Laparoscopic top-down right hemicolectomy: a new surgical technique to complete mesocolic excision

Introduction

Laparoscopic colorectal cancer resection has emerged as a feasible and safe alternative to open surgery in terms of safety and oncological outcomes (1). To date, the extent of lymphadenectomy is one of the most contentious issues in the treatment of right-sided colon cancer (2). In 2009, Hohenberger (3) introduced the concept of complete mesocolic excision (CME), emphasizing the surgical dissection through the embryological planes to remove the diseased colon and its mesentery with accessory lymphovascular supply. CME is less feasible and safe than standard surgery due to the increased risk of central vascular injury; it also requires more operative experience and more time compared to standard right hemicolectomy (2). In right-sided CME, the ileocolic and right colic vessels are divided at their origin. For cecum and ascending colon cancers, only the right branch of the middle colic artery is centrally divided. In the case of hepatic flexure tumors, central ligation of the middle colic artery and vein becomes necessary (4). Moreover, the vascular anatomical variants of the gastrocolic trunk and central vascular pedicles represent significant challenges during vascular dissection (5).

This paper discusses our top-down approach to laparoscopic right hemicolectomy with CME, evaluating its safety and feasibility. It also suggests how preliminary mobilization can simplify central compartment dissection. This technique was proposed to simplify the pre-existing procedure and reduce the risk of vascular injuries. We report the results of our initial experience in a consecutive series of patients treated with the top-down approach by a single surgeon. The article was presented in accordance with the SUPER reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-33/rc).

Preoperative preparations and requirements

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this study, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

This is a retrospective, single-center study. All consecutive patients who underwent laparoscopic right hemicolectomy for cancer at the Department of General Surgery, Guglielmo da Saliceto Hospital in Piacenza were included. The study period spanned from 1 January 2020 to 31 December 2023. Written informed consent was obtained for data and video sharing from each included patient. Each patient was prepared before surgery according to ERAS guidelines (6). Inclusion criteria were: adult patients >18 years; diagnosis of right-sided colon cancer; patients who underwent laparoscopic right hemicolectomy with the standard approach or laparoscopic CME with the top-down approach. Exclusion criteria were: patients who underwent open surgery; and patients who underwent concurrent major abdominal procedures. The surgical operations performed by the same surgeon (F.B.) were compared: non-CME right hemicolectomies performed with the standard approach and CME top-down right hemicolectomies.

Step-by-step description

The first step of the procedure starts with the preoperative evaluation of anatomy using computed tomography (CT) scan of the abdomen in order to identify vessels and understand their position with respect to the other anatomic landmarks.

The patient’s positioning and trocar placement are summarized in Figure 1. A video of the procedure is available in Video S1.

Figure 1 Trocar positioning.

The patient is placed in the supine position and, when necessary, in reverse Trendelenburg position and left side tilted.

The surgeons lie on the left of the patient because the initial dissection starts from the top and is extended laterally. During this phase, the left position of the operators improves the ergonomics during the initial dissection which is the most difficult step of the procedure.

First, the small bowel is mobilized to the left quadrants. The greater omentum is dissected from the origin of the gastroepiploic trunk and maintains the omental fusion with the transverse mesocolon.

The omental dissection carries on the dorsal part of the descending duodenum and is prolonged along the peritoneal layer of the mesocolic flexure. This dissection creates a direct plan that allows the direct visualization of the Told plan.

The dissection continues from the top of the hepatic flexure down to the ileocecal area mobilizing the colon medially. This maneuver allows the continuous and progressive detachment of the second and third duodenal portions, the exposition of the pancreatic head, and the complete separation of Toldt and Gerota fascias (Figure 2).

Figure 2 Exposition of the pancreatic head and the complete separation of Toldt and Gerota fascias.

The colon is then placed on right paracolic gutter. The first assistant performs continuous traction of the transverse mesocolon with vertical exposure of the middle colic pedicle (MCP).

A direct window is opened at Treves’s avascular area, which can be used as a high traction area. A peritoneal incision along the superior mesenteric vein (SMV) is performed, and a further window is opened in the transverse mesocolon on the right side of the MCP. The simultaneous mesocolic traction allows a gentle dissection, in the mediolateral approach, of the middle colic vein from the lymph vascular tissue. The dissection progressively exposes the ileocolic vein and the ileocolic artery (ICA), which are clipped and sectioned (Figure 3).

Figure 3 Isolation of SMV with exposition of the ileocolic vein and artery. ICA, ileocolic artery; ICV, ileocolic vein; SMV, superior mesenteric vein.

