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 Table of Contents  
Year : 2023  |  Volume : 9  |  Issue : 1  |  Page : 2

The application value of the anatomy and treatment of inferior mesenteric artery in laparoscopic surgery for left-sided colorectal cancer

1 Department of Radiology, Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, China
2 Department of Radiology, Affiliated Hospital 2 of Nantong University; Nantong Key Laboratory of Intelligent Medicine Innovation and Transformation, Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, China

Date of Submission18-May-2022
Date of Decision28-Jun-2022
Date of Acceptance11-Jul-2022
Date of Web Publication11-Jan-2023

Correspondence Address:
Bosheng He
Department of Radiology, Affiliated Hospital 2 of Nantong University, Nantong 226001, Jiangsu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/digm.digm_27_22

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The inferior mesenteric artery (IMA) is the blood supply vessel in the left colorectal cancer (CRC) and is the focus for clinicians during the operation of the left-sided CRC. Different IMA treatment methods will affect the blood supply of the anastomotic bowel after the operation, thus affecting the prognosis. Nevertheless, the individual anatomical variation rate of IMA is great. It is the crucial to perform precise high/low ligation and standardized lymph node dissection according to the anatomical characteristics of IMA in laparoscopic radical resection of left-sided CRC. In the present study, we reviewed the effects of IMA length, classification, the relationship with adjacent vessels and ureter, and different IMA treatments on the prognosis of patients.

Keywords: Colorectal cancer, Inferior mesenteric artery, Laparoscope, Left colic artery

How to cite this article:
Chen J, He B. The application value of the anatomy and treatment of inferior mesenteric artery in laparoscopic surgery for left-sided colorectal cancer. Digit Med 2023;9:2

How to cite this URL:
Chen J, He B. The application value of the anatomy and treatment of inferior mesenteric artery in laparoscopic surgery for left-sided colorectal cancer. Digit Med [serial online] 2023 [cited 2023 Jun 8];9:2. Available from: http://www.digitmedicine.com/text.asp?2023/9/1/2/367585

  Introduction Top

Colorectal cancer (CRC) has been the third malignant tumor worldwide. The new cases of CRC account for about 10% and it is next only to breast cancer and lung cancer.[1] With the improvement of living standards, people are more inclined to eat meat and eggs and vegetables as supplements. The number of CRC patients is increasing with each passing year.[2]

The main therapy method for CRC is surgical resection, supplemented by medical treatment. The main principles of surgery are total mesorectal excision, complete mesocolic excision, and standardized lymph node dissection.[3],[4] Surgical methods for CRC mainly include traditional laparotomy, laparoscopic radical resection, and da Vinci robot radical resection. Traditional laparotomy induces long incision and large trauma, and along with low intestinal recovery, high postoperative incision infection and various abdominal complications. Due to the high cost and high failure rate of robotic surgery, it is not recommended to be widely carried out in a short period time.[5],[6],[7],[8] Compared with the above two surgical methods, laparoscopic surgery not only possess advantages of less damage, high safety, quick recovery, and low cost, but also can reduce the patient's inflammatory response in terms of biological safety and improve the immune function. Therefore, laparoscopic surgery is gradually becoming the first choice for CRC surgery.[5],[9]

However, considering how to ligate inferior mesenteric artery (IMA) under laparoscopy and where the best ligation, there is disagreement options among scholars.[10] Different treatments of IMA directly affect the dissection of lymph nodes during surgery, the protection of pelvic nerve plexus, and the blood supply of the anastomotic bowel, which in turn affects the patient's survival time, bowel and bladder function, and postoperative anastomotic leakage.[11] In the present study, we briefly reviewed the effects of the IMA anatomy, classification, and treatment on the prognosis of patients with CRC.

