Modification of the vascular preparation after high tie ligation to improve colonic perfusion and increase the length of the colon limb in low anterior rectal resection.

Introduction: High tie ligation of the inferior mesenteric artery (IMA) is the standard technique in oncological low anterior rectal resection. However, high tie may reduce blood flow to the colon, impairing distal tissue perfusion, anastomotic healing, and potentially causing necrosis. Therefore, a modified high tie technique (MoHiTi) was developed that preserves the arterial arc from the left colic artery via the proximal IMA to the first sigmoidal branch.

Methods: In this prospective cohort study, all patients with rectal cancer undergoing low anterior resection with TME and a stapled side-to-end anastomosis were included. The arterial arc between the left colic artery, proximal inferior mesenteric artery, and the outgoing first sigmoidal artery branch was preserved. The dissection lines with standard dissection or MoHiTi technique were marked and the gain of length of the proximal colon limb was measured.

Results: Thirty-one patients met the inclusion criteria; two refused participation and in two cases the arcade could not be preserved. Consequently, 27 patients (93%) successfully underwent the MoHiTi procedure. All surgeries were performed as minimally invasive resections with a protective loop ileostomy or transverse colostomy. The major complication rate (Clavien-Dindo ≥ 3) was 18.5%, including one anastomotic leak (3.7%) and three cases of presacral abscess; no ischemia was observed, and no reoperations were required. The modified technique achieved a gain in proximal colon length of 12 cm (range, 10-17 cm).

Conclusion: The MoHiTi modification is feasible, offering an extended colon length that facilitates a better-perfused, tension-free anastomosis.