A critical view of safety in left colectomy surgery: A case of renal artery injury

IntroductionThe standardization of the laparoscopic approach in left hemicolectomy was facilitated by the vascular anatomy of the left colon, which has few anatomical variants. The current technique for left hemicolectomy consists in approaching the inferior mesenteric artery (IMA), after identification of the inferior mesenteric vein (IMV), from above (craniocaudal) or from below (caudocranial). The type of approach is decided on the basis of the vascular window between the IMV and IMA. However, vascular abnormalities of adjacent organs can call into question the steps of the standardized technique.Case presentationWe describe a case of iatrogenic left renal artery injury caused during left laparoscopic hemicolectomy due to an abnormality of the renal vessels. The artery originated from the aorta more caudally than usual with respect to the normal population.DiscussionWhat happened made us question the security of the standardized approach in practice, especially in patients with vascular anomalies. The use of advanced imaging programs, such as 3D reconstruction, can help to prevent iatrogenic damages, but not all hospitals have such technology, especially in rural areas.ConclusionWe propose, to further decrease the risk of iatrogenic injuries, a “critical view of safety” for left colic surgery, in which, before any potential arterial resection, a careful craniocaudal and caudocranial dissection of the Toldt-Gerota plane could be useful in identifying the IMA at the center of this plane. Moreover, a preoperative imaging study is of paramount importance in all surgical procedures.     

MSCTA肠系膜下动脉成像的临床应用

目的探讨多层螺旋CT血管造影（MSCTA）在肠系膜下动脉（IMA）成像中的临床应用价值。方法选择因直肠或左半结肠癌和血管性病变行MSCTA检查的患者75例，采用容积再现（VR）血管生长技术（AV）进行血管重建，观察肿瘤供血动脉及IMA狭窄或闭塞后的侧支循环情况。结果35例直肠癌患者中，显示肿瘤供血动脉：直肠上动脉35、直肠下动脉29例、骶正中动脉6例、乙状结肠动脉4例；7例乙状结肠癌由乙状结肠动脉供血；3例直肠乙状结肠交界区癌中，1例乙状结肠动脉供血，2例乙状结肠动脉和直肠上动脉供血；2例降结肠癌由左结肠动脉供血；5例脾曲癌由左结肠动脉升支和中结肠动脉左支供血。23例IMA狭窄或闭塞患者均有Riolan动脉弓侧支循环形成。结论MSCTA能清楚显示IMA参与肿瘤供血及准确评价其狭窄或闭塞后侧支循环形成情况。     

A case of sigmoidectomy for sigmoid colon cancer with severe pulmonary arterial hypertension associated with mixed tissue connected disease: A case report

IntroductionPatients with mixed connective tissue disease (MCTD) have higher rates of pulmonary arterial hypertension (PAH) than the general population. PAH is a risk for perioperative respiratory and heart failure, and marked edema of colonic stoma after sigmoidectomy. We report a case of sigmoidectomy for sigmoid colon cancer in a patient with PAH associated with MCTD for whom perioperative treatment was planned to control pulmonary arterial pressure (PAP), and a surgical strategy to avoid complications attributable to PAH and MCTD was employed.Case presentationA 52-year-old woman with sigmoid cancer and severe PAH associated with MCTD underwent surgery. We controlled PAH by using intravenous epoprostenol. We selected open surgery without laparoscopy and Hartmann's operation. After surgery, severe perioperative complications were not detected, and the patient discharged from hospital 17 days after the operation.DiscussionDuring surgery under general anesthesia, the mortality rate of PAH is high because of heart and respiratory failure. We planned to switch the PAH treatment from an oral agent to intravenous epoprostenol only in the preoperative period, and selected open surgery. We ligated the inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) below the branch of LCA to avoid marked edema of stoma. Consequently, we could avoid severe intraoperative and postoperative complications.ConclusionsControlling PAP using epoprostenol, open surgery, stoma and the ligation level for the IMA and IMV preventing are important to avoid perioperative complications of sigmoid colon cancer complicated by severe PAH.     