  Anatomical Structure Of Inferior Mesenteric Artery And Peripheral Vessels Top

Inferior mesenteric artery anatomical feature and classification

IMA is the last mismatched branch of the anterior wall of the abdominal aorta, located below the beginning of the superior mesenteric artery (SMA), directly above the bifurcations of the common iliac artery, and about the level of L3 lumbar vertebra.[12] It is the crucial process to search for IMA root in colorectal surgery. Rapid and accurate localization can shorten the operation time, avoid damage of related blood vessels and nerves due to long searching, and affect anastomotic blood supply.[12]

The main blood supply area of IMA is the distal portion of the entire intestine, including the left third of the transverse colon, descending colon, and the upper segment of the sigmoid colon and rectum. Usually, the main blood supply areas are supplied by three branches of IMA. These branches are divided from proximal to distal into the left colic artery (LCA) which located retroperitoneally and supplying descending colon, sigmoid artery (SA) which supplying sigmoid colon, and superior rectal artery (SRA) of rectal.[13] The anatomical characteristics of these IMA branches are particularly important in colorectal surgery and directly affect the choice of IMA treatment.

At present, the classification of IMA mostly adopts the four types of IMA proposed by a Japanese scholar Yada et al.[14] in the 1990s: (1) in type I, LCA arises independently, and SA and SRA are separated together [Figure 1]a; (2) in type II, LCA and SA are separated at the same point of IMA, and SRA is isolated [Figure 1]b; (3) in type III, LCA, SA, and SRA are all separated in one spot [Figure 1]c; and (4) in type IV, LCA is absent [Figure 1]d. A study contained 123 patients with total abdominal computed tomography (CT) scan were conducted in the Sixth Affiliated Hospital of Sun Yat-sen University. The study suggested that 49.6% (61/123) of IMA belonged to type I, 19.5% (24/123) belonged to type II, 28.5% (35/123) belonged to type III, and 2.4% (3/123) belonged to type IV.[15] This result was similar to the IMA classification in the University of Tokyo Hospital in 2015.[16]
Figure 1: Branch types and distribution of IMA. (a) Type I; (b) Type II; (c) Type III; (d) Type IV. AA: Abdominal aorta, IMA: Inferior mesenteric artery, LCA: Left colic artery, SA: Sigmoid artery, SRA: Superior rectal artery.

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Recently, scholars[17] proposed another novel structured anatomical classification, namely, IMA five classification system, to describe the running and morphological characteristics of the IMA terminal branches for more accurate vascular ligation. In class I, LCA is separate originally, and SA and SRA share a common trunk before they are separated. Based on this, the class I are further divided into three subclasses: (1) in subclass IA, LCA is further separated into ascending and descending branches, while SA has no branches; (2) in subclass IB, LCA has no branches, while SA has small branches; and (3) in subclass IC, there is no LCA trunk and LCA arises directly from the IMA trunk. The class II is similar to the previously mentioned type III, that is, LCA, SA, and SRA arise from one same point. Based on this, there are two subclasses: (1) in subclass IIA, LCA has branches and (2) in subclass IIB, LCA has no branches. In class III, SRA is originated first from IMA. In class IV, ascending lumbar artery arises from IMA. Class V is rare. In class V, IMA is first separate into LCA ascending branch and then LCA descending branch. SA and its branches originate from LCA descending branch, and the three bifurcations anastomose with each other for multiple times. Finally, SRA separates from IMA.

Mesenteric connection between superior mesenteric artery and inferior mesenteric artery

The vascular connection between SMA and IMA is critical in colorectal surgery involving ligation of the origin of the IMA.[18] Marginal aortic arch and Riolan aortic arch are the primary mesenteric connections between the two arterial systems.

Marginal arterial arch is a continuous arterial duct at the junction with the intestinal wall and is also the most important and peripheral mesenteric connection.[18] It starts from ileal branch of ileocolic artery; connects the ascending and descending branches of the right colonic artery, the left and right branches of the middle colonic artery, the ascending and descending branches of LCA, and the branches of SA; and terminates at the SRA. In addition, the marginal arterial arch is directly connected with intestinal wall through straight artery to supply blood for the colon.[18] Relevant studies[19] show that marginal arterial arch does not always exist and will be interrupted at the left corner of the colon. At this time, if the LCA distal end is divided into ascending and descending branches at the left corner of the colon, a V-shape structure will be formed at the end and directly connected with the marginal artery. This V-shape structure can serve as a secondary anastomotic aortic arch that complements the functionality and effectiveness of the marginal arteries.

