Psoas myovascular window: A secure gateway for safeguarding the ureter at left laparoscopic colorectal resections

Abstract

Despite its established competency, laparoscopic colorectal surgery is underutilized, even today. This is primarily attributed to the lack of structured training and the resultant steep learning curve. Moreover, these surgical interventions are frequently complicated by potentially life-threatening ureteric injuries ranging from an alarming 5-15%. To avert this, the essential pragmatic step is to access the “holy” avascular mesocolon/retroperitoneum interface accurately and protect the ureter as quickly and convincingly as possible. However, this tends to be easier said than done. Recent literature illustrates numerous methods focusing exclusively on perioperative localization of the ureter. However, such methods plausibly lack simplicity, accessibility and cost-effectiveness. Herein, we describe a particular way of dissecting around the inferior mesenteric artery that aims to identify and safeguard the left ureter very early in the course of mesocolic mobilization. We call this the “psoas myovascular window” technique. Having applied this technique on 82 consecutive occasions, we have consistently observed its precision, rapidity and ability to reduce the operative time (by avoiding random search of the ureter). It potentially allows surgeons to acquire the desired proficiency and self-confidence reasonably early on at their learning curves. To our knowledge, such a technique has yet to be reported in the literature.