Annals of the Royal College of Surgeons of England (1984) vol.

66

The surgical

anatomy

of

the marginal artery

PETER J BILLINGS FRCSt

Surgical Registrar

JOHN C NICHOLLS FRCS

Consultant Surgeon
Hemel Hempstead General

Hospital, Herts.

Key words: MARGINAL ARTERY; ISCHAEMIC COLITIS; AORTIC ANEURYSM; DEFUNCTIONING COLOSTOMY

Sumnary
Two examples of the clinical importance of the marginal artery are
given. They should alert the colorectal surgeon to the possibility of
anatomical abnormalities leading to major complications in this
surgical field.
Successful colo-rectal and aortic surgery is based upon the
preservation of the blood supply to the descending colon and
rectum from the marginal artery, when the inferior mesenteric artery is obliterated. The importance of the marginal
artery is perhaps underrated, and by describing two recent
problems this importance is emphasised.
The entity of a marginal artery to the colon is well
understood by surgeons and radiologists, but not so clearly
by anatomists.
The first description of it, however, was given by Van
Haller in 1786. Somewhat more recently Griffiths made a
detailed study of the vascular anatomy of the distal colon
(1). The marginal artery forms the important anastomosis
between the superior and inferior mesenteric arteries because
it is supplied by branches of both vessels. Although the
vascular pattern of the colon is somewhat variable the
marginal artery was consistently present in all cases. The
middle colic artery was absent in 22% and the left colic
artery absent in 6% in his series.
Marston (2) has shown that although the marginal artery
is a constant feature, the point of anastomosis between the
superior and inferior mesenteric vessels at the splenic flexure
may be critically narrow. If blood flow in either mesenteric
vessel is impaired adequate compensatory flow may not
occur through this narrowed segment. This may lead to
ischaemic complications in the jeopardised area of supply.
The first example (below) shows how a colostomy raised to
the left of the middle colic artery may interfere with the
marginal artery. The colonic anastomosis had been performed according to the principles suggested by Heald (4)
when using a stapling device. A good pulsatile blood flow
was obtained at the level of the anastomosis; the splenic
flexure was fully mobilised and the anastomosis was accomplished without tension. It is emphasised by Griffiths (1) and
Goligher (3) th-at an initial defunctioning transverse
colostomy should be raised well to the right of the middle
colic artery. The enables a subsequent radical resection of
sigmoid colon or rectum to be performed with high ligation
of the inferior mesenteric artery. The blood supply of the
descending colon will then depend on the marginal artery,
receiving its blood supply from the undisturbed left branch of
the middle colic artery. It may be that in this first patient

construction of a simple loop colostomy interfered with the

marginal artery at this point and thus cut off the critical supply
to the anastomosis. As the colostomy was raised at the end ofthe
procedure, the limitations of blood supply to the anastomotic
segment would not necessarily be observed.
The second example demonstrates that an inadequate
blood supply through the marginal artery at the splenic
flexure may lead to ischaemic colitis if the inferior mesenteric
is occluded. The inferior mesenteric artery is often tied in
operations on the abdominal aorta, but the incidence of
ischaemic colitis in elective surgery on the abdominal aorta is
quoted as l-2% in retrospective series, rising to 6% in a
prospective series (5). In the emergency surgery of ruptured
aortic aneurysms the incidence is as high as 32% with a
corresponding high mortality (75%o), although this figure is
probably related to factors other than inferior mesenteric
artery occlusion (6). One case has been previously reported
of an abdominal aortic aneurysm presenting with ischaemic
colitis (7), very similar to our own. That case was found to
have ischaemic bowel extending from the hepatic flexure to
the anus in the presence of a large abdominal aortic
aneurysm.

Patients
PATIENT I

A 68-year-old man was admitted for resection of a carcinoma

of the rectum 9 cm from the anal margin. A mobile tumour
of the rectum was found and a low anterior resection
performed using the Russian SPTU stapling gun. The
splenic flexure was fully mobilised, a pulsatile blood supply
obtained at the site of anastomosis and intact 'doughnuts'
obtained after stapling. A covering left transverse colostomy
was then raised.
He had a stormy postoperative course becoming shocked
and septicaemic on the night after the operation. He then
made a slow recovery. His colostomy always looked a little
blue but a normal action occurred on the fifth postoperative
day. On the seventh postoperative day he discharged pus per
rectum, and rectal examination revealed complete disruption of the anastomosis. A rectal sinogram showed a large
posterior cavity and complete separation of the staples. His
anastomotic disruption was managed conservatively and he
was eventually discharged home after 6 weeks.
Three weeks after discharge he was re-admitted with
intermittent intestinal obstruction, which was attributed to a
stricture in the proximal limb of the colostomy. He had been
in hospital for 2 weeks when he suddenly complained of
severe abdominal pain with signs of peritonitis and radiologically visible free gas under the diaphragm. Laparotomy

f Present address: The Middlesex Hospital, London W1

The Editor would welcome any comments on this paper by readers
Fellows and Members interested in submitting papers for consideration for publication
should first write to the Editor

Surgical anatomy of the marginal artery

revealed an incidental mycotic aneurysm of the abdominal
aorta and a totally ischaemic colon distal to the colostomy
which had perforated. No operative procedure was judged
possible and he died postoperatively.

335

At post-mortem examination a ruptured abdominal aortic

aneurysm, extending up to the level of the renal arteries and
involving the origin of the inferior mesenteric artery, was
found.

PATIENT 2

A previously fit 57-year-old man was admitted as an emergency with a 10-day history of intermittent bloody diarrhoea
and mild left iliac fossa pain. His admission was finally
precipitated by a bout of severe lower abdominal pain. On
admission he was not shocked or pyrexial. There was some
mild lower abdominal tenderness and fresh blood was
present on rectal examination.
Initially he settled on intravenous fluids but 48 hours after
admission he became shocked and developed signs of peritonitis. At operation, gangrenous colon was found extending
from the distal third of the transverse colon to the rectum. An
unsuspected, apparently intact, aortic aneurysm was present. A left hemicolectomy was performed. Clotted blood was
noted in the mesenteric vessels. The aneurysm was not
resected because of the poor condition of the patient and the
risk of infection in the prosthesis. Despite intensive resuscitation he died postoperatively.

References
I Griffiths JD Surgical anatomy of the blood supply of the distal
colon. Ann R Coll Surg Engl 1956;19:241-56.
2 Marston A. Intestinal ischaemia. Arnold, 1977.
3 Goligher JC. Surgery of the anus, rectum and colon. 3rd ed.
London: Bailliere Tindall, 1975:613.
4 Heald RJ. Towards fewer colostomies-the impact of circular
stapling devices on the surgery of rectal cancer in a district
general hospital. Br J Surg 1980;67: 198-200.
5 Ernst CB, Hagihara PF, Daugherty ME, Sachatello CR, Griffen
WO. Ischaemic colitis incidence following abdominal aortic
reconstruction: a prospective study. Surgery 1976;4:417-21.
6 Bandyk DF, Florence MG, Johansen KJ. Colon ischaemia
accompanying ruptured abdominal aortic aneurysm. J Surg Res
1981 ;30:297-303.
7 Wald M. Gangrene of the distal two thirds of transverse colon,
left colon, rectum and anal canal due to superior mesenteric
vascular insufficiency. Dis Colon Rectum 1964;7:303-5.

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