High and Low Ligation of the Inferior Mesenteric Artery
KEY STEPS
Insertion of ports and position of patient as detailed in the respective chapter for each procedure.
Laparoscopic assessment and movement of the small bowel and omentum toward right and upper quadrants.
Inferior mesenteric pedicle defined and mobilized, carefully protecting fascia around vessel, defining ureter, and protecting autonomic nerves.
With high ligation, the inferior mesenteric artery divided above the left colic artery, while with low ligation, the inferior mesenteric artery divided below the left colic artery.
ADDITIONAL ADVICE
When performing medial mobilization of the inferior mesenteric artery, move the mesentery above and one can often see a transition between retroperitoneal fat and the mesentery.
Make your incision along the groove between the mesentery and retroperitoneum. In obese patients when it is difficult to see a groove, it may be easier to make an incision distal to the sacral promontory, letting CO2 into the presacral space.
If there is difficulty finding the plane medially, change to a lateral to medial dissection.
For a benign disease, a low ligation of the inferior mesenteric artery (IMA)/inferior mesenteric vein may be performed.
DEFINING AND DIVIDING THE INFERIOR MESENTERIC PEDICLE
An atraumatic bowel clamp is placed on the rectosigmoid mesentery at the level of the sacral promontory, approximately half way between the bowel wall and the promontory itself. This area is then stretched up toward the left lower quadrant
port, stretching the inferior mesenteric vessels away from the retroperitoneum. In most cases, this demonstrates a groove between the right, or medial side of the inferior mesenteric pedicle and the retroperitoneum. In some cases, a color change can be noted. In others, usually thinner patients, when the mesentery is grasped and moved, it can be seen that deep to the peritoneum the mesenteric fat is moving, and the retroperitoneal fat is steady, demonstrating where the incision needs to be made (Fig. 4.1).
port, stretching the inferior mesenteric vessels away from the retroperitoneum. In most cases, this demonstrates a groove between the right, or medial side of the inferior mesenteric pedicle and the retroperitoneum. In some cases, a color change can be noted. In others, usually thinner patients, when the mesentery is grasped and moved, it can be seen that deep to the peritoneum the mesenteric fat is moving, and the retroperitoneal fat is steady, demonstrating where the incision needs to be made (Fig. 4.1).
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