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

Abstract

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.