The Riolan arch is a colonic arterial arches that connects the left branch of the middle colon artery to the ascending branch of the left colon artery. When blood supply of IMA is blocked, SMA can compensate for blood supply to the left colon through the Riolan arch. However, the Riolan arch exists only between 7% and 10%.[20] Therefore, the presence or absence of Riolan arch is significantly important in the ligation of IMA during CRC surgery. Karatay et al.[21] suggested that preoperative abdominal CT angiography is helpful to evaluate the marginal artery and the Riolan arch in patients undergoing colorectal surgery; by doing so, it is helpful to further develop a reasonable resection plan and reduce postoperative complications. Huang et al.[22] first explored the relationship between Riolan artery arch and IMA classification and anastomotic fistula in patients with rectal cancer. The results showed that high ligation was mostly used in type III IMA because the initial part of LCA was close to SRA and SA, which would block the blood supply of LCA to the splenic flexure of the left colon and increase the occurrence of anastomotic fistula. This study[22] further suggested that IMA low ligation and standardized lymph node dissection should be used to replace IMA high ligation to ensure anastomosis of intestinal blood supply in patients with type III IMA and absent Riolan aortic arch. Wang and Shi[23] explored the guiding significance of the presence or absence of the Riolan aortic arch for laparoscopic IMA management in patients with rectal cancer. They recommend that patients without the Riolan aortic arch should be treated a low ligation, along with standard dissection of surrounding lymph nodes. Whereas for patients with the Riolan aortic arch, high ligation without preserving LCA is more recommended.

Relationship between inferior mesenteric vein as well as its branch blood vessels and inferior mesenteric vein as well as ureteral

In the separation and ligation of the inferior mesenteric vessels involved in laparoscopic colorectal surgery, the difficulties of surgical operation extremely increase due to the close connection of IMA, IMV, and the surrounding ureter. Once there is an injury, it will not only cause massive bleeding but also affect postoperative urination and defecation. Therefore, it is particularly important to understand the position among them.

LCA, as the branch vessel of IMA, can be divided into several types according to two classifications. In the first classification,[24] LCA can be divided into three types according to the position relationship with the left kidney: (1) in high medial type, LCA and IMV adhered to the medial side of the left kidney and moved upward, ending in the left third of the transverse colon; (2) in median type, LCA crosses the left kidney and terminates in the middle and upper descending colon; and (3) in low lateral type, LCA runs at the lower pole of the left kidney and ends at the junction of descending sigmoid colon. In the second classification,[21] LCA can be divided into three types according to its anatomical position with IMV at IMA root level: (1) in near medial type, LCA runs near the medial side of IMV; (2) in near lateral type, LCA runs at a distance <15 mm outside the IMV; and (3) in distal type, LCA runs at a distance >15 mm outside the IMV. The second classification is different from the first of locating mesenteric vessels through the left kidney. The second classification pays more attention to the risk distance between LCA and IMV. When LCA and IMV are close to each other, it is necessary to take more extra care when treating the IMA, avoiding accidental injury to IMV.

In addition, Zuo et al.[25] reconstructed abdominal and pelvic CT images by postprocessing technology and then evaluated the anatomical relationship among IMA, IMV, and ureter. The study suggested that the ureter was closest to IMA at the aortic branch, furthest from IMA at the level of IMA root, closest to IMV at the level of LCA root, and furthest from IMV at the plane of sacrum promontory. Moreover, the study[25] further confirmed that it was more functional to use the sacral promontory than the aortic bifurcation for IMA root location in laparoscopic CRC surgery. Therefore, it is necessary to pay great attention to avoid ureter injury in the treatment of inferior mesenteric vascular. In view of this, it is extremely important for patients with CRC to perform a CT 3-dimensional reconstruction before surgery to clarify the position relationship around the inferior mesenteric vessels.

  Treatment Of Inferior Mesenteric Artery And Its Effects On The Prognosis Top

Two treatments for inferior mesenteric artery

The main treatment for IMA is mainly divided into two types. The one is to perform ligation at about 1 cm below the initial part of the abdominal aorta. This method neglects the classification of IMA and the running of LCA, only standardly clear the high ligation of group NO. 253 lymph nodes around the IMA root. This simple "ligation when meet vessels" operation not only removes lymph node more completely but also provides sufficient intestinal anastomosis length. The other method is to open the arterial sheath to expose IMA branches first, judge the classification, find LCA and perform ligation under its root (except type IV), and finally clean IMA and its surrounding lymph nodes for low ligation. This operation is complex, but LCA is preserved, which ensures the blood supply of the proximal colon together with the marginal arterial arch.[10] The advantages and disadvantages of the two ligation methods have been controversial since 1908, with conflicting views on the value of the two IMA treatments in CRC surgery.

