Authors: Mark Buunen Marilyne M Lange Max Ditzel GeertJan Kleinrensink Cees J H van de Velde Johan F Lange
Publish Date: 2009/07/16
Volume: 24, Issue: 11, Pages: 1317-
Abstract
Hightie ligation is a common practice in rectal cancer surgery However it compromises perfusion of the proximal limb of the anastomosis This anatomical study was designed to assess the value of lowtie ligation in order to obtain a tensionfree anastomosisConsecutive high and lowtie resections were performed on 15 formalinfixed specimens with or without splenic flexure mobilization If the proximal colon limb could reach the superior aspect of the symphysis pubis with more than 3 cm the limb would be long enough for a tensionfree colorectal anastomosisIn 80 of cases it was not necessary to perform hightie ligation as sufficient length was gained with lowtie ligation The descending branch of the left colic artery was the limiting factor in the other 20 of cases Resecting half the sigmoid resulted in four times as many tensionfree anastomoses after lowtie resectionIn the majority of cases it was not necessary to perform hightie ligation in order to create a tensionfree anastomosis Lowtie ligation was applicable in 80 of cases and might prevent anastomotic leakage due to insufficient blood supply of the proximal colon limbAnastomotic leakage is a severe complication after rectal cancer surgery Significant morbidity and mortality are reported and numerous risk factors have been identified 1 2 One of the causes of anastomotic leakage is represented by too much tension on the anastomosis due to a short proximal colon limb leading to decreased perfusion Many surgeons prefer to perform hightie ligation ie ligation of the inferior mesenteric artery because of oncological reasons 3 4 As a result the left colic artery must be sacrificed making the blood supply to the anastomosis completely dependent on an intact marginal artery of Drummond 5As no consensus exists on hightie ligation for oncological reasons we investigated if a tensionfree anastomosis at the level of the pelvic floor as in total mesorectal excision TME for rectal carcinoma can be made by performing lowtie ligation ie ligation of the superior rectal artery As some surgeons excise the entire sigmoid together with the rectum with respect to a better quality of the proximal colon limb we both determined the possibility of lowtie ligation after excision of half and the entire sigmoidA total of 15 human formalinfixed specimens seven males and eight females aged 60 to 98 years median age 81 years were the subject of this study Any specimen with previous abdominal or vascular diseases was excluded No ethical committee approval was necessary for this studyThe ventral abdominal wall was opened through a midline incision and the small intestine was removed en bloc in order to get a clear view of the dorsal abdominal wall The peritoneum was incised at the level of bifurcation of the aorta The inferior mesenteric artery IMA was identified All vessels branching off of IMA were identified by fine anatomical dissection to the point of the smallest visible branches The IMA left colic artery LCA descending branch of the left colic artery sigmoid arteries and the superior rectal artery SRA were all marked by a unique colored thread
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