The importance of the Moskowitz artery as a lesser-known collateral pathway in the medial laparoscopic approach to splenic flexure mobilisation and its evaluation with preoperative computed tomography

Abstract

Introduction: The collateral pathways between the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) play an important role in colonic surgery. The most well-known are the Drummond marginal artery and Riolan's arch. The Moskowitz artery, also known as the meandering mesenteric artery, is a lesser-known collateral pathway and represents another link between SMA and IMA. The Moskowitz artery runs along the colonic mesentery floor and represents the link between the proximal segment of the middle colic artery and the ascending branch of the left colic artery.

Aim: To comprehend the presence and importance of the Moskowitz artery (meandering mesenteric artery) in preoperative patients by using computed tomography (CT) studies.

Material and methods: We retrospectively reviewed all abdominal CT images performed using intravenous contrast for any reason at the Radiology Department of Yeditepe University Hospital between April 2015 and September 2018. Patients older than 18 years with intravenous contrast (arterial and venous phases with a cross-section thickness of 0.625 mm), who underwent abdominal CT scan, and patients without any abdominal surgery were included in the study. As a result of the screening, 109 CT scans with eligibility criteria were included in this study.

Results: There were 109 cases in this study; 50 (45.9%) of them were male and 59 (54.1%) were female. Moskowitz artery was found in 18 (16.5%) cases; 8 were males and 10 were females. Riolan's arch was present in 30 cases, of whom 15 were male and 15 were female. In our study Moskowitz artery and Riolan's arch were monitored as separate vascular structures, and in all cases with Moskowitz artery, Riolan's arch was also present. There was a statistically significant difference (p < 0.05) between the combined MCA emerging type and the presence of MA, and 12 cases with combined branch and 6 cases with single branch had Moskowitz artery. There was a statistically significant difference (p < 0.05) between LCA types and the presence of MA, and the Moskowitz artery was the most common seen at type 1 LCA.

Conclusions: Knowledge of the relationship between Riolan's arch and the Moskowitz artery is valuable, and preoperative evaluation of this artery may be beneficial in the presence of Riolan's arch. In addition, preoperative radiological evaluation and its importance are prominent in minimising intraoperative bleeding during splenic flexure mobilisation with a medial laparoscopic approach and reducing the risk of colorectal anastomosis leakage.

Keywords: Moskowitz artery; collateral pathway; inferior mesenteric artery; meandering mesenteric artery; superior mesenteric artery.

Figure 1

Upper image represents the collateral structures at the splenic flexure level; the yellow marked structure at the lateral side is the Drummond marginal artery (DA), the brown marked structure in the middle is Riolan’s arch (RA), and the blue marked structure at the medial side is the Moskowitz artery (MA) MCA – middle colic artery, RA – Riolan’s arch, DA – Drummond artery, MA – Moskowitz artery, SMA – superior mesenteric artery, IMA – inferior mesenteric artery, LCA – left colic artery.

Figure 2

Three main types branching of the left colic artery from IMA are observed: A – the left colic artery originates from IMA as an independent single branch (type 1), B – left colic artery and sigmoid artery emerge as a common branch (type 2), C – left colic artery, sigmoid artery (SA) and superior rectal artery (SRA) simultaneously originate from the IMA AA – abdominal aorta, LCA – left colic artery, IMA – inferior mesenteric artery, SA – sigmoid artery, SRA – superior rectal artery.

Figure 3

The image depicts the origin of the middle colic artery (MCA) from the superior mesenteric artery in three main ways. It is noteworthy that the MCA takes origin as a single branch in (A) and (C) and as a combined branch in (B) SMA – superior mesenteric artery, MCA – middle colic artery, RCA – right coronary artery, ICA – inferior colic artery.

Photo 1

In abdominal CT examination obtained in arterial phase the Moskowitz artery is indicated by yellow arrows in coronal (A) and axial (B) images