If the ICA runs anterior to the SMV, it is divided close to its origin at the superior mesenteric artery (SMA). If the ICA crosses the dorsal to the SMV, its division is performed at the level of the right border of the SMV.

After the ileocolic vessels’ dissection, the traction on the two previous windows, through the continuous traction of the first assistant on transverse mesocolon and the countertraction of the surgeon, facilitates the dissection of the lymph vascular tissue from the pancreas. This also creates a simultaneous “automatic” gentle dissection of the avascular lateral and anterior side of the SMV. The lymph nodes dissection from the pancreatic head is stopped at this level, where the Henle trunk can be seen in its lateral portion. Maintaining fixed traction, the dissection comes down from the transverse mesocolon window along the right side of the MCP until its origin. During this dissection, the right brunch of the MCPs and the right colic artery are exposed when present (Figure 4). The two windows on the right and transverse mesocolon create the complete and safe exposure of the central lymphatic compartment containing the Henle’s trunk, previously isolated from the origin of the gastroepiploic trunk, allowing the simplified dissection of the Henle trunk removing the central lymph vascular compartment with the identification of a possible right superior colic vein (Figure 5).

Figure 4 Right branch of the middle colic pedicle and the right colic artery. MCP, middle colic pedicle; RBMCA, right branch of middle colic artery; RCA, right colic artery.

Figure 5 The creation of right and transverse mesocolon windows with the complete and safe exposure of the central lymphatic compartment containing the Henle’s trunk. SMV, superior mesenteric vein.

After complete mobilization of the terminal ileum, cecum, ascending colon, and proximal transverse colon, the terminal ileum and transverse colon are transected using a laparoscopic linear cutter stapler. The specimen is then removed via a small Pfannenstiel incision.

Intracorporeal anastomosis is usually performed. The ileum and transverse colon are aligned in an isoperistaltic configuration. A seromuscular stay suture is placed between the ileum and transverse colon and retracted toward the right side of the abdomen to optimize alignment. A colotomy and enterotomy are made and the mechanical stapler is placed and fired, creating the anastomosis. The common enterotomy is then closed using two layers of barbed sutures of monofilament. The mesentery usually is not closed, and the adequate orientation of the bowel is always checked.

Postoperative results

A total of 69 patients were analyzed. The top-down right hemicolectomy with CME was performed in 16 patients, the standard medial-to-lateral procedure without CME was performed in 53 patients. Data from the 69 included patients were reported in Table 1. The subgroup analysis was made comparing 16 non-CME right hemicolectomies with standard approach (medial-to-lateral) and 16 CME top-down right hemicolectomies, these 32 operations were performed by the same surgeon (F.B.) (Table 2).

Intraoperative apparent complications (vascular injuries and massive bleeding) were not reported both in CME and non-CME procedures. Top-down CME showed a shorter surgical time to standard procedure and less postoperative course of a standard technique, both in general and subgroup analysis. The number of retrieved lymph nodes was non-statistically higher in the top-down group. Postoperative complications were higher in medial-to-lateral procedures (60.3%) than (18.7%) top-down procedures (P=0.04).

Postoperative blood transfusion was performed only in 3 (4.3%) patients treated with standard laparoscopic right hemicolectomy. No major complications (Clavien-Dindo > 3b) were observed in top-down procedures. The 90-day mortality wasn’t reported in both groups.

Tips and pearls

• Preoperative evaluation of anatomy using CT scan of the abdomen is important to identify vessels and understand their position with respect to the other anatomic landmarks.
• Identification of gastroepiploic vessels origin during the first omentum dissection.
• Extend the mobilization of transverse colon including hepatic flexure in order to expose completely of the third duodenal portions, the pancreatic head, and the complete separation of Toldt and Gerota fascias.
• The extension of duodenal dissection together with the identification of gastroepiploic vessel origin is fundamental to achieving and creating a safety window to maintain a clear field with constant traction.

Discussion

The two main approaches for CME right hemicolectomy are the medial-to-lateral approach described by Strey et al. (7) imagining the dissection as flipping through the “page of a book” to achieve the correct plan and the bottom-up approach, first described by Zou et al. (8). Medial-to-lateral approach presents some limitations, especially in obese patients. The identification of correct plane between the Toldt and Gerota fascias, like maintaining the suspension of the mesocolon during the dissection can be difficult (9).

