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

Unveiling the hidden: identification and management of overlooked blood vessels in laparoscopic left hemicolectomy for splenic flexure cancer

BACKGROUND

During laparoscopic left hemicolectomy procedures, a previously overlooked consistently thick blood vessel within the gastrocolic ligament near the splenic hilum may contribute to post-operative bleeding complications. The purpose of this study was to investigate the identification and management of the previously overlooked blood vessel.

METHODS

This is a retrospective descriptive study of patients undergoing laparoscopic left colectomy for splenic fexure cancer conducted at a national gastrointestinal surgery centre in China. Consecutive patients with splenic fexure cancer who underwent laparoscopic left colectomy using our"five-step process"(n = 34) between January 2021 and July 2023 were included.

RESULTS

The vessels can be effectively exposed using the aforementioned "five-step process." It was observed that the overlooked vessels consistently present in all patients were identified as the omental branch of the left gastroepiploic artery and vein.

CONCLUSION

We have identified the origin of previously overlooked blood vessels and recommended a safe method for their management. This may offer advantages to colorectal surgeons performing laparoscopic left colectomy for splenic flexure cancer.

Cadaveric and CT angiography study of vessels around the transverse colon mesentery

BACKGROUND

Laparoscopic and robotic surgery for transverse colon cancer are difficult due to complex fusion of the foregut and midgut and variation of the vessels of the transverse colon. Although the vessels of the right colon have been investigated, middle colic artery (MCA) variation and the relationship with vessels around the transvers colon are unknown. We investigated variation of the MCA using computed tomography angiography (CTA) and cadaver specimen and the relationship between the superior mesenteric vein (SMV) and MCA using CTA. The classification of vessels around the transverse colon may lead to safer and reliable surgery.

METHODS

This study included 505 consecutive patients who underwent CTA in our institution from 2014 to 2020 and 44 cadaver specimens. Vascular anatomical classifications and relationships were analyzed using CT images.

RESULTS

The MCA was defined as the arteries arising from the superior mesenteric artery (SMA) that flowed into the transverse colon at the distal ends. The classifications were as follows: type I, branching right and left from common trunk; type II, the right and left branches bifurcated separately from the SMA; and type III, the MCA branched from a vessel other than the SMA. Type II was subclassified into two subtypes, type IIa with one left branch and type IIb with two or more left branches from SMA. In the CTA and cadaver studies, respectively, the classifications were as follows: type I, n = 290 and n = 31; type IIa, n = 211 and n = 13; type IIb, n = 3 and n = 0; and type III, n = 1 and n = 0. We classified the relationship between the MCA and left side of the SMV into three types: type A, a common trunk runs along the left edge of the SMV (n = 173; 59.7%); type B, a right branch of the MCA runs along the left edge of the SMV (n = 116; 40.0%); and type C, the MCA runs dorsal of the SMV (n = 1; 0.3%).

CONCLUSIONS

This study revealed that The MCA branching classifications and relationship between the SMV and MCA. Preoperative CT angiography may be able to reliably identify vessel variation, which may be useful in clinical practice.

Transmesocolic approach in laparoscopic complete mesocolic excision for right sided colon cancers

Introduction

A mesocolic plane, central vascular ligation (CVL) and proper proximal-distal margins are the essential components of complete mesocolic excision (CME). In the transmesocolic approach, we identify the middle colic vessels and enter the lesser sac through the mesocolon for ascending colon and caecum tumors.

Aim

To investigate the feasibility and identify the technical details of this technique.

Material and methods

The clinical and pathological findings of 26 patients who had undergone laparoscopic right hemicolectomy with CME between 2010 and 2020 were collected retrospectively. All operation videos were recorded and reviewed by the authors with regard to the components of CME. In the transmesocolic approach, dissection starts with identification of the middle colic vessels directly. After division of the middle colic vessels, we enter the omental bursa and dissection continues from superior to inferior direction.

Results

There were 26 patients in the study. The mean age was 59.3 ±16.1. There were 15 female and 11 male patients with a mean body mass index of 25.9 ±16.1 kg/m². The mean operative time was 137.6 ±19.4 min. The mean length of hospital stay and the time to first flatus were 7.5 ±4.6 days and 2.3 ±1.5 days, respectively. None of the patients were re-admitted to the hospital in 30 days. There was no 30-day mortality in the patients. There were no major complications.

Conclusions

The transmesocolic approach seems to be feasible and safe for CME in right sided colon cancers. However, more prospective randomized studies are needed to use the transmesocolic approach as a standard technique.

Angiographic characteristics of the intermesenteric artery

PURPOSE

The literature reports the presence of the intermesenteric artery (IA), an anastomosis connecting the superior mesenteric artery (SMA) to the inferior mesenteric artery (IMA) in 9-18% of human cadaver dissections. This is the first study describing the morphological and demographic characteristics of the IA based on in vivo imaging.

METHODS

A total of 150 consecutive abdominal computed tomography (CT) angiographies of adult patients identified by sex and age were analyzed. The IA was assessed for its presence, point of origin, pathway, point of insertion, and diameter at its origin. The diameters of the SMA, IMA, and other arteries from which the IA originated and into which it inserted were measured by CT angiography using Radiant™ and Osirix MD™ software.

RESULTS

The IA was found in 17 (51.5%) of the females and 60 (51.3%) of the males. The diameters of the SMA and IMA were larger in the males than in the females, but there was no sex difference in the diameter of the IA. The diameter of the SMA was larger than that of the IMA, and the diameter of the IA was smaller than that of the other arteries evaluated. An IA connecting the SMA and IMA trunks was found in 25.9% of the cases, while other connections between the branches of those trunks through an IA occurred less frequently.

CONCLUSIONS

The intermesenteric artery is more frequently found than the literature refers and in most of cases directly connects the upper and lower arterial mesenteric circulations.