High tie versus low tie vascular ligation of the inferior mesenteric artery in colorectal cancer surgery: impact on the gain in colon length and implications on the feasibility of anastomoses.

BACKGROUND

There is no demonstrated benefit of high-tie versus low-tie vascular transections in colorectal cancer surgery.

OBJECTIVE

The aim of this study was to compare the effects of high-tie and low-tie vascular transections on colonic length after oncological sigmoidectomy, the theoretical feasibility of colorectal anastomosis at the sacral promontory, and straight or J-pouch coloanal anastomosis after rectal cancer surgery with total mesorectal excision.

DESIGN

This study is an anatomical study on surgical techniques.

SETTINGS: This study was conducted in a surgical anatomy research unit.

PATIENTS: Thirty fresh nonembalmed cadavers were randomly assigned to high-tie and low-tie groups (n = 15).

INTERVENTIONS: Oncological sigmoidectomy followed by total mesorectal excision was performed.

MAIN OUTCOME MEASURES: The distances from the proximal colon limb to the lower edge of the pubis symphysis were recorded after each step of vascular division.

RESULTS

The successive mean gains in length in high-tie vs low-tie vascular transections were 2.9±1.2 cm vs 3.1 ± 1.8 cm (p = 0.83) after inferior mesenteric artery division, 8.1 ± 3.1 cm vs 2.5 ± 1.2 cm (p = 0.0016) after inferior mesenteric vein division at the lower part of the pancreas, 8.1 ± 3.8 cm vs 3.3 ± 1.7 cm (p = 0.0016) after sigmoidectomy. The mean cumulative gain in length was significantly higher in high-tie vs low-tie vascular transections (19.1 ± 3.8 vs 8.8 ± 2.9 cm, p = 0.00089). After secondary left colic artery division, the gain in length was similar to that of the high-tie group (17 ± 3.1 vs 19.1 ± 3.8 cm) (p = 0.089). Colorectal anastomosis at the promontory and straight and J-pouch coloanal anastomosis feasibility rates were 100% in the high-tie group, 87%, 53%, and 33% in the low-tie group, but 100%, 100%, and 87% after secondary left colic artery division.

LIMITATIONS: This anatomical study, based on cadavers rather than live patients, does not evaluate colon limb vascularization.

CONCLUSIONS

The gain in colonic length is 10 cm greater for high-tie vascular transections. With low-tie vascular transections, high inferior mesenteric vein division produced a small additional gain in length, and secondary left colic artery division produced the same length gain as high-tie vascular transections.