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Major bleeding is one of the most frightening events that can happen to a surgeon in the operating room (OR), especially in minimally invasive procedures. Having a system in mind to approach the problem is essential to help tackle the issue in an organized way.

In all cases of bleeding, follow the algorithm (Figure 18-1).

Figure 18-1

Algorithm to deal with any major bleeding.


  • Division of the inferior mesenteric artery (IMA) is an essential step in all left colon and rectal operations, especially in oncological resections.

  • High ligation of the IMA is defined as division of the vessel proximal to the left colic artery takeoff, and low ligation when the IMA is divided after the left colic artery takeoff.

  • Division of the IMA can be achieved by different ways. The IMA can be controlled by vessel sealing device (such as LigaSure), bipolar, clips, Endoloop a stapler, or combination of different methods.

  • Injury to the IMA a major intraoperative complication that might happen during the division of the vessel and swift action is needed.


Heavily Calcified IMA

This can be seen from the preoperative computed tomography (CT) scan. Occasionally, the energy device will not be able to control the vessel completely, and thus leads to bleeding when the vessel is divided. If the patient is known to have significant atherosclerosis, and there was calcification on preoperative CT scan, then consider using clips or staples rather than an energy source to control the vessel, or modify the technique and use clips in the proximal side of the IMA “staying side” and then using an energy source distally or use Endoloop on the proximal stump in addition to the energy device.

Excessive Tension

If the surgeon and assistant are focusing completely on the IMA dissection, and are not paying attention to the amount of tension that is exerted to lift up the mesentery of the sigmoid colon upward, then excessive traction can lead to injury to the IMA especially after the dissection around the IMA is started or during the division of the IMA. This can be avoided if the assistant and the surgeon who is pulling the mesentery upward relax completely during division of the IMA.

Failure of the Instruments

Although failure of the energy device is rare, if it happens, it can lead to a major intraoperative bleeding.

Injury to the IMA While Skeletonizing the Vessel

“Over skeletonizing” the IMA might lead to an injury. An example is by using the laparoscopic scissors to skeletonize the IMA, ...

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