多层螺旋CT血管成像评价左结肠动脉、肠系膜下静脉解剖位置分型在腹腔镜结直肠癌根治术中的应用

目的:通过多层CT血管成像技术(MSCTA)回顾性分析左结肠动脉(LCA)与肠系膜下静脉(IMV)的解剖位置分型、IMV回流变异情况及IMV于根部以上水平的分支情况.方法:回顾性收集2018年9月至2021年11月92例患者(其中左半结肠癌8例、乙状结肠癌25例、直肠癌59例)的腹部CT增强扫描结果,并进行血管重建与术...     

多层螺旋CT血管成像在肾静脉血栓诊断和治疗中的应用

目的探讨多层螺旋CT血管成像（multi-slice spiral CT angiography,MSCTA）在肾静脉血栓（renal vein thrombosis,RVT）诊断和治疗中的临床应用价值。方法收集首诊RVT患者8例,慢性期RVT并左肾静脉重度狭窄或闭塞患者5例,均行CT平扫、动脉期及静脉期增强扫描,采用容积再现（volume rendering,VR）血管生长技术（addvessel,AV）进行血管重建,分析RVT、肾静脉侧支循环表现。结果13例RVT患者中,首诊8例（双侧3例,左侧5例）,CT平扫呈均匀稍高密度影,增强扫描示肾静脉主干及分支内见充盈缺损影,4例血栓延伸至下腔静脉内,1例合并左腰静脉干、左睾丸静脉内血栓,1例左睾丸静脉侧支循环形成。慢性期5例,CT平扫左。肾静脉结构显示不清,左肾静脉主干4例不显影,1例细如线样,均显示左卵巢静脉曲张,右卵巢静脉、双侧髂内静脉侧支循环形成。结论MSCTA能准确诊断RVT及肾静脉侧支循环,指导临床制定治疗方案。     

Case report: Primary aortosigmoid fistula − A rare cause of lower gastrointestinal bleeding

IntroductionA primary aortoenteric fistula (PAEF) is a communication between aorta and the gastrointestinal tract. It is a rare condition that is difficult to diagnose and therefore associated with a high mortality.Presentation of caseWe report a rare case of a 66-year old man with an unstable bleeding PAEF. A salvage procedure was performed with a covered stent. Later, a sigmoidectomy was performed with resection of the fistula. Postoperatively, the patient suffered an infection that was treated well with antibiotics and he was discharged two weeks later with complete resolution of the fistula.DiscussionAortoenteric fistulas are more common secondary to previous vascular surgery of aorta, however, PAEF’s involve the sigmoid in 2%. Seldom, fistulization can be due to diverticulitis that can be difficult to diagnose.ConclusionRetroperitoneal bleeding from the left iliac artery is more common due to a ruptured aneurysm. This case, however, demonstrates a special PAEF formation as a very rare complication of diverticulitis. The pathophysiology of the PAEF is very unique along with the anatomic localization in the sigmoid colon and left external iliac artery.     

Retroperitoneoscopic donor nephrectomy for retroaortic renal vein draining into left common iliac vein

Laparoscopic donor nephrectomy (LDN) for both retroaortic and circumaortic veins is described. LDN for left retroaortic vein draining into the common iliac vein (CIV) is not described previously. We report 2 cases of laparoscopic harvesting of left kidney having retroaortic renal vein draining into the left CIV and successful transplantation.     

Occlusion of left common iliac vein by a distended urinary bladder in a male with paraplegia due to spinal cord injury

STUDY DESIGN: A report of a male subject who sustained paraplegia at T-5 level due to spinal cord injury (SCI) 18 years ago, and in whom, occlusion of the left common iliac vein by a distended bladder was detected during a routine follow-up. OBJECTIVES: To illustrate a rare complication of chronic distension of the urinary bladder viz occlusion of the left common iliac vein, which persisted even after providing adequate bladder drainage by intermittent catheterisation. SETTING: Regional Spinal Injuries Centre, Southport, UK. METHODS: As part of a routine follow-up, we performed intravenous urography by injecting 50 ml of Ultravist 300 in a vein over the dorsum of the left foot. Opacification of collateral veins in the pelvis was seen in the 5- and 10-min films, which suggested iliac venous occlusion. In order to confirm the diagnosis, contrast was injected intravenously in the left foot and venography was performed. RESULTS: Venography revealed a distended left common iliac vein with contrast flowing into the right internal iliac vein through collateral veins in the pelvis; the right common iliac vein and inferior vena cava were patent. Duplex Doppler sonography showed compression of left common iliac vein by the posterior wall of a distended bladder with absence of blood flow through the compressed segment. Computerised tomography (CT) confirmed the diagnosis of extrinsic compression of the left common iliac vein against the promontory of sacrum by a distended bladder. CT excluded other causes for iliac vein occlusion. CONCLUSION: In a male subject with SCI, chronic bladder distension produced occlusion of the left common iliac vein. Health professionals caring for individuals with SCI should be aware that long-standing bladder distension could cause pressure effects upon adjacent structures in the pelvis.     