The top-to-bottom described by Levard et al. (10) in 2012, included the ligation of the right mesenteric and right MCPs from above, resulting in a higher risk of vascular and organ injuries compared to the medial-to-lateral approach and also to the present approach, especially in obese patients. Levard approach may result in an inadvertent MCP injury, requiring at the end of the dissection an enlargement of the colic resection due to bowel ischemia.

Traditionally CME has been reported as a surgical procedure with major technical difficulties (11) and for these reasons the widespread of this approach to right colon cancer was limited. The initial results of top-down approach to laparoscopic right hemicolectomy with CME seem promising, presenting several potential advantages over other approaches. First, the dissection of the transverse mesocolon from the duodenum and pancreas with their top view reduces the risk of organ injuries. Second, the simultaneous visualization of the central lymph vascular compartment through the double windows created during the complete mobilization of the right and transverse colon could guide the safe dissection of MCP and Henle’s trunk. The secure exposure afforded by creating these two windows makes safe separation of vessels and structures that have to be resected from the other organs, minimizing the risk of injury. This is the main advantage of the technique that help in the application of this approach also in less experienced surgeons. These two fundamental steps contribute to the good results of this series, including shorter operative times, a higher number of retrieved lymph nodes, and positive postoperative outcomes.

This technique was created thinking of the laparoscopic approach. The robotic top-down approach may be performed safely thanks to the fact that the patient often does not require a lateral tilt or even Trendelenburg positioning. Additionally, preparation/mobilization performed at the beginning of the procedure allows the maintenance of a fixed operating field throughout the entire procedure, which can potentially be advantageous in robotic surgery. Top-down techniques using the robotic approach should be evaluated in future studies.

This study has several limitations. The retrospective nature of a single institution and the small sample size were thus subject to bias and possible confounding factors that may have influenced the results. Future prospective and randomized clinical trials would provide strong evidence and reduce the risk of bias. This technique was performed by only one surgeon without results of reproducibility from other surgeons.

Conclusions

The results of this preliminary analysis showed a safe approach to laparoscopic CME avoiding vascular injuries and prolonged surgical time. Top-down laparoscopic hemicolectomy with CME represents a promising approach to right CME improving the confidence of the surgeon and reduce the complications related to its complexity.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-33/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-33/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-33/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this study, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Bray F, Ferlay J, Soerjomataram I, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424. Erratum in: CA Cancer J Clin 2020;70:313. [Crossref] [PubMed]
2. Xu L, Su X, He Z, et al. Short-term outcomes of complete mesocolic excision versus D2 dissection in patients undergoing laparoscopic colectomy for right colon cancer (RELARC): a randomised, controlled, phase 3, superiority trial. Lancet Oncol 2021;22:391-401. [Crossref] [PubMed]
3. Hohenberger W, Weber K, Matzel K, et al. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation--technical notes and outcome. Colorectal Dis 2009;11:354-64; discussion 364-5. [Crossref] [PubMed]
4. Benz S, Tannapfel A, Tam Y, et al. Proposal of a new classification system for complete mesocolic excison in right-sided colon cancer. Tech Coloproctol 2019;23:251-7. [Crossref] [PubMed]
5. Kuzu MA, İsmail E, Çelik S, et al. Variations in the Vascular Anatomy of the Right Colon and Implications for Right-Sided Colon Surgery. Dis Colon Rectum 2017;60:290-8. [Crossref] [PubMed]
6. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS(®)) Society Recommendations: 2018. World J Surg 2019;43:659-95. [Crossref] [PubMed]
7. Strey CW, Wullstein C, Adamina M, et al. Laparoscopic right hemicolectomy with CME: standardization using the "critical view" concept. Surg Endosc 2018;32:5021-30. [PubMed]
8. Zou L, Xiong W, Mo D, et al. Laparoscopic Radical Extended Right Hemicolectomy Using a Caudal-to-Cranial Approach. Ann Surg Oncol 2016;23:2562-3. [Crossref] [PubMed]
9. Franklin A, Patterson A, Taylor J, et al. Laparoscopic Right Hemicolectomy in a Morbidly Obese Patient Using a Medial Approach with an Intracorporeal Anastomosis. Am Surg 2015;81:301-2. [Crossref] [PubMed]
10. Levard H, Denet C, Gayet B. Laparoscopic right colectomy from top to bottom. J Visc Surg 2012;149:e34-7. [PubMed]
11. Prevost GA, Odermatt M, Furrer M, et al. Postoperative morbidity of complete mesocolic excision and central vascular ligation in right colectomy: a retrospective comparative cohort study. World J Surg Oncol 2018;16:214. [PubMed]