There are still controversies as to the location of ligating the inferior mesenteric artery and the central lymph node dissection during rectal cancer surgery. The reason is that the level of evidence in this area is low. Existing studies are mostly retrospective, analyses or small-sample randomized controlled trials. These results showed no significant differences between high-ligation and low-ligation, in terms of anastomotic leakage and other short-term postoperative complications. Low-ligation seems better for the recovery of postoperative genitourinary function. Due to the low rate of central lymph node metastasis and many other confounding factors that affect the survival rate, it is difficult to conclude the survival benefits of ligation site or central node dissection. It is necessary to carry out some targeted, well-designed, large-scale randomized controlled trials to explain the related issues of inferior mesenteric artery ligation site and extent of central lymphadenectomy.
Humans ; Laparoscopy/methods* ; Ligation/methods* ; Lymph Node Excision/methods* ; Mesenteric Artery, Inferior/surgery* ; Mesentery ; Rectal Neoplasms ; Rectum/surgery* ; Retrospective Studies

Splenic flexure colon cancer occurs at a relatively lower rate than colon cancer of other sites. It is also associated with more advanced disease and higher rate of acute obstruction. The splenic flexure receives blood supply from both superior and inferior mesenteric arteries (SMA and IMA), and therefore has lymphatic drainage to both areas. The blood supply is also highly variable, causing difficulties in determining the main feeding vessels and the main direction of lymph drainage. Few studies with limited cases focused on this specific tumor site with respect to the patterns of lymph node spread, especially the main lymph node status and the value of its dissection. The lack of information limits the development of a consensus on the extent of surgical resection and lymphadenectomy. Adequate mobilization of the colon facilitates a sufficient length of bowel resection and the high ligation of feeding arteries from both SMA and IMA. Further evidence on the chnoice of procedures and the extent of lymph node dissection need multicenter collaboration, with the use of modern techniques, including CT 3D reconstruction of the colon and angiography, as well as intraoperative fluorescent real-time imaging of lymph nodes.
Colon, Transverse/surgery* ; Colonic Neoplasms/surgery* ; Humans ; Laparoscopy ; Lymph Node Excision/methods* ; Lymph Nodes/pathology* ; Mesenteric Artery, Inferior/surgery*

The concept of total mesorectal resection provides a quality control standard that can be followed for radical resection of rectal cancer, but some anatomical problems are still controversial. Compared with traditional open surgery, laparoscopic radical rectal surgery has better surgical vision, better neurological protection, better operating space. However, if the surgeon has insufficient understanding of the anatomy, collateral damage may occur, such as uncontrollable bleeding during the operation, postoperative urination and defecation dysfunction and so on. Based on the interpretation of the researches at home and abroad, combined with the clinical experience, we elucidate some associated issues, including anatomic variation of inferior mesenteric vessels, the controversy of inferior mesenteric artery ligation plane, the controversy of lymph node dissection in No. 253, the anatomical variation of middle rectal artery, and the anatomical controversy of lateral lymph node dissection in rectal cancer, in order to provide better cognitive process for the clinical front-line surgeons.
Humans ; Laparoscopy ; Lymph Node Excision ; Lymph Nodes ; Mesenteric Artery, Inferior ; Rectal Neoplasms/surgery* ; Rectum

Japanese Society for Cancer of the Colon and Rectum (JSCCR) guideline 2019 recommended that lymph node dissection for advanced rectal cancer should include the lymphatic adipose tissue at the root of the inferior mesenteric vessels, but the ligation site of the inferior mesenteric artery (IMA) was not determined, and the NCCN guideline did not indicate clearly whether to retain the left colonic artery (LCA). Controversy over whether to retain LCA is no more than whether it can reduce the incidence of anastomotic complications or postoperative functional damage without affecting the patients' oncological outcome. Focusing on the above problems, this paper reviews the latest research progress. In conclusion, it is believed that the advantages of retaining LCA are supported by most studies, which can improve the blood supply of the proximal anastomosis, and technically can achieve the same range of lymph node dissection as IMA high ligation. However, whether it affects the survival of patients, reduces the incidence of anastomotic leakage, and improves the quality of life of patients, more high-quality evidence-based medical evidence is still needed.
Arteries ; Humans ; Laparoscopy ; Mesenteric Artery, Inferior/surgery* ; Quality of Life ; Rectal Neoplasms/surgery*

