Yonsei Med J.  2013 Nov;54(6):1484-1490. 10.3349/ymj.2013.54.6.1484.

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

Affiliations
  • 1Section of Colon and Rectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea. namkyuk@yuhs.ac, sss_Allah@hotmail.com

Abstract

PURPOSE
Our 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 METHODS
We 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.
RESULTS
A 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.
CONCLUSION
During 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.

Keyword

Inferior mesenteric vein; collateral; arc of Riolan; meandering artery

MeSH Terms

Duodenum/anatomy & histology
Female
Humans
Ligation/*methods
Male
Mesenteric Veins/*surgery
Middle Aged
Pancreas/anatomy & histology
Prospective Studies

Figure

  • Fig. 1 Inferior mesenteric vein variations, 1) Drain at the confluence, 2) Drain at superior mesenteric vein, 3) Drain into splenic vein. PV, portal vein; SV, splenic vein; SMV, superior mesenteric vein; IMV, inferior mesenteric vein.

  • Fig. 2 Open view; type A class, 1) Collateral vessel crosses the inferior mesenteric vein at the lower of the pancreas, 2) IMV cut end, 3) Lower border of the pancreas, 4) Duodenum, 5) Aorta, 6) Cut end of the inferior mesenteric artery, 7) Left colic. IMV, inferior mesenteric vein.

  • Fig. 3 (A) Open view; type B; 1) Inferior mesenteric vein, 2) Arc of Riolan, 3) Dissection of starting point separates the artery from the vein, 4) Duodenum, 5) Pancreas. (B) laparoscopic view; type B; 1) Collateral artery (Arc of Riolan), 2) Inferior mesenteric vein, 3) Duodenum. (C) Laparoscopic view; type B; 1) Collateral artery (Arc of Riolan), 2) Inferior mesenteric vein, 3) Duodenum.

  • Fig. 4 Laparoscopic view; type C, 1) inferior mesenteric vein (IMV), 2) Duodenum, 3) Ligament of Treitz, 4) Pancreas. No arterial relation to IMV.

  • Fig. 5 The percentage of each type of collateral vessels in relation to inferior mesenteric vein.

  • Fig. 6 Laparoscopic view demonstrates the critical zone of inferior mesenteric vein (IMV), showing that the arc of Riolan crosses the IMV at the lower border of the pancreas to the right side. Ligation of the IMV should be below the arc of Riolan.

  • Fig. 7 (A) Robotic view of inferior mesenteric artery; R) Arc of Riolan, L) Left colic artery, S) Sigmoid artery, A) Aorta. (B) Robotic florescent view; R) Arc of Riolan, L) Left colic, S) Sigmoid artery.