Successful third renal transplantation in a child with an occluded inferior vena cava: A novel technique to use the venous interposition between the transplant renal vein and the infrahepatic inferior vena cava

A girl aged 11 years and 3 months with occlusion of the inferior vena cava had experienced two renal transplant graft failures since birth. The third renal transplant from a live donor was carried out. Preoperative evaluation showed that the arteries from the right common to the right external iliac artery were absent, and the ilio‐caval vein was occluded below the level of the renal vein. The donor's renal artery was anastomosed to the aorta. The donor's ovarian and large saphenous veins were used to extend the transplant renal vein to the recipient's patent inferior vena cava. The present report concludes that the extension of a short donor renal vein using other donor veins is a viable therapeutic option for pediatric patients with vascular occlusions.     

Laparoscopic resection of sigmoid colon cancer with intestinal malrotation: A case report

IntroductionIntestinal malrotation is a congenital abnormality which occurs due to a failure of the normal 270° rotation of the midgut. The non-rotation type is usually asymptomatic and discovered incidentally on imaging studies. Intestinal malrotation accompanied by colon cancer is extremely rare.Presentation of caseA 53-year-old male presented with postprandial abdominal discomfort. Colonoscopy showed a 14 mm polyp in the sigmoid colon and endoscopic polypectomy was performed. Pathological evaluation revealed an adenocarcinoma invading the submucosa more than 1000 μm with positive vertical and horizontal margins. A contrast enhanced computed tomography scan showed an anatomic variant of the ileocolic and inferior mesenteric arteries originating from a common channel branching from the abdominal aorta. Laparoscopic sigmoid colon resection was performed. The patient did well post operatively.DiscussionThe usual trocar placement for laparoscopic left side colectomy was used, and we found no difficulties intraoperatively. To secure safe ligation, the divisions of the common channel branching from the abdominal aorta were exposed as in a usual D3 dissection, and the inferior mesenteric artery was ligated after confirmation of the bifurcation of the ileocolic and inferior mesenteric artery.ConclusionTo the best of our knowledge, this is the first report of laparoscopic resection of a sigmoid colon cancer with intestinal malrotation. It was performed without difficulty using the usual trocar placement, with appropriate attention to the variant in vascular anatomy.     

左腰静脉、左腰升静脉和骶正中静脉的解剖形态及其临床意义

目的：观察左腰静脉、左腰升静脉及骶正中静脉的解剖学变异情况，为前侧腹膜外入路人工腰椎间盘置换术提供该区域的解剖学依据，以减少术中血管副损伤。方法：解剖40例成人尸体标本L3椎体以下左侧以及骶前的下腔静脉属支，重点观察左侧腰静脉、左腰升静脉及骶正中静脉的解剖学特点。结果：左侧L3、L4、L5静脉存在于85％、97．5％和67．5％的标本中，位置与外径相对恒定，内侧汇入下腔静脉或左髂总静脉，外侧与左腰升静脉相交通：左腰升静脉存在于47．5％的标本中，位置较恒定，但起点、外径以及形态均有较大的变异；所有标本中均可找到骶正中静脉，其外径变异不大，但是数目及止点均有明显变异，并且可不伴行骶正中动脉。结论：下腔静脉于下腰椎水平左侧及骶前的属支变异多样，从左侧腹膜外手术入路暴露下腰椎间盘时，需要术前了解左腰静脉、左腰升静脉及骶正中静脉的情况并在术中做相应处理。     