The preservation of left colonic artery (LCA) has been accepted by more and more surgeons in the radical resection of rectal cancer, but whether it can reduce anastomotic complications and affect the oncology efficacy remains controversial. This consensus elaborates the significance, anatomical structure, key points of operation techniques, indications and contraindications, and surgical approaches of LCA preservation. Each statement and recommendation was recognized by most experts in the field of colorectal surgery. The purpose of this consensus is to improve the cognitive level of Chinese colorectal surgeons on LCA preservation, so as to standardize the surgical strategies and methods of LCA preservation and furthermore practice, and promote it. The pending issues in this consensus need further high-quality clinical studies.
Anastomotic Leak ; Arteries ; China ; Consensus ; Humans ; Laparoscopy ; Mesenteric Artery, Inferior ; Rectal Neoplasms/surgery*

Controversy remains on how to manage left colic artery (LCA) when it comes to laparoscopic proctectomy. With regard to the level of detachment, a high tie of inferior mesenteric artery (IMA) is meant as a ligation at the origin of aorta, while the low tie is the ligation of IMA below the initiation part of left colic artery which is left. Several key points of LCA preservation, including clinical value, oncologic safety and the difficulty of operation, have always been debated. Some scholars hold the point of view that the preservation of LCA will hamper the lymph nodes dissection around the inferior mesenteric artery, resulting in incorrect pathological staging and dismal outcome. Of note, low tie prolongs the duration of operation and increases the anastomotic tension. However, increasing research results have established its clinical values. The value for reducing the risk of anastomotic leakage and the effect on the lymph nodes dissection at the root of inferior mesenteric artery will be discussed based on previous studies and our clinical practice. We came up with a novel concept of "the lymph nodes in the triangular domain of inferior mesenteric artery which consists of abdominal aorta, inferior mesenteric vein(IMV)/LCA and IMA" instead of traditional No.235 lymph nodes. In our innovative approach of total mesorectal excision guided by vessel, a crack was made at the root of aorta and the dissection was performed along IMA, reaching the origin of LCA. The lymph nodes will be harvested as a whole. After achieving process standardization, vessel-oriented approach and left colic artery preservation makes this region susceptible to lymphadenectomy, protecting submesenteric plexus and guarantying the oncological safety without increasing operative difficulty.
Humans ; Laparoscopy ; Ligation ; Lymph Node Excision ; Mesenteric Artery, Inferior ; surgery ; Rectal Neoplasms ; surgery

Vessel identification and dissection are the key processes of laparoscopic complete mesocolic excision (CME). Vascular injury will lead to complications such as prolonged operative time, intraoperative hemorrhage and ischemia of anastomotic stoma. Superior mesenteric artery (SMA), superior mesenteric vein(SMV), gastrointestinal trunk, left colic artery(LCA), sigmoid artery and marginal vessels in the mesentery have been found with possibility of heteromorphosis, which requires better operative techniques. Surgeons should recognize those vessel heteromorphosis carefully during operations and adjust strategies to avoid intraoperative hemorrhage. Preoperative abdominal computed tomography angiography(CTA) with three-dimensional reconstruction can find vessel heteromorphosis within surgical area before operation. Adequate dissection of veins instead of violent separation will decrease intraoperative bleeding and be helpful for dealing with the potential hemorrhage. When intraoperative hemorrhage occurs, surgeons need to control the bleeding by simple compression or vascular clips depending on the different situations. When the bleeding can not be stopped by laparoscopic operation, surgeons should turn to open surgery without hesitation.
Colonic Neoplasms ; surgery ; Dissection ; Hemorrhage ; prevention & control ; Humans ; Laparoscopy ; Mesenteric Artery, Inferior ; Mesenteric Veins ; Mesocolon ; surgery

OBJECTIVETo investigate the application value of the clearance of No.253 lymph nodes with priority to fascial space and preserving left colic artery (LCA) in patients undergoing laparoscopic radical proctectomy.

