Left colic artery: to take or not to take it? That is the question

Preservation of the left colic artery has clinical, functional and oncologic implications and is an ongoing debate. The inferior mesenteric artery (IMA) branches according to Latarjet's classification: Type I, where the left colic artery has a separate origin, which is found in approximately 70% of the cases; and Type II, with a fan-shaped branching pattern. Performing a low ligation of the inferior mesenteric artery (IMA) with  preservation of the left colic artery is more complex technically but provides excellent vascular supply due to preservation of IMA blood flow, while potentially limiting mesenteric length and the number of lymph nodes harvested. On the other hand, standard high ligation without preservation of the left colic artery is technically easier to perform, allows dissection of the lymph nodes at the origin of the IMA and provides excellent mesenteric length but relies solely on marginal vessel blood supply from the middle colic artery. Additionally, the high dissection of the inferior mesenteric vein (IMV) may increase the risk of damage to the left colic artery due to the small distance to the IMV (less than 20 mm).

Several studies in the literature have compared results with and without preserving the left colic artery. Some publications showed that low ligation of IMA with preservation of left colic artery in laparoscopic low anterior resection for rectal cancer achieved same radical clearance of lymph nodes as high ligation without prolonged operation time, increase on morbidity and similar functional results. On the other hand, high ligation of the IMA does not represent a source of increased anastomotic leak in rectal cancer surgery as it is considered to provide a poorer blood supply on the proximal end of the anastomosis. Finally, when discussing about oncologic results, there is no conclusive data regarding improved survival among patients who underwent high ligation based on extensive lymphadenectomy.

So when should we preserve the left colic artery and when not? The general consensus seems to be to preserve the left colic artery when the splenic flexure is not mobilized, the inferior mesenteric vein is maintained and the length of the anastomosis is adequate for a tension-free anastomosis. The mesosigmoid section will be performed accordingly, preserving the artery. By contrast, taking the left colic artery is recommended when the splenic flexure is mobilized and the IMV is sectioned.

Do you agree with these recommendations? Leave us your comments and start a debate that will enrich our surgical community!!!