Laparoscopic inferior mesenteric-gonadal vein bypass for the treatment of nutcracker syndrome Danfeng Xu, MD, Yi Gao, MD, Jie Chen, MD, Junkai Wang,

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Laparoscopic inferior mesenteric-gonadal vein bypass for the treatment of nutcracker syndrome Danfeng Xu, MD, Yi Gao, MD, Jie Chen, MD, Junkai Wang, MD, Jianqing Ye, MD, Yushan Liu, MD Journal of Vascular Surgery Volume 57, Issue 5, Pages 1429-1431 (May 2013) DOI: 10.1016/j.jvs.2012.10.092 Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 1 Trocar positioning. The patient was placed in a lateral oblique position, with a 45-degree angle introduced between the coronal plane of the patient and the horizontal plane. 1, 10 mm trocar for camera; 2, 10-mm trocar for the laparoscopic harmonic scalpel; 3-5, 5-mm trocar for other instruments (scissors, forceps, the laparoscopic retractor, and suction). Blue 2 and 3 are the work ports for the operator. Pink 4 and 5 are the work ports for the assistant. Yellow 1 is the port for a 30° laparoscope. AAL, Anterior axillary line; MCL, midclavicular line. Journal of Vascular Surgery 2013 57, 1429-1431DOI: (10.1016/j.jvs.2012.10.092) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 2 The laparoscopic approach. A, The inferior mesenteric vein (IMV ) is resected and prepared for end-end anastomosis to the left gonadal vein (LGV). B, The LGV is resected 2-4 cm to the left renal vein (LRV ). It must be confirmed that there is no valve on the way to the LRV. As the figure shows, blood flow pours after unclamping without any valve. C, Laparoscopic anastomosis of the LGV to the IMV using 5/0 polytetrafluoroethylene running suture. D, Completed anastomosis. The inferior mesenteric-gonadal vein bypass is filled. Journal of Vascular Surgery 2013 57, 1429-1431DOI: (10.1016/j.jvs.2012.10.092) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 3 A, Regional vascular anatomy demonstrates location of the inferior mesenteric vein (IMV) in relation to the left gonadal vein (LGV ). B, Inferior mesenteric-gonadal vein bypass forms a venous circuit between the left renal vein (LRV ) and the portal venous system. IVC, Inferior vena cava; PV, portal vein; SP, spleen vein. Journal of Vascular Surgery 2013 57, 1429-1431DOI: (10.1016/j.jvs.2012.10.092) Copyright © 2013 Society for Vascular Surgery Terms and Conditions