Inferior Mesenteric Artery Ligation Level in Rectal Cancer Surgery beyond Conventions: A Review

Simple Summary This research is dedicated to exploring the enduring discussion about the optimal level of ligation of the inferior mesenteric artery (IMA) during rectal cancer surgery, with an emphasis on historical, technical, and patient-centered dimensions. The study seeks to elucidate the unresolved issues by critically evaluating factors, such as the anastomotic leakage risk, genitourinary function implications, and oncological outcomes. The aim is to offer a nuanced perspective that transcends conventional paradigms, guiding surgeons and researchers toward a more individualized approach, mainly based on patient anatomy and surgeon preference. Efforts made by this research can lead to the refinement of surgical techniques and a better understanding of the intricate considerations involved in rectal cancer surgery, which can contribute to the ongoing evolution of medical practices in this area.Abstract Within the intricate field of rectal cancer surgery, the contentious debate over the optimal level of ligation of the inferior mesenteric artery (IMA) persists as an ongoing discussion, influencing surgical approaches and patient outcomes. This narrative review incorporates historical perspectives, technical considerations, and functional as well as oncological outcomes, addressing key questions related to anastomotic leakage risks, genitourinary function, and oncological concerns, providing a more critical understanding of the well-known inconclusive evidence. Beyond the dichotomy of high versus low tie, it navigates the complexities of colorectal cancer surgery with a fresh perspective, posing a transformative question: "Is low tie ligation truly reproducible?" Considering a multidimensional approach that enhances patient outcomes by integrating the surgeon, patient, technique, and technology, instead of a rigid and categorical statement, we argued that a balanced response to this challenging question may require compromise.