Venovertebral vein: morphometric analysis and significance for the transabdominal spine surgeon

STUDY DESIGN: Prospective intraoperative findings review. OBJECTIVES: To describe the surgical anatomy of the innominate vessel, venovertebral vein, and consider its significance for transabdominal surgery. BACKGROUND DATA: It has not described in any anatomy textbook or reported papers. MATERIALS AND METHODS: In 50 patients who underwent anterior lumbar interbody fusion or total disc replacement, we found venovertebral vein in 37 patients (74%). The connection between venovertebral vein and the left common iliac vein was studied to determine where the venovertebral vein drained, and its relationship to the iliolumbar vein and middle sacral vein. All parameters were measured with vernier caliper and divider. RESULTS: All of the veins studied drained into the posterior margin of the left common iliac vein from the L5 vertebral body and were located between the iliolumbar vein and the middle sacral vein. The diagonal-vertical direction to the vertebral endplate was 64.8% (n=24). The mean diameter of venovertebral veins was 2.24+/-0.74 mm (range 1.0 to 3.8 mm). The mean length was 12.71+/-5.71 mm (range 5.45 to 35.10 mm). The distance from the L5 vertebral upper endplate to its origin ranged from 6.05 to 21.25 mm, with a mean of 12.51+/-3.36 mm. The distance of the 37 venovertebral veins studied from the middle sacral vein ranged from 0 to 10.6 mm, with a mean of 5.75+/-2.90 mm. The distance from the iliolumbar vein ranged from 14 to 38 mm, with a mean of 22.65+/-5.44 mm. The venovertebral vein was found to be closer to the middle sacral vein than to the iliolumbar vein statistically (P<0.05). CONCLUSIONS: The surgeon performing transabdominal spine surgery especially at the L4-5 level must remain alert to the existence of this innominate vein.     

The iliac vein occlusion]

Basing on roentgenological and morphological investigations the causes of the iliac veins passability disorder were studied up. In 45.1% of observations the stenosis was revealed of the left and in 1.2% of the right common iliac vein. Among the stenosis causes were osteal or cartilagenous prominences of vertebral column, intravascular structures (webs, membranes) in the left common iliac vein, the external iliac vein squeeze by internal iliac artery, retroperitoneal fibrosis, the right common iliac artery aneurysm, anomalous branching of parietal pelvic artery.     

Injuries of large vessels in high stage neuroblastoma surgery. A case report

Complete resection of the primary lesion in stage III neuroblastoma improves survival Neuroblastoma has a tendency towards surrounding and infiltrating the large vessels, leading to injuries during tumor resection. We operated on a stage III neuroblastoma, which resulted in the right and left common iliac artery and vein damage. The right common iliac artery and, veins were repaired by end to end anastomosis. There was a long gap between the two ends of the left common iliac artery and it was repaired using a mesenteric vein (marginal vein of the colon) graft. Digital subtraction angiography performed 6 months after the operation did not reveal any stenosis or aneurysmatic changes in the anastomoses. We conclude that short segments of large vessels may be sacrificed during the resection of neuroblastomas invading the vessel wall, and the resulting defects may be repaired by end to end anastomosis, or even by substituting mesenteric vein grafts, for the purpose of total or near total removal     

Abdominal aortic and iliac aneurysm presented as lower limb deep vein thrombosis: case report

Abstract

Introduction: We report a rare case of a symptomatic abdominal aneurysm presented as a lower limb deep vein thrombosis (DVT).

Case presentation: A 63-year old male presented to our hospital with a recent progressive onset of the right lower limb swelling and pain. The patient had a history of a previous cardiovascular disease. A Duplex ultrasound was performed, which confirmed a right lower limb DVT extending to the right iliac vein. The patient had a pulsatile abdominal mass. Computed tomography scan of the abdomen showed an abdominal aortic and a right iliac artery aneurysm compressing the thrombosed inferior caval and the right iliac vein. The patient was treated with low molecular weight heparin. After resolution of the DVT on day 3 of hospitalization, a surgery on the abdominal and iliac artery aneurysm was performed. The aneurysm was resected and an aortobifemoral bypass was placed using a Dacron prosthesis. The patient remained to be asymptomatic for 6 months after the surgery. Follow up computed tomography demonstrated a fully patent inferior caval and iliac vein and the absence of the aneurysmal disease.

