Multimedia Journal of Metaverse in MEDICINE
METHODOLOGY | JANUARY 2, 2025
Key operations at the “Angel Hair” level in surgery for sigmoid colon cancer: exposure of the inferior mesenteric artery and protection of the ureter
Dawei Yuan¹, Lei Meng¹, Gang Xu¹,, Dongmei Diao¹, Ruixiang Tang¹, Hao Zhang¹, Yong Zhang¹*
1 Department of Surgical Oncology, The First Affiliated Hospital of Xi’an JiaoTong University, Xi’an 710061, China.
2 Department of Otorhinolaryngology, Head and Neck Surgery, Xi’an 710061, China.
Corresponding Authors: Yong Zhang. E-mail: [email protected]
Address: Department of Surgical Oncology, The First Affiliated Hospital of Xi’an JiaoTong University, Xi’an 710061, China.
Summary
In the field of precision and complex surgery for sigmoid colorectal cancer, the “first incision” not only marks the beginning of the surgery, but also represents a profound exploration of surgical techniques and medical knowledge. This study provides a comprehensive analysis from multiple dimensions of the key procedures involved in entering the “Angel Hair” stage of surgery, namely the process of exposing the inferior mesenteric artery and protecting the ureter. At the level of ‘angel hair’, it is renowned for its delicacy and complexity, requiring surgeons to possess extremely high anatomical knowledge and surgical skills. This study will comprehensively showcase every detail of the surgical process, from the first-person perspective of the chief surgeon, combined with multiple perspectives such as surgical assistants, microscopic close ups, and 3D reconstruction models. This is not only a visual demonstration of surgical techniques, but also an in-depth exploration of medical anatomy and surgical theory. Through video demonstrations, we will delve into how to accurately locate and expose the inferior mesenteric artery while ensuring surgical safety, while effectively avoiding damage to the ureter, providing valuable academic references and practical guidance for medical professionals.
Keywords
Angel Hair; sigmoid colon cancer; inferior mesenteric artery; ureter
Introduction
The precision and safety of surgery for sigmoid colon cancer have always been core challenges in the field of colorectal surgery. Due to the deep anatomical location of the tumor adjacent to important structures such as the ureter and inferior mesenteric artery (IMA), even a slight carelessness during surgery may lead to serious complications such as massive bleeding, ureteral injury, or postoperative anastomotic leakage. In recent years, with the popularization of minimally invasive techniques, laparoscopic surgery has become mainstream, but its requirements for the surgeon’s anatomical knowledge and operational precision are more stringent.
The operation at the level of “Angel Hair” (i.e. IMA exposure and ureteral protection) is a key step for the success of the surgery. In traditional open surgery, the positioning of IMA relies on the operator’s experience and tactile feedback, while in laparoscopic surgery, due to the lack of direct touch, visual anatomical landmarks and intraoperative navigation techniques are required. Research has shown that precise ligation of IMA roots can reduce local recurrence rates and improve prognosis, while the incidence of ureteral injury is as high as 1% -5%, often leading to secondary surgery or long-term renal dysfunction. Therefore, how to achieve clear exposure of IMA and full protection of the ureter in a minimally invasive environment has become a key focus of surgical technology optimization.
In recent years, the application of intraoperative imaging techniques such as near-infrared fluorescence imaging and intraoperative ultrasound has provided new ideas for anatomical structure recognition. For example, Kuno et al. confirmed that indocyanine green fluorescence imaging can significantly improve intraoperative visibility in ureteral surgery. In addition, standardized recording and analysis of surgical videos have been proven to be an important tool for improving the effectiveness of surgical teaching, especially in teaching complex operations with unique advantages. However, existing research often focuses on a single technology and lacks systematic analysis of operational details from multiple perspectives.
This study is based on 6 surgical videos of sigmoid colon cancer, combined with first person perspective, microscopic close-up, and team cooperation recording, to explore in depth the operational points of the “Angel’s Hair” aspect. By analyzing the anatomical strategies of IMA exposure and technological innovations in ureteral protection, we aim to provide surgeons with a replicable operating framework, while promoting standardization of surgical techniques and educational innovation. This study is not only a summary of traditional experience, but also a practical exploration of the integration of emerging technologies, laying the foundation for the future application of intelligent navigation and robot assisted surgery.
Methods
1 Research Design
This study retrospectively analyzed 6 surgical videos of sigmoid colon cancer performed at the Department of Oncology, the First Affiliated Hospital of Xi’an Jiaotong University from January 2024 to June 2024. All included cases were patients diagnosed by pathology and underwent radical surgery, excluding those with tumor invasion of the ureter or anatomical abnormalities.
