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3D mesenteric angiogram-based assessment of Arc of Riolan crossing the inferior mesenteric vein: important considerations in high ligation during splenic flexure takedown in anterior resection

Authors
Toh, James Wei TattRamaswami, GeethaNguyen, Kim SonCollins, Geoffrey PeterSolis, EdgardoPathma-Nathan, NimalanEl-Khoury, TouficKim, Seon Hahn
Issue Date
Aug-2022
Publisher
Springer Verlag
Keywords
Arc of Riolan; Intermesenteric trunk; Meandering mesenteric artery; Colorectal surgery; Anatomy; Operative technique
Citation
Surgical and Radiologic Anatomy, v.44, no.8, pp.1165 - 1170
Indexed
SCIE
SCOPUS
Journal Title
Surgical and Radiologic Anatomy
Volume
44
Number
8
Start Page
1165
End Page
1170
URI
https://scholarworks.korea.ac.kr/kumedicine/handle/2021.sw.kumedicine/61300
DOI
10.1007/s00276-022-02992-x
ISSN
0930-1038
Abstract
Background Recent studies have described the finding of the Arc of Riolan (AoR) crossing the inferior mesenteric vein (IMV) seen during high ligation of IMV while performing minimally invasive colectomies. However, the AoR usually has a medial course, and this variant AoR anatomic course and the clinical importance of its preservation during splenic flexure takedown in anterior resection remains controversial. Methods After institutional approval (QA-5775), radiological identification of and mapping of the vessel horizontally crossing the IMV under the pancreas, when present, was performed at a single institution (Westmead Hospital, New South Wales, Australia). One hundred consecutive computed tomographic (CT) mesenteric angiograms conducted in 2018 were reviewed retrospectively to determine the presence of a vessel horizontally crossing the IMV. 3D reconstructions were used to map out its course to understand its origin and full course. Baseline characteristics, including demographic and comorbidity data, were obtained from the medical record. Results On 3D mesenteric angiogram reconstructions, a vessel crossing anterior to the IMV was present in 11 of 98 cases (11.2%). Two cases were excluded as the presence of this vessel was indeterminate. Eight of 11 patients (72.7%) were male, and the mean age was 49.3 years (range: 21–80 years). There was no statistically significant difference in age and comorbidities between the groups. Importantly, in all 11 cases, there was an arterial vessel crossing the IMV originating from the SMA and communicating with the IMA or a branch of the IMA, proving definitively that this vessel was by definition the AoR. Conclusion This 3D mesenteric angiogram mapping study has shown definitively that the vessel horizontally crossing anterior to the IMV and inferior to the pancreas is an arterial vessel from the SMA to IMA, and by definition the Arc of Riolan. When present, identification and preservation of this collateral arterial vessel during splenic flexure takedown in anterior resection may be important in reducing the risk of post-operative bowel ischaemia.
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