Conclusion: Although rare, our case confirms that the DVT should be considered as a possible symptom of an abdominal aneurysm in selected patients.     

Renal transplantation with iliac vein transposition

We evaluated a technique for implantation of right kidneys with short renal veins without the need for venous reconstruction. METHOD: The technique of iliac vein transposition was performed in six recipients who received right kidneys with short renal veins. Two cases were living related donors, two were living unrelated, one was an autotransplant, and one was a cadaver kidney recipient. The common and external iliac veins and arteries of the recipient were thoroughly mobilized, allowing for the lateral transposition of the external iliac vein with respect to the external iliac artery. The renal vessels were subsequently implanted in an end to side fashion onto the corresponding transposed external iliac vessels. After implantation, the iliac vein remained lateral with respect to the iliac artery. CONCLUSIONS: The technique described allows for the implantation of right kidneys without the need for venous reconstruction. Such an approach is especially useful in cases of grafts with short veins.     

256层螺旋CT对腹腔镜结直肠癌手术前肠系膜血管解剖结构评估的价值

目的探讨CT三维血管重建技术对结直肠癌患者术前进行肿瘤血管评估的临床价值．为腹腔镜结直肠癌手术提供参考。方法2010年2月至2010年12月间,对11例准备行腹腔镜结直肠癌根治术的患者术前进行256层螺旋CT扫描．通过三维血管重建技术观察其肠系膜血管解剖及变异情况．并将结果与腹腔镜术中所见进行对照。结果256层螺旋CT三维血管重建均清晰地显示出肠系膜血管解剖及变异情况．并与腹腔镜手术中所见吻合。3例右半结肠切除术患者中,1例回结肠动脉走行于肠系膜上静脉的腹侧．2例回结肠动脉走行于肠系膜上静脉的背侧：2例右结肠动脉和回结肠动脉分别直接起源于肠系膜上动脉．另1例未见右结肠动脉而由结肠中动脉右支参与供血。1例横结肠切除患者的结肠中动脉发自肠系膜上动脉。3例乙状结肠切除患者中,2例乙状结肠动脉与左结肠动脉共干起源于肠系膜下动脉．另1例乙状结肠动脉直接起源于肠系膜下动脉。4例直肠癌患者均由肠系膜下动脉延续的直肠上动脉供血。结论256层螺旋CT血管重建技术可以满足腹腔镜结直肠癌根治术前对肠系膜血管解剖及变异情况的观察．为手术提供重要参考。     

Abdominal aorta,inferior vena cava and their branches

The aorta enters the abdomen at T12 between the crura of the diaphragm and ends at L4 by dividing into the common iliac arteries, which in turn divide into the external and internal iliacs. The external gives no branches apart from just above its termination into the common femoral artery – the inferior epigastric and deep circumflex iliac. The internal iliac artery gives off numerous visceral and body wall branches to the pelvic organs, pelvic wall, perineum and buttock region. The aorta gives off visceral branches anteriorly (coeliac, superior and inferior epigastrics) and laterally (suprarenal, renal and gonadal – testicular and ovarian – as well as inferior phrenic, four lumbar and the middle sacral artery). The inferior vena cava commences by the junction of the common iliac veins in front of L5. It lies immediately to the right of the aorta but is considerably longer because it ascends to the right crus of the diaphragm to pierce the central tendon of the diaphragm at T8, having deeply grooved the posterior aspect of the liver at its bare area. The tributaries of the inferior vena cava differ from the branches of the aorta in two respects. First, those corresponding to the anterior visceral branches of the aorta form the portal vein, which passes into the liver at the porta hepatis. Venous blood then returns to the inferior vena cava via the right, middle, left and accessory hepatic veins. Second, the suprarenal and gonadal veins on the left side, unlike those on the right, which drain directly into the inferior vena cava, empty into the left renal vein, which then crosses the front of the aorta to enter the inferior vena cava.