Total robotic ligation of inferior mesenteric artery for type II endoleak after endovascular aneurysm repair

We present a case of totally robotic ligation of the inferior mesenteric artery (IMA) for treatment of a persistent endoleak from the IMA into the aneurysm sac after endovascular aneurysm repair (EVAR). An 84-year-old male underwent EVAR with a Gore Excluder stent graft for an asymptomatic infrarenal abdominal aortic aneurysm. Follow-up computed tomographic (CT) scan showed persistent type II endoleak from the IMA, with progressive enlargement of the aneurysm sac from 5 to 6.1 cm over an 18-month period. In this case, the patient underwent ligation of the IMA using the da Vinci Surgical System for the treatment of retrograde flow into the aneurysm sac. The total operating time was 249 min; of this, the robotic assistance time was approximately 180 min. No intraoperative complications occurred. The estimated blood loss was 50 mL and the urine output 650 mL. The patient was extubated immediately after the procedure and tolerated a regular diet the following day. He was discharged home with a urinary catheter on postoperative day 2. CT scan postoperatively and at 3-month follow-up demonstrated an occluded IMA and stabilization of the aneurysm sac size.     

Laparoscopic transperitoneal clipping of the inferior mesenteric artery for the management of type II endoleak after endovascular repair of an aneurysm

We report the case of a high risk patient with an abdominal infrarenal aortic aneurysm (AAA) who was treated by endovascular technique and the subsequent management of a type II endoleak by the laparoscopic approach. In this case, a 74-year-old woman with a 6-cm infrarenal AAA underwent endovascular repair using a bifurcated stent-graft device. Surveillance CT scan showed a persistent type II endoleak at 1 week and 3 months after the operation. Angiography confirmed retrograde flow from the inferior mesenteric artery (IMA). Attempted transarterial embolization of the IMA via the superior mesenteric artery was not successful. Laparoscopic transperitoneal IMA clipping was performed. Subsequent aortic duplex scan and CT scan confirmed complete elimination of the type II endoleak. We conclude that a combination of endovascular and laparoscopic procedures can be used to manage AAA successfully.     

High ligation of the inferior mesenteric artery in rectal cancer surgery

In rectal cancer surgery, it is unclear whether the inferior mesenteric artery (IMA) should be ligated as high as possible, at its origin, or low, below the origin of the left colic artery. We reviewed all relevant articles identified from MEDLINE databases and found that despite a trend of improved survival among patients who underwent high ligation, there is no conclusive evidence to support this. High ligation of the IMA is beneficial in that it allows for en bloc dissection of the node metastases at and around the origin of the IMA, while enabling anastomosis to be performed in the pelvis, without tension, at the time of low anterior resection. High ligation of the IMA does not represent a source of increased anastomotic leak in rectal cancer surgery and postoperative quality of life is improved by preserving the hypogastric nerve without compromising the radicality of the operation. More importantly, high ligation of the IMA improves node harvest, enabling accurate tumor staging. Although the prognosis of patients with node metastases at and around the origin of the IMA is poor, the survival rate of patients with rectal cancer may be improved by performing high ligation of the IMA combined with neoadjuvant and adjuvant therapy.     

Laparoscopic end-to-end aortobifemoral bypass with reimplantation of the inferior mesenteric artery

Background: Colic ischemia is a serious complication that can occur after abdominal aortic surgery. It has been described in two patients after laparoscopic aortic surgery. The goal of the current experiment was to determine the feasibility of inferior mesenteric artery (IMA) reimplantation during laparoscopic aortobifemoral bypass (LAFB). Methods: Six piglets were submitted to the laparoscopic approach according to the ``apron' technique previously described. The infrarenal aorta was clamped and an LAFB was performed using a dacron graft. The IMA was reimplanted in the body of the graft with a running 5-0 polypropylene suture. Results: Mean operation and dissection times were 282.5 min (range, 270–310 min) and 123 min (range, 110–140 min), respectively, with a mean blood loss of 108 ml (range, 80–150 ml). Aortic clamping and anastomotic times were 123 min (range, 110–135 min) and 33 min (range, 24–45 min), respectively. The IMA reimplantation took 55 min (range, 45–70 min). At autopsy, all anastomoses were patent with no stenosis nor leak. Conclusion: Laparoscopic IMA reimplantation during laparoscopic aortobifemoral bypass is feasible. Received: 10 July 1998/Accepted: 15 November 1998     

