Inferior Mesenteric Vein (IMV)
High ligation and division of the inferior mesenteric vein near the inferior border of the pancreas are essential for a low anastomosis with total mesorectal excision (TME) (Figure 3.1). As the entire sigmoid colon is commonly resected, high ligation of the inferior mesenteric vein (IMV) will provide the colon an additional 10 cm of reach into the pelvis. Many minimally invasive surgeons prefer to initiate their medial to lateral dissection in this area in an effort to arrive at the inferior mesenteric artery in the proper plane on Gerota’s fascia. By sweeping the small bowel to the patient’s right, which laparoscopically can be accomplished with the patient in steep Trendelenburg, airplaned right side down, the duodenojejunal junction is easily identified. By lifting the mesentery of the descending colon, a taut band can be generally identified running just lateral to the duodenojejunal junction, parallel to the aorta. This maneuver allows for easy identification of the inferior mesenteric vein. The plane of dissection is immediately anterior to Gerota’s fascia and is entered by putting the IMV on tension and dissecting under the vessel. The splanchnic and hypogastric nerve plexus can be swept posterior to vein, and if this plane is followed caudally, it will lead to the inferior mesenteric artery. The IMV is transected below the lower border of the pancreas. It is wise to leave a 1 cm stump inferior to the pancreas for transection of the IMV so that any resultant bleeding is easily controlled. The IMV is again transected distal as it comes into the region of the inferior mesenteric artery (IMA) at the takeoff of the left colic vessel.
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