METHODSFrom August 2015 to August 2016, 97 consecutive middle-low rectal cancer patients underwent laparoscopic radical proctectomy using the clearance of No.253 lymph nodes with priority to fascial space and preserving LCA at Department of General Surgery, Tangdu Hospital. Among 97 patients, 45 were females , 52 were males, mean age was (64.3±5.5) years and mean BMI was (22.4±1.8) kg/m. Brief steps of this clearance: traditional medial approach was the commencement of the dissection at the membrane bridge line in front of iliac vascular bifurcation, then entering into the Toldt's space; superior rectal artery served as the top of the tent and the Toldt's space was extended as far as possible; blunt separation was developed caudally (reaching 2 cm below the sacral promontory), cephalad (reaching the lower part of the pancreas), left laterally (reaching Toldt's line), dextrally (reaching abdominal aorta); after giving priority to fascias space, from the root of inferior mesenteric artery, LCA was exposed and No.253 lymph nodes were dissected. This regimen was suitable for the rectal adenocarcinoma patients without distant metastasis.

RESULTSThere was no tension in the intestine and mesenteria after anastomosis in all the 97 patients. One patient received LCA ligation during the clearance, because of thinner LCA resulting in bleeding. The other 96 cases completed the clearance and operation successfully. The mean No.253 lymphadenectomy time was 11-27(17.1±5.3) minutes. The mean number of harvested No.253 lymph node was 0-6(4±2). The No.253 lymph nodes of 6 patients were positive. No.253 regional mesentery was complete in 95 patients. The total harvested number of lymph node was 11-26(17.3±5.3). Six patients with positive lymph nodes aged from 68 to 72 years old and all of them underwent TME operation 6-8 weeks after neoadjuvant chemoradiotherapy. The mean operative time was 89-189(125±35) minutes. The mean estimated blood loss was 10.5-38.6(22.4±10.5) ml. The first exhaust time was 3.0-6.0(5.6±2.1) days. The mean time to extracting the drainage tube was 3.0-5.0(4.5±2.5) days. Anastomotic fistula appeared in 1 case and hemorrhage appeared in 1 case, and these 2 cases were cured by conservative treatment. No perioperative death occurred. The mean postoperative hospital stay was 3.0-10.0(3.6±2.6) days.

CONCLUSIONThe clearance of No.253 lymph nodes with priority to fascial space and preserving LCA in laparoscopic radical proctectomy is safe and feasible.

Aged ; Digestive System Surgical Procedures ; methods ; Female ; Humans ; Laparoscopy ; Lymph Node Excision ; Lymph Nodes ; Male ; Mesenteric Artery, Inferior ; surgery ; Middle Aged ; Rectal Neoplasms ; surgery

OBJECTIVETo evaluate the influences of inferior mesenteric artery (IMA) types and Riolan artery arcade absence on the incidence of anastomotic leakage(AL) after laparoscopic resection of rectal cancer.

METHODSClinical data of 116 local advanced rectal cancer patients who underwent laparoscopic resection in The Sixth Affiliated Hospital of Sun Yat-sen University from January 2012 to December 2014 were analyzed retrospectively. IMA and Riolan artery arcade were examined by preoperative computed tomography angiography (CTA) reconstruction. The influences of IMA type, Riolan artery arcade absence and ligation site (high or low) on AL were analyzed by Logistic regression.

