The Relation between Inferior Mesenteric Vein Ligation and Collateral Vessels to Splenic Flexure: Anatomical Landmarks, Technical Precautions and Clinical Significance

Abstract

PurposeOur aim to assess clinical significance of the relation between inferior mesenteric vein ligation and collateral blood supply (meandering mesenteric artery) to the splenic flexure with elaboration more in anatomical landmarks and technical tips.Materials and MethodsWe review the literature regarding the significance of the collateral vessels around inferior mesenteric vein (IMV) root and provide our prospective operative findings, anatomical landmarks and technical tips. We analyzed the incidence and pattern of anatomic variation of collateral vessels around the IMV.ResultsA total of 30 consecutive patients have been prospectively observed in a period between June 25-2012 and September 7-2012. Nineteen males and eleven females with mean age of 63 years. Major colorectal procedures were included. There were three anatomical types proposed, based on the relation between IMV and the collateral vessel. Type A and B in which either the collateral vessel crosses or runs close to the IMV with incidence of 43.3% and 13.3%, respectively, whereas type C is present in 43.3%. There was no definitive relation between the artery and vein. No intra or postoperative ischemic events were reported.ConclusionDuring IMV ligation, inadvertent ligation of Arc of Riolan or meandering mesenteric artery around the IMV root "in type A&B" might result in compromised blood supply to the left colon, congestion, ischemia and different level of colitis or anastomotic dehiscence. Therefore, careful dissection and skeletonization at the IMV root "before ligation if necessary" is mandatory to preserve the collateral vessel for the watershed area and to avoid further injury.

Indocyanine green-enhanced fluorescence to assess bowel perfusion during laparoscopic colorectal resection

“…Adequate vascular supply of the left colon depends on the patency of the inferior mesenteric artery, the left colic artery but also relies on patency of the middle colic artery and the marginal Drumond and eventually Riolan arcades [ 29 , 30 ]. Anatomic variations are frequent, and aberrations such as absence of the middle colic artery or inadequate vascularization of the splenic flexure are frequent (up to 25 %) [ 31 – 33 ].…”

“…The concept of high ligation of the vessels to achieve optimal oncological results [ 29 ] suppresses the vascular supply from the left colic artery, and vascularization of the proximal colon is dependent on marginal vessels running off the middle colic artery. With the progressive increase in the aging population undergoing surgery for colorectal disease, radiation, vascular disease can also be a factor of insufficient vascular supply, even in the case of low ligation of the inferior mesenteric artery.…”

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“…Careful attention should be paid to this area in what we call the"IMV critical zone". 28 In our recently published article, we studied this zone in detail and we found that in type A and B (Fig. 1a, b, c) the arc of Riolan "meandering" artery passes across the IMV or parallel to it respectively.…”

“…Thus ligation of IMV at these levels needs to be carefully attempted to avoid injury to the collateral vessels. 28 In certain circumstances the collateral vessels will be supplying the descending colon while the marginal artery is absent so incidental injury to collateral vessels might lead to ischaemia, necrosis, leak and stricture.…”

Multidetector Computed Tomographic Angiography for Optimal Cartography of the Visceral Abdominal Arterial Network: An Extensive Pictorial Review with Emphasis on Common and Uncommon Collateral Pathways, Complications and some Specific Syndromes

“…Vascular and abdominal surgeons are aware of this important collateral pathway between the IMA and the SMA. Indeed, inadvertent ligation or section of this important collateral network during aortic or abdominal surgery and especially in the presence of under-diagnosed stenosis of the SMA may have disastrous consequences, especially on the small intestine and left colon [ 29 30 ].…”