title: Level of arterial ligation in total mesorectal excision (TME): an anatomical study.
abstract: BACKGROUND
  High-tie ligation is a common practice in rectal cancer surgery. However, it compromises perfusion of the proximal limb of the anastomosis. This anatomical study was designed to assess the value of low-tie ligation in order to obtain a tension-free anastomosis.
  
  
  METHODS
  Consecutive high- and low-tie resections were performed on 15 formalin-fixed specimens, with or without splenic flexure mobilization. If the proximal colon limb could reach the superior aspect of the symphysis pubis with more than 3 cm, the limb would be long enough for a tension-free colorectal anastomosis.
  
  
  RESULTS
  In 80% of cases, it was not necessary to perform high-tie ligation as sufficient length was gained with low-tie ligation. The descending branch of the left colic artery was the limiting factor in the other 20% of cases. Resecting half the sigmoid resulted in four times as many tension-free anastomoses after low-tie resection.
  
  
  CONCLUSIONS
  In the majority of cases, it was not necessary to perform high-tie ligation in order to create a tension-free anastomosis. Low-tie ligation was applicable in 80% of cases and might prevent anastomotic leakage due to insufficient blood supply of the proximal colon limb.
authors.affiliation: Department of Surgery, Erasmus Medical Center, Room Z-835, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands. m.buunen@erasmusmc.nl
authors.forename: Mark
authors.initials: M
authors.lastname: Buunen
authors.forename: Marilyne M
authors.initials: MM
authors.lastname: Lange
authors.forename: Max
authors.initials: M
authors.lastname: Ditzel
authors.forename: Geert-Jan
authors.initials: GJ
authors.lastname: Kleinrensink
authors.forename: Cees J H
authors.initials: CJ
authors.lastname: van de Velde
authors.forename: Johan F
authors.initials: JF
authors.lastname: Lange
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D001158:Arteries / Q000601:surgery*; D005260:Female; D006801:Humans; D008026:Ligation; D008297:Male; D008875:Middle Aged; D011630:Pubic Bone / Q000473:pathology; D012007:Rectum / Q000098:blood supply / Q000473:pathology* / Q000601:surgery*