Reference

1. Park MG, Hur H, Min BS, Lee KY, Kim NK. Colonic ischemia following surgery for sigmoid colon and rectal cancer: a study of 10 cases and a review of the literature. Int J Colorectal Dis. 2012; 27:671–675.
Article
2. Netter Frank H.. Essentials Atlas of Human Anatomy. ISBN 0-914168-18-5 Copyright 1987.
3. Walker TG. Mesenteric vasculature and collateral pathways. Semin Intervent Radiol. 2009; 26:167–174.
Article
4. Sakorafas GH, Zouros E, Peros G. Applied vascular anatomy of the colon and rectum: clinical implications for the surgical oncologist. Surg Oncol. 2006; 15:243–255.
Article
5. Michels NA, Siddharth P, Kornblith PL, Parke WW. The variant blood supply to the descending colon, rectosigmoid and rectum based on 400 dissections. Its importance in regional resections: a review of medical literature. Dis Colon Rectum. 1965; 8:251–278.
Article
6. Kachlik D, Baca V. Macroscopic and microscopic intermesenteric communications. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2006; 150:121–124.
Article
7. Gourley EJ, Gering SA. The meandering mesenteric artery: a historic review and surgical implications. Dis Colon Rectum. 2005; 48:996–1000.
Article
8. Rosenblum JD, Boyle CM, Schwartz LB. The mesenteric circulation. Anatomy and physiology. Surg Clin North Am. 1997; 77:289–306.
9. Horton KM, Fishman EK. Volume-rendered 3D CT of the mesenteric vasculature: normal anatomy, anatomic variants, and pathologic conditions. Radiographics. 2002; 22:161–172.
Article
10. Bernstein WC, Bernstein EF. Ischemic ulcerative colitis following inferior mesenteric arterial ligation. Dis Colon Rectum. 1963; 6:54–61.
Article
11. Moskowitz M, Zimmerman H, Felson B. The meandering mesenteric artery of the colon. Am J Roentgenol Radium Ther Nucl Med. 1964; 92:1088–1099.
12. Douard R, Chevallier JM, Delmas V, Cugnenc PH. Clinical interest of digestive arterial trunk anastomoses. Surg Radiol Anat. 2006; 28:219–227.
Article
13. Pikkieff H. Über die Blutversorgung des Dickendarms. Zschr Anat Entw. 1931; 96:658–679.
14. Lin PH, Chaikof EL. Embryology, anatomy, and surgical exposure of the great abdominal vessels. Surg Clin North Am. 2000; 80:417–433.
Article
15. Baden JG, Racy DJ, Grist TM. Contrast-enhanced three-dimensional magnetic resonance angiography of the mesenteric vasculature. J Magn Reson Imaging. 1999; 10:369–375.
Article
16. Meaney JF. Non-invasive evaluation of the visceral arteries with magnetic resonance angiography. Eur Radiol. 1999; 9:1267–1276.
Article
17. Shirkhoda A, Konez O, Shetty AN, Bis KG, Ellwood RA, Kirsch MJ. Mesenteric circulation: three-dimensional MR angiography with a gadolinium-enhanced multiecho gradient-echo technique. Radiology. 1997; 202:257–261.
Article
18. Therasse E, Soulez G, Roy P, Gauvin A, Oliva VL, Carrier R, et al. Lower extremity: nonstepping digital angiography with photostimulable imaging plates versus conventional angiography. Radiology. 1998; 207:695–703.
Article
19. Grinnell RS, Hiatt RB. Ligation of the interior mesenteric artery at the aorta in resections for carcinoma of the sigmoid and rectum. Surg Gynecol Obstet. 1952; 94:526–534.
20. Goligher JC. The adequacy of the marginal blood-supply to the left colon after high ligation of the inferior mesenteric artery during excision of the rectum. Br J Surg. 1954; 41:351–353.
Article
21. Morgan CN, Griffiths JD. High ligation of the inferior mesenteric artery during operations for carcinoma of the distal colon and rectum. Surg Gynecol Obstet. 1959; 108:641–650.
22. Feldman M, Scharschmidt BF, Sleisenger MH. Sleisenger and Fordtran's: Gastrointestinal and liver Disease: Pathophysiology/Diagnosis/Management. 9th ed. Philadelphia: Saunders/Elsevier;2010.
23. Sakanoue Y, Kusunoki M, Shoji Y, Kusuhara K, Yamamura T, Utsunomiya J. Passage of a colon 'cast' after anoabdominal rectal resection. Report of a case. Dis Colon Rectum. 1990; 33:1044–1046.
24. Erguney S, Yavuz N, Ersoy YE, Teksoz S, Selcuk D, Ogut G, et al. Passage of "colonic cast" after colorectal surgery: report of four cases and review of the literature. J Gastrointest Surg. 2007; 11:1045–1051.
Article
25. Parc R, Cugnenc PH, Levy E, Huguet C, Loygue J. [Early post-operative complications in intestinal resections followed with colo-colitic or recto-colitic anastomoses. Clinical and biological manifestations of anastomotic complications. Therapeutic results about 523 cases (author's transl)]. Ann Chir. 1981; 35:69–82.
26. Einstein AJ, McLaughlin MA, Lipman HI, Sanz J, Rajagopalan S. Images in vascular medicine the Arc of Riolan: diagnosis by magnetic resonance angiography. Vasc Med. 2005; 10:239.
27. Cima RR, Bilings B. Strategies to avoid 3 common problems in colorectal surgery. Contemp Surg. 2008; 64:120–125.
28. Seike K, Koda K, Saito N, Oda K, Kosugi C, Shimizu K, et al. Laser Doppler assessment of the influence of division at the root of the inferior mesenteric artery on anastomotic blood flow in rectosigmoid cancer surgery. Int J Colorectal Dis. 2007; 22:689–697.
Article
Full Text Links
  • YMJ
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr