Jejunal Vein Research Articles

Anatomical variants of the jejunal veins and their technical implications in pancreaticoduodenectomy: a systematic review and meta-analysis.

One of the most common causes of bleeding during pancreaticoduodenectomy (PD) is dissection of the pancreatic head from the superior mesenteric vein (SMV) and superior mesenteric artery (SMA). Knowledge of the anatomical variants of the veins draining the proximal jejunum may allow a better control of bleeding during detachment of the uncinate process and pancreatic head from the mesenteric pedicle and division of the mesopancreas. The aim of this systematic review and meta-analysis is to evaluate the anatomical variations of the first jejunal vein (FJV) and jejunal trunk (FJT). Fourteen studies (1,888 patients) were included. We performed a systematic review of the available Literature according to the PRISMA guidelines. The analysis has shown that the posterior course of the FJT and FJV represents the most frequent topographical location (PPE 79.6%) with the anterior jejunal trunk (JT) having a lower rate (PPE 20.4%). Few articles reported the variations with separate trunks for the first and second jejunal vein. A thorough preoperative radiological assessment of the anatomical variation of FJT and FJV may confer some advantage to establish the best therapeutic strategy and the best surgical approach in case of pancreatic head carcinoma, as it can allow a better estimate of the extent of the neoplasm and improve the accuracy of surgical dissection with potential for reduced bleeding.

Robotic right‐sided colon cancer surgery: Dissecting the outermost layer of the autonomic nerve along the superior mesenteric artery

AbstractIn right‐sided colon cancer surgery, lymph node dissection around the superior mesenteric artery is necessary but technically challenging. Here we introduce the concept of “outermost layer‐oriented robotic surgery” to improve the safety, efficacy, and reproducibility of superior mesenteric artery nodal dissection. In this procedure, the thin, loose connective tissue layer between the autonomic nerve sheath of the superior mesenteric artery and adipose tissue bearing lymph nodes, termed “the outermost layer of the autonomic nerve,” is dissected. The procedure exposes the outermost layer of the nerve plexus covering the surface of the superior mesenteric artery with a width of approximately 1 cm, enabling direct visualization of the anatomy of the main arteries and, if they exist, jejunal veins which cross the superior mesenteric artery ventrally. This allows for sufficient dissection of main lymph nodes at the roots of the ileocolic artery, right colic artery, and middle colic artery and minimizes the risk of unforeseen bleeding. Thirty‐nine patients underwent robotic right hemicolectomy with this procedure. No intraoperative complications were observed. The median number of dissected lymph nodes was 50, including 16 main lymph nodes. The median operative time was 284 min, blood loss was 50 mL, and the median postoperative hospital stay was 8 days. Postoperative complications included two cases of Clavien–Dindo classification grade II, with no cases of grade III or higher. Chylous leakage as well as intractable diarrhea were not observed in any case. These findings demonstrate that the procedure can achieve safe and reliable lymph node clearance.

Jejunal vein tributary analysis and intraoperative clamp testing in avoiding congestion after pancreatoduodenectomy.

Although venous drainage of the jejunal loop may be maintained after sacrifice of jejunal vein tributaries during pancreatoduodenectomy, risk of severe jejunal mesenteric congestion following division of these tributaries can be difficult to predict. This study considered how best to predict safety of jejunal vein tributary dissection. Preoperative imaging findings and results of intraoperative clamp tests of jejunal vein tributaries during pancreatoduodenectomy were analyzed in 121 patients with hepatobiliary and pancreatic disease to determine whether this information adequately predicted safety of resecting superior mesenteric vein branches. Jejunal vein tributaries caudal to the inferior border of the pancreatic uncinate process tended to be fewer when tributaries cranial to this landmark were more numerous. Tributaries cranial to the border drained a relatively wide expanse of jejunal artery territory in the jejunal mesentery. The territory of jejunal tributaries cranial to the inferior border of the pancreas did not vary according to course of the first jejunal vein branch relative to the superior mesenteric artery. One patient among 30 (3%) who underwent intraoperative clamp tests of tributaries cranial to the border showed severe congestion in relation to a venous tributary coursing ventrally to the superior mesenteric artery. Jejunal venous tributaries drained an extensive portion of jejunal arterial territory, but tributaries located cranially to the inferior border of the pancreas could be sacrificed without congestion in nearly all patients. Intraoperative clamp testing of these tributaries can identify patients whose jejunal veins must be preserved to avoid congestion.

The Atlas of the Inferior Mesenteric Artery and Vein under Maximum-Intensity Projection and Three-Dimensional Reconstruction View

(1) Background: Understanding vascular patterns is crucial for minimizing bleeding and operating time in colorectal surgeries. This study aimed to develop an anatomical atlas of the inferior mesenteric artery (IMA) and vein (IMV). (2) Methods: A total of 521 patients with left-sided colorectal cancer were included. IMA and IMV patterns were identified using maximum-intensity projection (MIP) and three-dimensional (3D) reconstruction techniques. The accuracy of these techniques was assessed by comparing them with surgical videos. We compared the amount of bleeding and operating time for IMA ligation across different IMA types. (3) Results: Most patients (45.7%) were classified as type I IMA, followed by type II (20.7%), type III (22.6%), and type IV (3.5%). Newly identified type V and type VI patterns were found in 6.5% and 1% of patients, respectively. Of the IMVs, 49.9% drained into the superior mesenteric vein (SMV), 38.4% drained into the splenic vein (SPV), 9.4% drained into the SMV–SPV junction, and only 2.3% drained into the first jejunal vein (J1V). Above the root of the left colic artery (LCA), 13.1% of IMVs had no branches, 50.1% had one, 30.1% had two, and 6.7% had three or more branches. Two patients had two main IMV branches, and ten had IMVs at the edge of the mesocolon with small branches. At the IMA root, 37.2% of LCAs overlapped with the IMV, with 34.0% being lateral, 16.9% distal, 8.7% medial, and both the marginal type of IMV and the persistent descending mesocolon (PDM) type represented 1.4%. MIP had an accuracy of 98.43%, and 3D reconstruction had an accuracy of 100%. Blood loss and operating time were significantly higher in the complex group compared to the simple group for IMA ligation (p < 0.001). (4) Conclusions: A comprehensive anatomical atlas of the IMA and IMV was provided. Complex IMA patterns were associated with increased bleeding and operating time.

Investigation of the variation of vessels around the pancreatic head based on the first jejunal vein anatomy at pancreaticoduodenectomy.

Pancreaticoduodenectomy (PD) for pancreatic cancer carries a high risk of massive intraoperative blood loss. The artery first approach (AFA) prevents blood loss during PD, but the optimal approach is unclear. The first jejunal vein (FJV) often comprises multiple veins and broadly supports venous drainage of the proximal jejunum. Its ligation carries a risk of proximal jejunum congestion. Here we investigated the anatomical characteristics of PD-associated vessels and AFA approach selection based on FJV anatomy. This study included 148 Japanese living donors for liver transplantation. We reviewed their computed tomography images and assessed the anatomical pattern of PD-associated vessels in terms of FJV anatomy. The FJV traveled posterior to the superior mesenteric artery in 128 patients (86.5%, dorsal group) and anterior in 20 (13.5%, ventral group). The predominant draining vein of the inferior pancreaticoduodenal vein was the superior mesenteric vein in the ventral group (87.5%) and the FJV in the dorsal group (97.9%). Compared with the dorsal group, the ventral group had a significantly greater percentage with the superior mesenteric vein ventral to the superior mesenteric artery (30.0% versus 10.9%) and a significantly larger posterior superior pancreaticoduodenal vein diameter (3.2 ± 0.9 versus 2.7 ± 0.6mm, p = 0.0029). These results were validated in patients with pancreatic head cancer. The anatomical characteristics of PD-associated vessels differed significantly between groups defined by FJV anatomy. Understanding the venous anatomy, especially the FJV, could support selection of the best approach in AFA for PD.

Modified Intestinal Derotation Procedure with Reversed Kocherization to Facilitate Mesopancreas Excision During Pancreaticoduodenectomy.

Although intestinal derotation procedure has advantages of facilitating mesopancreas excision during pancreaticoduodenectomy, the wide mobilization takes time and risks injuring other organs. This article describes a modified intestinal derotation procedure in pancreaticoduodenectomy and its clinical impact on short-term outcomes. The modified procedure comprised the pinpoint mobilization of the proximal jejunum following reversed Kocherization. Among 99 consecutive patients who underwent pancreaticoduodenectomy between 2016 and 2022, the short-term outcomes of pancreaticoduodenectomy with the modified procedure were compared with those of conventional pancreaticoduodenectomy. The feasibility of the modified procedure was investigated based on the vascular anatomy of the mesopancreas. Compared with conventional pancreaticoduodenectomy (n = 55), the modified procedure (n = 44) involved less blood loss and shorter operation time (p < 0.001 and 0.017, respectively). Severe morbidity, clinically relevant postoperative pancreatic fistula, and prolonged hospitalization occurred less often with the modified procedure compared with conventional pancreaticoduodenectomy (p = 0.003, 0.008, and < 0.001, respectively). According to preoperative image findings, most (72%) patients had a single inferior pancreaticoduodenal artery sharing a common trunk with the first jejunal artery. The inferior pancreaticoduodenal vein drained into the jejunal vein in 71% of the patients. The first jejunal vein ran behind the superior mesenteric artery in 77% of the patients. By combining our modified intestinal derotation procedure with preoperative recognition of the vascular anatomy of mesopancreas, mesopancreas excision during pancreaticoduodenectomy can be performed safely and accurately.

First jejunal vein, jejunal trunk, and pancreatico-duodenectomy: resolving the literature conundrum.

A detailed knowledge of the surgical anatomy of tributaries of the superior mesenteric vein, especially proximal jejunal venous anatomy (first jejunal vein and jejunal trunk), is a key prerequisite for performing a safe pancreatico-duodenectomy. However, the available literature on the anatomical course and surgical relevance of these vessels is scarce, the nomenclature across the articles is heterogeneous, and the resulting evidence is confusing to interpret. Standardized terminology and an in-depth review of these vessels with regard to their course, termination, vascular relations, and variations will help the surgeons in planning and performing this complex surgery safely, especially when a venous resection and reconstruction is planned in cases of borderline resectable pancreatic cancer. A uniform nomenclature and a unifying classification are proposed in this review for these two tributaries to help resolve the literature conundrum. This standardized terminology and anatomical description will assist the radiologists in reporting pancreatic protocol-computed tomography scans and surgeons in selecting the appropriate steps for the different anatomical orientations of these tributaries for the performance of safe pancreatic surgery. This will also help future researchers communicate in well-defined terms in reference to these tributaries so as to avoid confusion in future studies.

Partial pancreatectomy and en bloc excision of thrombosed vessels in a dog with insulinoma of the right limb of the pancreas

AbstractA 7‐year‐old, neutered golden retriever was evaluated for acute episodes of weakness, ataxia and disorientation, low blood glucose and inappropriately high insulin levels. Results of computed tomography revealed irregular enlargement of the distal tip of the right pancreas associated with thrombosis of the pancreaticoduodenal and first jejunal vein. A partial pancreatectomy with en bloc excision of the thrombosed vessels was performed. The distal duodenum and proximal jejunum maintained normal peristalsis and remained viable, obviating the need for concurrent intestinal resection and anastomosis. Histopathology confirmed a completely excised insulinoma with an associated tumour thrombus (vascular invasion of tumour). The dog remains alive with no evidence of recurrence 18 months after surgery.

Do jejunal veins matter during pancreaticoduodenectomy?

When planning pancreaticoduodenectomy for pancreatic head cancer, the prevalence of anatomical variation of the proximal jejunal vein (PJV), the associated short-term surgical outcomes, and the level of PJV convergence to the superior mesenteric vein must be carefully analyzed from both technical and oncological points of view. The prevalence of the first jejunal trunk (FJT) and PJV located ventral to the superior mesenteric artery is 58%–88% and 13%–37%, respectively. Patients with the FJT had a larger amount of intraoperative bleeding and a higher proportion of patients requiring transfusions compared to those without a common trunk. The risk of transfusion was higher in patients with ventral PJV compared to those with dorsal PJV. Although less frequent, sacrificing the FJT can result in fatal venous congestion of the jejunum. Therefore, a well-planned approach for pancreaticoduodenectomy, based on preoperative evaluation of anatomical variation in the PJV, may help reduce intraoperative bleeding and postoperative morbidity. Additionally, the importance of invasion into the PJVs should be revisited in terms of resectability and oncological clearance.

Feasibility of “cold” triangle robotic pancreatoduodenectomy

BackgroundTriangle pancreatoduodenectomy adds to the conventional procedure the en bloc removal of the retroperitoneal lympho-neural tissue included in the triangular area bounded by the common hepatic artery (CHA), the superior mesenteric artery (SMA), and the superior mesenteric vein/portal vein. We herein aim to show the feasibility of “cold” triangle robotic pancreaticoduodenectomy (C-Tr-RPD) for pancreatic cancer (PDAC).MethodsCold dissection corresponds to sharp arterial divestment performed using only the tips of robotic scissors. After division of the gastroduodenal artery, triangle dissection begins by lateral-to-medial divestment of the CHA and anterior-to-posterior clearance of the right side of the celiac trunk. Next, after a wide Kocher maneuver, the origin of the SMA, and the celiac trunk are identified. After mobilization of the first jejunal loop and attached mesentery, the SMA is identified at the level of the first jejunal vein and is divested along the right margin working in a distal-to-proximal direction. Vein resection and reconstruction can be performed as required.C-Tr-RPD was considered feasible if triangle dissection was successfully completed without conversion to open surgery or need to use energy devices. Postoperative complications and pathology results are presented in detail.ResultsOne hundred twenty-seven consecutive C-Tr-RPDs were successfully performed. There were three conversions to open surgery (2.3%), because of pneumoperitoneum intolerance (n = 2) and difficult digestive reconstruction. Thirty-four patients (26.7%) required associated vascular procedures. No pseudoaneurysm of the gastroduodenal artery was observed. Twenty-eight patients (22.0%) developed severe postoperative complications (≥ grade III). Overall 90-day mortality was 7.1%, declining to 2.3% after completion of the learning curve. The median number of examined lymph nodes was 42 (33–51). The rate of R1 resection (7 margins < 1 mm) was 44.1%.ConclusionC-Tr-RPD is feasible, carries a risk of surgical complications commensurate to the magnitude of the procedure, and improves staging of PDAC.Graphical abstract

Vascular variants in laparoscopic extended right hemicolectomy with central vascular ligation for right colon cancer.

To evaluate the right colic vascularity, focusing on the confluences of veins. The subjects of this retrospective study were 100 patients who underwent laparoscopic extended right hemicolectomy (Lap-ERHC) between April 2015 and September 2020, at our hospitals. Veins draining into the superior mesenteric vein (SMV) included the ileocecal vein (ICV), the right colic vein (RCV), the middle colic vein (MCV), and the gastrocolic trunk of Henle (GCT). Veins draining into vessels other than the SMV were defined as accessory colic veins (aICV, aRCV or aMCV). The GCT, aRCV, and aMCV were found in 86, 89, and 15 patients, respectively. In 66 patients with one aRCV, drainage was split as the anterior superior pancreaticoduodenal vein (ASPDV) in 12, the right gastroepiploic vein (RGEV) in 7, and the GCT in 47. In 23 patients with two aRCVs, drainage was split as the ASPDV in 4, the RGEV in 1, the GCT in 11, and the ASPDV and GCT in 7. In 14 patients with one aMCV, drainage was split as the GCT in 8, the splenic vein in 5, and the first jejunal vein (FJV) in 1. One patient had two aMCVs, draining into the GCT and the FJV. The findings of our evaluation of vascular anatomy, focusing on confluences of the colic veins, provides useful information for colorectal surgeons.

Vascular variations encountered during laparoscopic surgery for transverse colon, splenic flexure, and descending colon cancer: a retrospective cohort study

BackgroundLaparoscopic surgery for cancer located in the transverse colon or splenic flexure is difficult because of vascular variability in this region and adjacent vital organs such as the pancreas, spleen, and duodenum.MethodsThis retrospective cohort study involved 51 patients who underwent laparoscopic surgery for colon cancer at Tokushima University Hospital from July 2015 to December 2020. Variations of the middle colic artery (MCA), left colic artery (LCA), middle colic vein (MCV), and first jejunal vein (FJV) and short-term outcomes of laparoscopic surgery in patients with each vascular variation were evaluated.ResultsVariations of the MCA, LCA, MCV, and FJV were classified into four, three, five, and three patterns, respectively. The short-term outcomes of laparoscopic surgery for transverse colon cancer in patients with MCA variations and those with FJV variations were evaluated, and no significant difference was found in the operation time, blood loss, postoperative complication rate, time from surgery to start of dietary intake, or time from surgery to discharge among the different variations. Additionally, no significant differences were found in the short-term outcomes of laparoscopic surgery for descending colon cancer in patients with LCA variations.ConclusionPreoperative assessment of vascular variations may contribute to the stability of short-term outcomes of laparoscopic surgery for transverse colon, splenic flexure, and descending colon cancer.

Surgical outcomes of pancreatectomy with jejunal vein resection for pancreatic head cancer

Yuichi NAGAKAWA*, Jin-Young JANG, Manabu KAWAI, Song Cheol KIM, Yosuke INOUE, Yasuhiro YABUSHITA, Jin Seok HEO, Masayuki HONDA, Teiichi SUGIURA, Shingo KAGAWA, Aoi HAYASAKI, Wooil KWON, Kenichiro UEMURA, Ho-Seong HAN, Motokazu SUGIMOTO, Yasuhisa ANDO, Masafumi NAKAMURA, Keita WADA, Yusuke KUMAMOTO, Hiroaki OSAKAE, Akihiko TSUCHIDA, Yoo-Seok YOON, Joon Seong PARK, Hiroki YAMAUE, Itaru ENDO. Ann Hepatobiliary Pancreat Surg 2022;26:S154. https://doi.org/10.14701/ahbps.2022S1.KOREA-JAPAN-4

Preoperative evaluation of vascular anatomy of right colic vessels using enhanced computed tomographic colonography.

The purpose of this study is to define the blood vessels from a surgical perspective and show the frequency of vascular anatomical anomalies as well as the positional relationship with the surrounding organs, including the number of jejunal veins that cross the dissection area in our series. From January 2016 to December 2018, 126 patients who received ileocecal resection or right hemicolectomy for colonic cancer in our institution were retrospectively analyzed by preoperative enhanced computed tomographic colonography images that were obtained using an 80-detector row CT scanner and workstation. The ileocolic artery/vein, right colic artery/vein and middle colic artery/vein were defined as the vessels that flow directly from or into the superior mesenteric artery/vein. All colic veins that flowed into the gastro-colic trunk were defined as accessory right colic veins. The accessory right colonic vein existed more than two in 62.6% of cases. In 11 cases (8.9%), the inflow point of the ileocecal vein was on the ventral side of the pancreas. There was one jejunal vein that straddled the dissection area in 31% and two in 6.3%. This study elucidated the vascular anatomy and positional relationship with surrounding organs that is required in central vascular ligation during complete mesocolic excision for right sided colon cancer.