High versus low ligation of the inferior mesenteric artery in rectal cancer

The argument for and against high ligation of the inferior mesenteric artery in rectal cancer has yet to be resolved. Between 1948 and 1983, 4250 patients underwent surgery for rectal carcinoma at St. Mark's Hospital, London. From these, 250 patients were selected who had undergone curative anterior resection of a Dukes' C adenocarcinoma and their records were examined. In 150 (60 per cent) the inferior mesenteric artery was ligated above the origin of the left colic artery. The outcome was analysed using the Dukes', Gastrointestinal Tumour Study Group and Astler-Coller classifications, either alone or in combination. Tumour differentiation and extent of local invasion were also considered. Despite this detailed analysis, no improved survival was seen in patients when the inferior mesenteric artery was ligated above the origin of the left colic artery.     

直肠癌术中从根部结扎肠系膜下动脉临床意义探讨

目的探讨直肠癌术中从根部结扎肠系膜下动脉的临床意义。方法回顾性分析华中科技大学同济医学院附属同济医院2000年1月至2005年12月499例肠系膜下动脉根部结扎的直肠癌临床病理资料。结果肠系膜下动脉根部淋巴结转移率为14．4％。肿瘤分化程度为低分化腺癌、黏液腺癌或印戒细胞癌，肿瘤浸润深度达到pT3和pT4的直肠癌病人，其肠系膜下动脉根部淋巴结转移率较高。结论低分化腺癌、黏液腺癌或印戒细胞癌，浸润深度达到pT3和pT4时，直肠癌肠系膜下动脉根部淋巴结转移率较高，在行直肠癌根治手术时应行肠系膜下动脉根部结扎以提高5年存活率。     

Laparoscopic lymph node dissection around the inferior mesenteric artery with preservation of the left colic artery

Aim  

Curative resection of sigmoid and rectal cancer includes “high tie” of the inferior mesenteric artery (IMA). However, IMA ligation compromises blood flow to the anastomosis, which may increase the leakage rate. Accordingly, some surgeons employ a technique of lymph node (LN) dissection around the IMA, preserving the IMA and left colic artery (LCA). The same technique was reported to need longer time in laparoscopic surgery due to technical difficulties. We present herein a simple and secure method of laparoscopic LN dissection around the IMA that allows preservation of the IMA and LCA, and report the operative results.     

Laparoscopic treatment of superior mesenteric artery syndrome.

BACKGROUND: Superior mesenteric artery syndrome is caused by compression of the third portion of the duodenum by the superior mesenteric artery. Many disease states predispose one to this condition. METHODS: We present a case report of a young female patient who presented with gastro-duodenal obstruction from superior mesenteric artery syndrome and subsequently underwent surgical treatment with minimally invasive techniques. Pathophysiology of SMA syndrome is reviewed. RESULTS: The cause of superior mesenteric artery syndrome is variable but always results in duodenal obstruction. Surgery is one treatment option that is effective and can be performed laparoscopically. CONCLUSION: Laparoscopic duodenojejunostomy is an acceptable method of treating superior mesenteric artery syndrome.     

Colonic necrosis subsequent to catheter-directed thrombin embolization of the inferior mesenteric artery via the superior mesenteric artery: A complication in the management of a type II endoleak

The optimal management of endoleaks after endovascular repair of abdominal aortic aneurysms remains to be established. In this report, we describe a persistent side-branch, or type II, endoleak 1 year after endograft implantation treated with catheter-directed embolization of the aneurysm sac and the inferior mesenteric artery via the superior mesenteric artery, with embolization agents including thrombin, lipiodol, and gelfoam powder. Shortly after the embolization procedure, colonic necrosis developed in the patient, manifested by peritonitis, which necessitated a partial colectomy. This case underscores the devastating complication of colonic ischemia as a result of catheter-directed embolization of the inferior mesenteric artery in the management of an endoleak.     

High ligation of the inferior mesenteric artery with hypogastric nerve preservation in rectal cancer surgery

We describe herein a technique of performing upward node dissection following high ligation of the inferior mesenteric artery for patients with T3 and T4 rectal carcinomas. The course of the hypogastric nerve is confirmed macroscopically during the procedure to ensure its preservation. This technique offers both increased radicality and the prevention of ejaculatory dysfunction. This work was supported in part by a Grant-in-Aid for Scientific Research from the Japanese Ministry of Education, Culture, and Science.     