2 Surgical team and equipment
The surgery was performed by a senior surgical team using minimally invasive laparoscopic techniques, equipped with high-definition laparoscopic systems, 3D reconstruction imaging navigation, and intraoperative ultrasound equipment.
3 Surgical steps
(1) Preoperative preparation: Clarify anatomical rela-tionships through CT, MRI, and ureterography.
(2) Surgical approach: Laparoscopic five hole method is used to establish pneumoperitoneum.
(3) Key operations:
a. Exposure of inferior mesenteric artery: Separated within the Toldt gap, revealing the root of the artery, and confirmed its position using 3D navigation.
b. Ureteral protection: Intraoperative ultrasound monitoring of ureteral position, blunt separation to avoid in-
jury.
(4) Tumor resection and anastomosis: After completing key structural protection, the tumor is removed according to standard procedures and the digestive tract is reconstructed.
4 Data collection and analysis
Each surgery is recorded from the following pers-
pectives: First person perspective (head mounted camera); Surgical assistant perspective; Microscopic close-up.
5 Ethical Statement
Approved by the Ethics Committee of the First Affiliated Hospital of Xi’an Jiaotong University (Approval No. 20230921）, All patients sign informed consent forms.
Methods Video
RESULTS
This study comprehensively demonstrates the key operations at the “Angel Hair” level in the surgery of sigmoid colon cancer through detailed analysis of 6 surgical videos. All cases successfully exposed the inferior mesenteric artery and fully protected the ureter, without intraoperative ureteral injury or other serious complications. The average surgical time is 180 ± 30 minutes, and the intraoperative blood loss is controlled at 50 ± 20 mL. Multi perspective video recording clearly presents surgical details, while microscope close-up and first-person perspective provide intuitive guidance for the operation
Discussion
This study focuses on the key operations at the “angel hair” level in surgery for sigmoid colon cancer, revealing the technical points of fine anatomical separation and intraoperative ureteral protection. The results showed that all cases successfully completed the exposure of the inferior mesenteric artery (IMA) and ureteral protection without intraoperative complications, which is consistent with the emphasis on the importance of anatomical plane separation in existing research. For example, Hohenberger et al. proposed that precise separation of Toldt gaps is the anatomical basis for IMA root exposure and can significantly reduce the risk of vascular injury. This study further validated the safety and reproducibility of the technology through close-up microscopy and first person perspective.
Ureteral protection is another core challenge of this type of surgery. In this study, the combination of intraoperative ultrasound monitoring and blunt dissection technique effectively avoided ureteral injury, consistent with the findings of Kuno et al. They pointed out that intraoperative imaging assisted techniques such as ultrasound can improve the accuracy of ureteral localization, especially for complex or recurrent cases. In addition, multi perspective video recording provides intuitive visual references for surgical teaching, which is in line with the concept of “structured analysis of surgical videos” proposed by Hashimoto et al. and helps promote the standardization of surgical techniques.
However, the limitations of this study include a small sample size and a single center design. In the future, it is necessary to expand the sample size and conduct multi center validation. In addition, the potential application of robot assisted technology in this field has not been fully explored. For example, Kim et al. reported that robotic systems have higher operational flexibility and stability in IMA exposure, and this direction deserves further research.
In summary, this study validated the safety of the “Angel Hair” level operation through multi perspective technology and provided a scalable technical framework for clinical practice. Future research needs to combine emerging technologies such as real-time artificial intelligence navigation to further optimize surgical procedures and ultimately improve patient prognosis.
Conclusion
This study confirms that fine anatomical knowledge and skilled surgical techniques are key to ensuring successful operation at the “Angel Hair” level in surgery for sigmoid colon cancer. The accurate positioning of the inferior mesenteric artery and effective protection of the ureter significantly reduce surgical risks, providing important technical references for clinical practice. This study provides strong support for improving surgical accuracy and safety, and helps to promote further optimization and popularization of related technologies.
Author Contributions
Dawei Yuan wrote the first draft. Lei Meng, Gang Xu, Dongmei Diao and Ruixiang Tang contributed to the critical revision of the manuscript. Hao Zhang and Yong Zhang reviewed and revised the manuscript. All authors have read and agreed to the published version of the manuscript.
Funding
None.
Conflicts of Interest
The authors declare no conflict of interest.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Received: 22 November 2024
Accepted: 20 December 2024
Published on line: 2 January 2025
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