A critical view of safety in left colectomy surgery: A case of renal artery injury.

Abstract

IntroductionThe standardization of the laparoscopic approach in left hemicolectomy was facilitated by the vascular anatomy of the left colon, which has few anatomical variants. The current technique for left hemicolectomy consists in approaching the inferior mesenteric artery (IMA), after identification of the inferior mesenteric vein (IMV), from above (craniocaudal) or from below (caudocranial). The type of approach is decided on the basis of the vascular window between the IMV and IMA. However, vascular abnormalities of adjacent organs can call into question the steps of the standardized technique.Case presentationWe describe a case of iatrogenic left renal artery injury caused during left laparoscopic hemicolectomy due to an abnormality of the renal vessels. The artery originated from the aorta more caudally than usual with respect to the normal population.DiscussionWhat happened made us question the security of the standardized approach in practice, especially in patients with vascular anomalies. The use of advanced imaging programs, such as 3D reconstruction, can help to prevent iatrogenic damages, but not all hospitals have such technology, especially in rural areas.ConclusionWe propose, to further decrease the risk of iatrogenic injuries, a “critical view of safety” for left colic surgery, in which, before any potential arterial resection, a careful craniocaudal and caudocranial dissection of the Toldt-Gerota plane could be useful in identifying the IMA at the center of this plane. Moreover, a preoperative imaging study is of paramount importance in all surgical procedures.