotic leakage. Although the gain in colonic length was longer in high compared to low ligation, low ligation can be safely performed for anastomosis in rectal cancer surgery in most cases [22,23] . In this analysis, there was no patient in the low ligation group requiring division of the LCA because of anastomotic tension.…”

S3-Leitlinie – Kolorektales Karzinom

“…Die abgangsnahe Unterbindung der A. mesenterica inferior hat keine prognostische Bedeutung, sie wird aber häufig aus operationstechnischen Gründen zur ausreichenden Mobilisation des linken Hemikolons zur Rekonstruktion durchgeführt [718]. Allerdings zeigen anatomische Studien, dass in vielen Fällen auch ohne zentrale Absetzung eine tiefe Anastomose möglich ist [719]. Der Wert einer Dissektion der Lymphknoten am Stamm der A. mesenterica inferior proximal des Abgangs der A. colica sinistra ist nicht gesichert (Evidenzstärke 2b) [720 -723] …”