肠系膜下动脉低位结扎和高位结扎对腹腔镜直肠癌根治术的疗效影响

目的分析肠系膜下动脉(IMA)低位结扎和高位结扎对腹腔镜直肠癌根治术的疗效影响。 方法以2013年3月至2017年3月收治的215例接受腹腔镜直肠癌根治术的患者为研究对象,进行回顾性分析。按照患者治疗术式,将接受IMA低位结扎者纳入低位结扎组127例,将接受IMA高位结扎者纳入高危结扎组88例。采用SPSS18.0进行分析,术后短期并发症发生情况采用χ²检验;手术情况、恢复情况等计量资料以( ±s)表示,独立t检验,以P<0.05为差异有统计学意义。 结果低位结扎组术中残端缺血性改变发生率和术后首次排气时间均低于高位结扎组,其术后性功能障碍或尿失禁发生率高于后者,差异有统计学意义(P<0.05)。 结论腹腔镜直肠癌根治术中,两种结扎方式疗效相当,IMA低位结扎对于患者术后早期恢复具有积极意义,但较高危结扎有着更高的盆腔自主神经损伤风险,需根据患者实际情况做出决策。     

Mycotic aneurysm of the inferior mesenteric artery

This is the first reported case of successful management of a mycotic aneurysm of the inferior mesenteric artery. The only helpful clinical manifestations were episodes of previous abdominal pain and a history of bacterial endocarditis. The surgical management involved simple excision without revascularization of the inferior mesenteric artery.     

Survival after high or low ligation of the inferior mesenteric artery during curative surgery for rectal cancer.

In an attempt to determine whether "high ligation" of the inferior mesenteric artery during surgery for cancer of the rectum and rectosigmoid confers any significant 5-year survival advantage over "low ligation," the outcome of 1370 patients was reviewed. There were 784 patients in whom the inferior mesenteric artery was ligated below the origin of the left colic artery (low ligation) and 586 in whom it was ligated above this level (high ligation). The distribution of histologic grades of the tumors and incidence of venous invasion were similar in both groups. Five-year follow-up was complete in 98.5%. No difference in the crude or age-corrected 5-year survival was found for patients with Dukes A, B, C overall, or C1 tumors, whether having had a low or high ligation. In hopes of identifying a population that benefited from high ligation, C1 patients were further subgrouped according to tumor location and number of involved lymph nodes. However, in no such subgroup was any significant high ligation advantage seen. In conclusion, high ligation of the inferior mesenteric artery has not been found to improve 5-year survival in patients with cancer of the rectum or rectosigmoid.     

肠系膜下动脉高位结扎后顽固性便秘21例临床分析

目的分析进展期乙状结肠癌或直肠上段癌行根治性切除术后顽固性便秘的致病因素,并总结其治疗经验。方法对江汉大学附属医院胃肠外科2004年1月至2014年12月收治的共21例顽固性便秘病人临床资料进行回顾性分析。结果所有病例既往均为进展期乙状结肠癌或直肠上段癌于外院行根治性手术,原手术均明确记录为肠系膜下动脉高位结扎。术后2~4年(平均3.4年)逐渐出现顽固性便秘,以腹痛、腹胀、大便次数减少及排便困难为主要临床表现。所有病例术前行X线钡剂灌肠造影均显示一共同特征,即结肠脾曲未游离,降结肠未切除,降结肠结肠袋消失,犹如小肠;结肠传输试验均提示为慢传输型,排粪造影均未见出口梗阻。12例再次接受手术,余9例因个人因素放弃手术,仍选择保守治疗(灌肠或口服泻药通便)。所有病人均随访至今,随访时间24~168个月,平均87.8个月,手术组术后效果显著,1年内均恢复正常排便(1~2次/d);而保守治疗组便秘症状无改善。结论乙状结肠癌或直肠上段癌根治术中行肠系膜下动脉高位结扎,而未游离结肠脾曲行包括降结肠、乙状结肠和直肠腹膜返折以上部分肠切除。其后果是部分病人降结肠慢性缺血,结肠形态及生理功能退化,导致顽固性便秘发生(慢传输型便秘)。其有效治疗为再手术行降结肠切除,横结肠-直肠吻合。