Effects of inferior mesenteric artery treatments on oncology efficacy

The positive status of IMA peripheral lymph nodes in patients with CRC is closely related to tumor recurrence rate and survival rate.[26],[27] IMA root lymph nodes are the third station of lymph node metastasis in left colon cancer, also known as group 253 lymph nodes. They exist between the root of IMA and the first branch of IMA, collecting lymphatic drainage of left colon and rectum, and are the main targets of lymphatic metastasis of CRC.[28] Yuan et al.[29] suggested that the rate of IMA root lymph node metastasis was 13.5%, which was associated with the clinical pathological features of the tumor. Therefore, thorough clearance of lymph nodes around blood vessels is a key issue in surgery of CRC.

Relevant study[30] showed that IMA high ligation exhibited a more thorough cleaning of the surrounding lymph node compared to low ligation, further improved the detection rate of lymph node. Although patients with lymph node metastases in the origin of the IMA and its surrounding show poor prognosis, the IMA high ligation can improve the survival rate of patients with rectal cancer in combination with neoadjuvant therapy and adjuvant therapy. However, large-sample, multicenter researches are absent. Nowadays, with increasing improvement of examination technology and surgical techniques, the detection rate of lymph node under low IMA ligation has gradually reached high IMA ligation. On the one hand, the detection rate of lymph node can be improved by injecting methylene blue into IMA root or carbon nanoparticle tracers. On the other hand, extensive lymph node dissection can be performed without sacrificing LCA, by collecting lymph node tissue along the proximal LCA of IMA, which called apical lymph node dissection of IMA.[31],[32],[33] A retrospective study was conducted by Park et al.[34] to compare the incidence of complications, oncology, and functional outcomes between high and low ligation of IMA in patients with distal sigmoid colon and rectal cancer, and no significant difference was found in long-term survival between the two ligation methods. A meta-analysis was performed by Si et al.[35] to investigate the differences of the lymph node metastasis rate and long-term survival benefit between the two ligation methods in patients with CRC and found no significant difference in the total number of lymph nodes dissected, the number of lymph nodes dissected around the IMA root, local recurrence rate, and operation time between the two methods. However, Nayeri et al.[36] exhibited that low IMA ligation not only did not affect the long-term survival rate of patients but also reduced postoperative complications compared with high IMA ligation.

Nevertheless, we cannot deny that these two IMA treatments can both meet the requirements of lymph node detection recommended by the American Joint Council on Cancer and the American Institute of Pathology to accurately assess postoperative staging and guide postoperative treatment for patients with CRC.[37]

Effects of inferior mesenteric artery treatment on anastomotic leakage

Anastomotic leakage and anastomotic stenosis are common postoperative complications in patients with CRC. Reoperation is required in come severe cases, which might increase the psychological and physiological burden of patients. Anastomotic leakage is caused by a variety of factors, such as long operation time, repeated multiple blood transfusions, contamination of the surgical area, and short distance between the anastomotic site and the anal edge. Among them, the most considerable reason is the blood supply obstacle and excessive tension of anastomosis site.

The blood flow of the left colon is supplied by the marginal arterial arch formed by the middle colon artery and IMA. High ligation of the IMA root results causes that the blood supply of intestinal anastomosis is only supplied by the marginal artery, which is easy to results in the blood flow barrier of anastomosis. Although some studies[38] have shown that high ligation is about 9 cm longer than low ligation in the length of free intestinal canal, which remarkably reduces the anastomotic pressure of intestinal canal, this is only anatomically analyzed and has not been proved in clinical experiments. Zeng and Su[39] conducted a meta-analysis to compare postoperative anastomotic leakage rates in 3652 patients with low ligation and 2265 patients with high ligation and indicated that IMA with high ligation has a higher risk of anastomotic leakage in sigmoid and rectal cancer surgery. Feng et al.[40] conducted a prospective study and suggested that low ligation of IMA along with lymph node dissection at the vascular root could protect the blood supply of anastomosis and reduced postoperative complications. You et al.[41] analyzed the surgical indicators, economic indicators, pathological results, perioperative complications, and survival rate of patients with rectal cancer in a retrospective cohort study. The results showed that the low IMA ligation group had higher anal retention rate, shorter hospital stay, lower hospital cost, and fewer cases of anastomotic leakage and stenosis.