The Use of a Vascular Roadmap at Surgery Evens out Surgeons Expectations on Operating Time, Blood Loss, Lymph Nodes Harvest and Operative Difficulty when Performing Right Colectomy with Extended D3 Mesenterectomy

To determine how individual vascular road-mapping impacts the surgeonsâ?? expectations in difficulty in D3 right colectomy for cancer, and compare these expectations to the results previously published. Aim/summary background data:Literature still lacks data on surgeons expectations using preoperative 3D roadmap of the vascular system. Surgeons filled out a survey asking expectations about operation time, estimated blood loss, amount of lymph nodes harvested and difficulty. The patients were classified into 4 groups and 2 subgroups according to the crossing pattern of the ileocolic artery and the jejunal veins. SPSS was used for statistical analysis. Results: Twelve surgeons were included. Eight of them expected type 2 anatomy to be least time consuming while 11/12 indicated anatomy group 4 to be the most. Five surgeons expected low blood loss in group 2 anatomy patients while 10/12 expected higher blood loss in group 4 anatomy patients. Three anticipated that group 2 would generate the highest lymph node yield and while 2/12 surgeons expected the lowest in anatomy group 4. Eight surgeons perceived group 2 as the least challenging while 10/12 experienced group 4 as the most difficult. Compared to previously published results only group 4b operating time met surgeons expectations. Using a vascular roadmap at surgery evens out surgeons expectations in operation time, blood loss, lymph node harvested and difficulty. Comparing expectations to previously published data shows operating time in one anatomy group as the only factor where these expectations were met.

Anatomical Study of the Duodenojejunal Uncinate Process Vein: A Key Landmark for Mesopancreatoduodenal Resection During Pancreaticoduodenectomy.

BackgroundThe mesopancreas or mesopancreatoduodenum is an important anatomical concept during pancreaticoduodenectomy (PD) in patients with periampullary carcinoma. This study investigated whether the duodenojejunal uncinate process vein (DJUV), which is defined as the vein draining from the upper jejunum to the superior mesenteric vein adjacent to the uncinate process, is a useful anatomical landmark for the caudal border of mesopancreatoduodenum resection during PD.MethodsThis study enrolled 100 adult patients with hepatobiliary pancreatic disease who underwent preoperative multidetector‐computed tomography (CT). The anatomy of the key blood vessels involved during PD, and the relationship between these vessels and the DJUV, were analyzed by preoperative CT.ResultsThe first jejunal vein was the DJUV in 85 cases, whereas the second jejunal vein was the DJUV in 15 cases. Furthermore, the DJUV was classified into two subtypes depending on its positional relationship with the superior mesenteric artery (SMA). The inferior pancreaticoduodenal artery and vein were located on the cranial side of the DJUV in all cases. The distance between the middle colonic artery, used as a guide for regional lymph nodes, and the point where the DJUV intersected the SMA was within 10 mm in 80% of cases. These results imply that using the DJUV as a landmark for the caudal border of the mesopancreatoduodenum provides a safe approach and enables sufficient dissection of regional lymph nodes and tissues around the SMA.ConclusionThe DJUV may be a useful anatomical landmark for the caudal border of the mesopancreatoduodenum resection during PD.

Anatomical change of SMV branches after the Cattell Braasch maneuver facilitates safe resection around the uncinated process in pancreatoduodenectomy

BackgroundThe aims of the present study were to demonstrate the anatomical change of superior mesenteric vein (SMV) branches and to show how the Cattell Braasch maneuver facilitates a safer ligation of these venous branches during a pancreatoduodenectomy (PD).MethodsBetween January 2010 and December 2019, 97 patients with peripancreatic tumors underwent pancreatectomy. We retrospectively reviewed preoperative triple-phase enhanced computed tomography (CT) images and analyzed variations in SMV branches. Anatomical changes in SMV branches after the Cattell Braasch technique were observed using our operation video and illustrations.ResultsThe first jejunal vein (J1v) in 75% of patients ran posterior to the superior mesenteric artery (SMA), while the remainder (25%) ran anterior to it. The inferior pancreatoduodenal vein (IPDV) was preoperatively detected in 91% of patients. The IPDV drained into the J1v in 74% of patients and into the SMV in 37%. After the Cattell Braasch maneuver, the J1v which ran posterior to the SMA now was found to lie to the right anterolateral side the SMA and the visualization of both the J1v and the IPDV were much more clearly visualized.ConclusionsThe most frequent venous variation was the IPDV draining into the J1v posterior to the SMA. After the Cattell Braasch maneuver, the IPDV was now located to the right anterolateral anterior aspect of the SMA which facilitates its visualization and should allow a safer ligation.

