The uncinate process first approach: a novel technique for laparoscopic right hemicolectomy with complete mesocolic excision
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Current evidence suggests that complete mesocolic excision (CME) for right-sided colon cancer could be beneficial in terms of long-term survival. However, CME is a considerably more complex operation than standard right hemicolectomy; this is especially true for the laparoscopic approach. Consequently, we have explored a new laparoscopic approach that provides surgical radicality at the mesenteric root on the one hand and maximum safety on the other hand.
The key feature of the uncinate process first approach (UFA) is the commencement of the dissection at the fourth part of the duodenum using a medial to lateral approach, thus mobilizing the whole mesenteric root posteriorly before the central parts of the mesenteric vessels are accessed. Twenty-eight selected patients with right-sided colon cancer underwent surgery using the UFA and were compared with 51 patients who underwent an open CME procedure (CON). In 11/28 and 51/51 patients in the UFA and CON groups, respectively, a planimetric assessment of the specimen was performed.
Surgical time was longer (144.8 vs. 202.5 min; p < 0.000) and postoperative stay shorter (8.0 vs. 10.5 days; p < 0.01) for the laparoscopic approach. The area of the resected mesentery (UFA, 15,097 mm2; CON, 15,788 mm2; p = 0.47) and the lymph node count (UFA, 59.0; CON, 51.0; p = 0.09) was not significantly different; additionally, no difference was observed regarding anastomotic leakage (both n = 0) and postoperative mortality (UFA, 0/28; CON, 1/51; p = 1.0).
Laparoscopic right hemicolectomy with CME using the UFA provides adequate radicality according to the CME principles and seems feasible and as safe as an open technique. However, future trails will have to demonstrate whether the theoretical advantages of the UFA, with a higher degree of mobility and accessibility of the mesenteric root, translate into a significant clinical benefit, especially relative to the other laparoscopic techniques.
KeywordsUncinate process first approach Complete mesocolic excision Right hemicolectomy Colon cancer Laparoscopic hemicolectomy CME
The contribution of Mrs Alexandra Gayer in managing the database is gratefully acknowledged.
Compliance with ethical standards
The authors, Professor Tannapfel, Dr. Stricker, Dr. Tam and Professor Benz, have no conflicts of interest or financial ties to disclose.
- 1.Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S (2009) Standardized surgery for colonic cancer: complete mesocolic excision and central ligation–technical notes and outcome. Colorectal Dis 11(4):354–364. doi: 10.1111/j.1463-1318.2008.01735.x (discussion 364–355) CrossRefPubMedGoogle Scholar
- 2.Culligan K, Walsh S, Dunne C, Walsh M, Ryan S, Quondamatteo F, Dockery P, Coffey JC (2014) The mesocolon: a histological and electron microscopic characterization of the mesenteric attachment of the colon prior to and after surgical mobilization. Ann Surg 260(6):1048–1056. doi: 10.1097/SLA.0000000000000323 CrossRefPubMedGoogle Scholar
- 7.West NP, Hohenberger W, Weber K, Perrakis A, Finan PJ, Quirke P (2010) Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol 28(2):272–278. doi: 10.1200/JCO.2009.24.1448 CrossRefPubMedGoogle Scholar
- 9.Juo YY, Hyder O, Haider AH, Camp M, Lidor A, Ahuja N (2014) Is minimally invasive colon resection better than traditional approaches? First comprehensive national examination with propensity score matching. JAMA Surg 149(2):177–184. doi: 10.1001/jamasurg.2013.3660 CrossRefPubMedPubMedCentralGoogle Scholar
- 11.Rondelli F, Trastulli S, Avenia N, Schillaci G, Cirocchi R, Gulla N, Mariani E, Bistoni G, Noya G (2012) Is laparoscopic right colectomy more effective than open resection? A meta-analysis of randomized and nonrandomized studies. Colorectal Dis 14(8):e447–469. doi: 10.1111/j.1463-1318.2012.03054.x CrossRefPubMedGoogle Scholar
- 17.Mori S, Baba K, Yanagi M, Kita Y, Yanagita S, Uchikado Y, Arigami T, Uenosono Y, Okumura H, Nakajo A, Maemuras K, Ishigami S, Natsugoe S (2014) Laparoscopic complete mesocolic excision with radical lymph node dissection along the surgical trunk for right colon cancer. Surg Endosc. doi: 10.1007/s00464-014-3650-3 Google Scholar
- 18.Feng B, Sun J, Ling TL, Lu AG, Wang ML, Chen XY, Ma JJ, Li JW, Zang L, Han DP, Zheng MH (2012) Laparoscopic complete mesocolic excision (CME) with medial access for right-hemi colon cancer: feasibility and technical strategies. Surg Endosc 26(12):3669–3675. doi: 10.1007/s00464-012-2435-9 CrossRefPubMedGoogle Scholar