Low ligation of IMA can preserve LCA, thus providing double guarantee for the blood flow of intestine anastomosis. Some researchers[42] suggested that the blood flow of proximal intestine in patients with low ligation was higher than that in patients with high ligation of IMA by Doppler flow analyzer. In addition, previous studies have demonstrated[43] that the effect of tension-free anastomosis can also be achieved when low IMA ligation is performed along with high ligation IMV and free splenic curvature intestine in rectal cancer surgery.

However, a literature[44] believed that no significant differential effects was found with the two ligation methods. This may be due to atherosclerosis in IMA in some patients, resulting in vascular occlusion and stenosis, which cannot provide adequate blood supply for the left colon.

Effects of inferior mesenteric artery treatment on autonomic nerve function

Pelvic autonomic nerve injury is one of the important factors causing urinary and reproductive dysfunction in patients with CRC after surgery.

The vulnerable areas of pelvic autonomic nerves include the IMA root area of the inferior mesenteric plexus, the left and right hypogastric nerve running area formed by the inferior epigastric plexus at the promontory of the sacrum, the pelvic plexus, the anterior sacral fascia area of the second to fourth vertebrae of the pelvic splanchnic nerves, and the neurovascular bundle area covering the prostatic fascia.[45] When nerve fibers in these areas are pulled and damaged, they can cause postoperative urination, sexual function, and internal anal sphincter contraction disorder.[46]

Although some studies[46],[47] suggested that high ligation at 0.5-1.0 cm of IMA root avoided autonomic nerve fibers area and thus avoided nerve injury, Kudo[48] insisted that nerve would be damage regardless of where the IMA root was ligated due to the close distance between the left bundle of the epigastal inferior plexus and IMA. Campbell et al.[49] conducted dissection on ten embalmed cadavers (simulating high and low ligation of IMA) and found that the loss of autonomic ganglia in low ligation of IMA was lower than that in high ligation. Fiori et al.[50] performed a prospective, randomized, open-label, parallel-group study, and 46 patients with rectal cancer who accept early radical laparoscopic resection were included. The study compared the different effects of two different ligation methods on postoperative quality for patients through the international standard in the form of a questionnaire survey. The results found that patients with low IMA ligation exhibited lower postoperative defecation, urination, and dysfunction, as well as the higher overall scores compared to those with high IMA ligation.

  Expectation and Conclusion Top

IMA anatomical features like walking trend and branches variation and its relationship with peripheral vascular nerves determine the treatment of IMA, which in turn affects the occurrence of postoperative anastomotic leakage, urination, defecation, and reproductive function of patients after surgery. Therefore, it is necessary to investigate the anatomical characteristics of the inferior mesenteric vessels through preoperative three-dimensional CT vascular reconstruction and provide guidance for intraoperative IMA ligation. Recently, the imaging examination technology is increasingly advanced. Virtual monoenergetic images (VMIs) on dual-energy computed tomography can not only reduce the noise level of the low-level image but also optimize its image quality, so that the low-level image can be routinely used in clinical, which has obvious advantages for displaying some small vessels. In addition, artificial intelligence (AI) technology is also improving. AI can automatically identify some image features based on plenty of image learning and efficient processing and analysis of new algorithms. We believe that in the near future, we can achieve IMA automatic typing with the help of AI. Clinicians can also be familiar with the characteristics of mesenteric vessels through imaging technology in advance and develop individualized laparoscopic colorectal surgery plans based on the clinical tumor stages and the basic physical conditions of patients.

Financial support and sponsorship

This study was supported by grants from The Fund of Health and Family Planning Commission of Jiangsu (ZD2021059), The fifth round of the "Programme 333" of Jiangsu (BRA2020198) and The social development fund of Nantong (HS2019002).

Conflicts of interest

There are no conflicts of interest.

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