Overview

High ligation and division of the inferior mesenteric vein (IMV) near the inferior border of the pancreas are essential for a low anastomosis with total mesorectal excision (TME),[1] as shown in the video below. High ligation of the IMV will provide the colon an additional 10 cm of reach into the pelvis, which is helpful to make a tension-free anastomosis for a lower rectal cancer resection.[2] Many surgeons who perform minimally invasive surgeries prefer to initiate their medial-to-lateral dissection in this area in an effort to arrive at the inferior mesenteric artery (IMA) in the proper plane on Gerota’s fascia. By sweeping the small bowel to the patient’s right, which can be accomplished laparoscopically with the patient in steep Trendelenburg with right-sided tilt positioning, the duodenojejunal junction is easily identified.[3] 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 IMV. 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 the vein; when this plane is followed caudally, it will lead to the IMA. The IMV is transected near the inferior border of the pancreas. It is wise to leave a 1-cm vascular stump inferior to the pancreas so that any bleeding from the IMV stump is more easily controlled. The IMV is again transected distally as it comes into the region of the IMA at the takeoff of the left colic vessel, which helps to straighten the descending colon, thus providing more length for construction of an anastomosis in the pelvis.