Unusual contribution of the first jejunal vein in the formation of the portal vein

Jejunum is drained into superior mesenteric vein through a series of jejunal veins. The way in which the first jejunal vein terminates is of great importance in upper abdominal surgery and radiological procedures. Knowledge of its variations is particularly important in surgical procedures like orthotropic hepatic transplantation, hepatic vein reconstruction, pancreatic surgery and surgical procedures of duodenojejunal junction. We saw a first jejunal vein opening directly into the portal vein. Further, the inferior mesenteric vein drained into the first jejunal vein. This case could be useful to gastroenterologists, general surgeons and radiologists.

Precision anatomy for safe approach to pancreatoduodenectomy for both open and minimally invasive procedure: A systematic review.

Minimally invasive pancreatoduodenectomy (MIPD) has recently gained popularity. Several international meetings focusing on the existing literature on MIPD were held; however, the precise surgical anatomy of the pancreas for the safe use of MIPD has not yet been fully discussed. The aim of this study was to carry out a systematic review of available articles and to show the importance of identifying the anatomical variation in pancreatoduodenectomy. In this review, we described variations in surgical anatomy related to MIPD. A systematic search of PubMed (MEDLINE) was conducted, and the references were identified manually. The search strategy yielded 272 articles, with 77 retained for analysis. The important anatomy to be considered during MIPD includes the aberrant right hepatic artery, first jejunal vein, first jejunal artery, and dorsal pancreatic artery. Celiac artery stenosis and a circumportal pancreas are also important to recognize. We conclude that only certain anatomical variations are associated directly with perioperative outcomes and that identification of these particular variations is important for safe performance of MIPD.

Re-interpreting mesenteric vascular anatomy on 3D virtual and/or physical models: positioning the middle colic artery bifurcation and its relevance to surgeons operating colon cancer

BackgroundThe impact of the position of the middle colic artery (MCA) bifurcationand the trajectory of the accessory MCA (aMCA) on adequate lymphadenectomy whenoperating colon cancer have as of yet not been described and/or analysed in theliterature. The aim of this study was to determine the MCA bifurcation position toanatomical landmarks and to assess the trajectory of aMCA.MethodsThe colonic vascular anatomy was manually reconstructed in 3D fromhigh-resolution CT datasets using Osirix MD and 3-matic Medical and analysed. CTdatasets were exported as STL files and supplemented with 3D printed models whenrequired.ResultsThirty-two datasets were analysed. The MCA bifurcation was left to thesuperior mesenteric vein (SMV) in 4 (12.1%), in front of SMV in 17 (53.1%) and rightto SMV in 11 (34.4%) models. Median distances from the MCA origin to bifurcation were3.21 (1.18–15.60) cm. A longer MCA bifurcated over or right to SMV, while a shorterbifurcated left to SMV (r = 0.457, p = 0.009). The main MCA direction was towards right in19 (59.4%) models. When initial directions included left, the bifurcation occurredleft to or anterior to SMV in all models. When the initial directions included right,the bifurcation occurred anterior or right to SMV in all models. The aMCA was foundin 10 (31.3%) models, following the inferior mesenteric vein (IMV) in 5 near thelower pancreatic border. The IMV confluence was into SMV in 18 (56.3%), splenic veinin 11 (34.4%) and jejunal vein in 3 (9.4%) models.ConclusionAwareness of the wide range of MCA bifurcation positions reported iscrucial for the quality of lymphadenectomy performed. The aMCA occurs in 31.3% modelsand its trajectory is in proximity to the lower pancreatic border in one half ofmodels, indicating that it needs to be considered when operating splenic flexurecancer.