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| Name | Technical features in preservation of the left colic artery in colorectal oncologic surgery |
| Video Uploader | Video From Il Giornale di Chirurgia JISA |
| Upload Date | This Video Uploaded At 15-06-2023 13:18:29 |
| Video Discription | Technical features in preservation of the left colic artery in colorectal oncologic surgery Massimiliano Ardu, Diletta Cassini, Marta Spalluto, Giovanni Tarchi, Gianandrea Baldazzi ASST Ovest Milanese, Ospedale Nuovo di Legnano, via Giovanni Paolo II, 20025, Legnano, MI Corresponding author: Massimiliano Ardu, ASST Ovest Milanese, Ospedale Nuovo di Legnano, via Giovanni Paolo II, 20025, Legnano, MI, [email protected] The extent of lymphadenectomy in rectal-sigmoid cancer is matter of debate. Although vascular ligation at the origin of the sigmoid branches is generally accepted as a good standard of care there is some evidence that a more extensive lymphadenectomy at the origin of the mesenteric artery, namely lymph node station n253 (JSCCR classification), could have a stadiative advantage. (1). In order to achieve that goal, a high or low ligation of the IMA can be performed. High ligation of the IMA consists in the ligation of about two centimeters above its emergence from the aorta. Low ligation of the IMA consists in the preservation of left colic artery (LCA) by ligation of the IMA distal to the emergence of the LCA with the dissection of the lymph nodes at the root of the IMA. The aforementioned technique has several advantages in terms of post-operative outcomes, functional outcomes and, at the same time does not affect the oncological outcomes (2). The incidence of anastomotic leakage seems to be inferior (3), colorectal functions and genito-urinary functions are less impaired (4) with no differences in terms of operative time and blood loss (5). Nevertheless, laparoscopic low ligation is technically demanding and thus not many surgeons adopt this technique. In this video we show a laparoscopic low ligation plus n.253 lymph nodes dissection for rectal cancer surgery. A 59 year old male with a history of rectal bleeding was referred to our department for rectal bleeding. Rectal cancer 8cm from the anal verge was found with a preoperative staging of T3N+ with no extramural vascular invasion (EMVI) and no circumferential resection margin (CRM) or sphincter threatened. Therefore, after a multidisciplinary consultation, CHRT pre-surgical intervention was indicated. Pneumoperitoneum is obtained with a Veress needle and 4 trocars are placed, ten mm periumbilical at the mid-point between the xiphoid and the pubis, another ten mm in the right iliac fossa, five mm in the right ipocondrium and the left flank. The first step of the intervention consists in the identification of the space between the Toldt’s and Gerota’s fascia below the inferior mesenteric vein (IMV). Splenic flexure and descending colon mobilization are the next steps. At this point, IMA is identified and dissected free until the identification of the LCA. Posterior to LCA always lies the IMV that is ligated at this level and not at the inferior border of the pancreas unless it appears necessary for a tension free anastomosis. Low ligation is then performed and the intervention is carried on and concluded following the usual steps. Loop ileostomy was performed as a safe step considering that the patient underwent CHRT. The operative time for this surgery was 170 min, blood loss about 50ml. The patient was discharged on the fourth postoperative day. Pathological examination was G2 pT3N1b (lymph nodes 3/25), no adjuvant therapy was indicated. We have adopted this technique as a standard of care in every case of sigmoid and rectal cancer surgery in the last 10 years. Although technically demanding, preservation of LCA confers numerous advantages and should be adopted more extensively References 1. Japanese Society for Cancer of the Colon and Rectum. Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma: the 3d English Edition [Secondary Publication]. J Anus Rectum Colon. 2019 30;3(4):175-195 2. Zheng H, Li F, Xie X, Zhao S, Huang B, Tong W. Preservation versus nonpreservation of the left colic artery in anterior resection for rectal cancer: a propensity score-matched analysis. BMC Surg. 2022;10;22(1):164. 3. Zeng J, Su G. High ligation of the inferior mesenteric artery during sigmoid colon and rectal cancer surgery increases the risk of anastomotic leakage: a meta-analysis. World J Surg Oncol. 2018;16(1):157. 4. Bai X, Zhang CD, Pei JP, Dai DQ. Genitourinary function and defecation after colorectal cancer surgery with low- and high-ligation of the inferior mesenteric artery: A meta-analysis. World J Gastrointest Surg. 2021;13(8):871-884. 5. Yin TC, Chen YC, Su WC, et al. Low Ligation Plus High Dissection Versus High Ligation of the Inferior Mesenteric Artery in Sigmoid Colon and Rectal Cancer Surgery: A Meta-Analysis. Front Oncol. 2021;11:774782.4 |
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