RESULTSThe proportion of IMA types(I(-IIII() was 57.8%(67/116), 10.3%(12/116), 31.0%(36/116) and 0.9%(1/116), respectively. Riolan artery arcade absence was found in 60.3%(70/116). Eight (6.9%) patients suffered from AL. IMA type III( had significantly higher AL incidence as compared to other IMA types [19.4%(7/36) vs. 1.2%(1/80), P=0.001]. Meanwhile, patients with Riolan artery arcade absence also had significantly higher AL incidence[11.4%(8/70) vs. 0.0%(0/46), P=0.030]. However, the difference in AL incidence between high and Low IMA ligation was not statistically significant [8.0%(7/87) vs. 3.4%(1/29), P=0.531]. Seven of these 8 AL patients were found in IMA type III( with Riolan artery arcade absence and high ligation. Multivariate analysis showed that IMA type III( (P=0.001) and Riolan artery arcade absence (P=0.002) were independent risk factors of AL.

CONCLUSIONSIMA type III( with Riolan artery arcade absence increases AL incidence significantly in laparoscopic resection of rectal cancer. IMA type and Riolan aretry arcade absence or not contribute to the selection of IMA ligation site in the operation. For the colorectal cancer patients with IMA type III( and Riolan artery arcade absence, selective low IMA ligation with root lymph node dissection should be recommended.

Adult ; Anastomotic Leak ; Arteries ; Colorectal Neoplasms ; surgery ; Female ; Humans ; Incidence ; Laparoscopy ; Ligation ; Lymph Node Excision ; Lymphatic Metastasis ; Male ; Mesenteric Artery, Inferior ; Middle Aged ; Rectal Neoplasms ; surgery ; Retrospective Studies

OBJECTIVETo evaluate the clinical significance of low ligation of inferior mesenteric artery (IMA) and preservation of left colic artery in laparoscopic radical operation for rectal cancer.

METHODSClinical data of 103 rectal cancer patients undergoing laparoscopic radical operation in Ruijin Hospital from May 2015 to January 2016 were retrospectively analyzed, including 61 cases with preservation of left colic artery (low ligation group, LL group) and 42 cases without preservation of left colic artery (high ligation group, HL group). Clinical conditions during operation and after operation were compared between the two groups.

RESULTSAll the patients underwent operation successfully without transferring to laparotomy, intra-operative or post-operative death, and severe intra-operative or anesthetic complications. Age, gender, BMI, ASA score, tumor size and tumor location were not significantly different between the two groups. Four cases(9.5%) in HL group presented ischemic changes in colonic stump during operation, receiving additional colonic resection and no such ischemic changes were found in LL group (P=0.025). The number of harvested lymph node was 16.1±6.8 in HL group and 15.5±7.2 in LL group, number of harvest lymph node in the root of IMA was 4.2±1.7 in HL group with positive rate of 9.5%(4/42) and 4.3±1.7 in LL group with positive rate of 4.9%(3/61), both were not significantly different between the two groups. Lower margin was (2.2±1.4) cm in LL group and (2.8±1.7) cm in HL group, and difference was not significant as well(all P>0.05). There were no significant differences in terms of operation time, blood loss, post-operative complication, recovery of bowel movement and hospital stay. Median follow-up time was 4.5 months(2 to 10 months) and no long-term complications and local recurrence were found.

CONCLUSIONLow ligation of IMA with preservation of left colic artery in laparoscopic radical operation for rectal cancer can provide better blood supply for proximal colon and anastomosis, and can achieve same radical clearance of lymph nodes as high ligation without prolonged operation time, which is worth clinical promotion.

Colon ; Female ; Humans ; Laparoscopy ; Length of Stay ; Ligation ; Lymph Node Excision ; Lymph Nodes ; Male ; Mesenteric Artery, Inferior ; Mesenteric Artery, Superior ; Neoplasm Recurrence, Local ; Operative Time ; Postoperative Complications ; Rectal Neoplasms ; surgery ; Retrospective Studies