Surgical Endoscopy

, Volume 33, Issue 11, pp 3842–3850 | Cite as

The fusion fascia of Fredet: an important embryological landmark for complete mesocolic excision and D3-lymphadenectomy in right colon cancer

  • Alvaro Garcia-Granero
  • Gianluca PellinoEmail author
  • Matteo Frasson
  • Delfina Fletcher-Sanfeliu
  • Fernando Bonilla
  • Luis Sánchez-Guillén
  • Alberto Domenech Dolz
  • Vicent Primo Romaguera
  • Luis Sabater Ortí
  • Francisco Martinez-Soriano
  • Eduardo Garcia-Granero
  • Alfonso A. Valverde-Navarro
Dynamic Manuscript



The fusion fascia of Toldt is a well-known landmark used by colorectal surgeons. On the contrary, the fusion fascia of Fredet (the plane between the ascending mesocolon and the visceral duodenal-pancreatic peritoneum) still remains a neglected embryological structure. Aim of this study was to provide an anatomic description of this fascia and its application to minimally invasive D3-lymphadenectomy (D3-L) and complete mesocolic excision (CME) for right colon cancer.


First phase: Cadaveric dissection and anatomic description of the fascia of Fredet. Second phase: prospective evaluation of its surgical application in a consecutive series of laparoscopic right hemicolectomies with CME and D3-L at a tertiary hospital.


The fascia of Fredet was identified and dissected in one fresh and two formalin-fixed cadavers. The trunk of Henle and the medial border of the superior mesenteric vein defined the medial limit of this embryologic plane. Seventeen patients were operated on. Laparoscopic dissection of the fascia of Fredet was possible in every patient. Median operative time was 210 (120–380) min. There were no major postoperative complications. All cases were adenocarcinomas, except one adenomatous polyp. T stage was Tis in three, T2 in two, T3 in seven, and T4 in five patients. Median number of harvested lymph nodes was 24 (9–39). Lymphatic invasion was found in six patients. All resections were classified as satisfactory mesocolic excision and R0. Median postoperative length of stay was 6 (4–20) days. Median follow-up time was 28 (16–41) months. Local and distal recurrence rate was 0.


The fusion fascia of Fredet is useful to achieve CME and D3-L in right colon cancers with reduced risk of intraoperative complications. This structure is particularly suitable for minimally invasive surgery; therefore, we encourage awareness of the fascia of Fredet by colorectal surgeons.


Laparoscopy Colorectal surgery Fascia Surgical anatomy Fredet Training 


Compliance with ethical standards


Drs. Alvaro Garcia-Granero, Gianluca Pellino, Matteo Frasson, Delfina Fletcher Sanfeliu, Fernando Bonilla, Luis Sánchez-Guillén, Alberto Domenech Dolz, Vicent Primo Romaguera, Luis Sabater Ortí, Francisco Martinez-Soriano, Eduardo Garcia-Granero, and Alfonso A. Valverde-Navarro have no conflicts of interest or financial ties to disclose.

Supplementary material

Supplementary material 1 (MP4 108,581 kb)

Supplementary material 2 (MP4 339,503 kb)

Supplementary material 3 (MP4 299,899 kb)


  1. 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 11:354–365CrossRefGoogle Scholar
  2. 2.
    Watanabe T, Itabashi M, Shimada Y et al (2012) Japanese Society for cancer of the colon and rectum (JSCCR) guidelines 2010 for the treatment of colorectal cancer. Int J Clin Oncol 17:1–29CrossRefGoogle Scholar
  3. 3.
    Mike M (2012) Laparoscopic right colectomy. In: Kano N (ed) Laparoscopic colorectal cancer surgery. Operative maneuvers based on the fascial composition in the embryological standpoint. Tokyo, Igakushoin, pp 116–133Google Scholar
  4. 4.
    Rouviére H (1924) Anatomie humaine descriptive et topographique. Masson, ParisGoogle Scholar
  5. 5.
    Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A (eds) (2010) AJCC cancer staging manual, 7th edn. Springer, New YorkGoogle Scholar
  6. 6.
    Mike M, Kano N (2013) Reappraisal of the vascular anatomy of the colon and consequences for the definition of surgical resection. Dig Surg 30:383–392CrossRefGoogle Scholar
  7. 7.
    García-Granero Á, Sánchez-Guillén L, Fletcher-Sanfeliu D, Sancho-Muriel J, Alvarez-Sarrado E, Pellino G et al (2018) Surgical anatomy of D3-Lymphadenectomy in right colon cancer, gastrocolic trunk of henle and surgical trunk of gillot. video vignette. Colorectal Dis 20:935–936CrossRefGoogle Scholar
  8. 8.
    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 260:1048–1056CrossRefGoogle Scholar
  9. 9.
    Mike M, Kano N (2015) Laparoscopic surgery for colon cancer: a review of the fascial composition of the abdominal cavity. Surg Today 45:129–139CrossRefGoogle Scholar
  10. 10.
    Jin G, Tuo H, Sugiyama M, Oki A, Abe N, Mori T, Masaki T, Atomi Y (2006) Anatomic study of the superior right colic vein: its relevance to pancreatic and colonic surgery. Am J Surg 191:100–103CrossRefGoogle Scholar
  11. 11.
    Frasson M, Faus C, Garcia-Granero A, Puga R, Flor-Lorente B, Cervantes A, Navarro S, Garcia-Granero E (2012) Pathological evaluation of mesocolic resection quality and ex vivo methylene blue injection: what is the impact on lymph node harvest after colon resection for cancer? Dis Colon Rectum 55:197–204CrossRefGoogle Scholar
  12. 12.
    Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA (2013) The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 258:1–7CrossRefGoogle Scholar
  13. 13.
    van Bree SH, Bemelman WA, Hollmann MW, Zwinderman AH, Matteoli G, El Temna S, The FO, Vlug MS, Bennink RJ, Boeckxstaens GE (2014) Identification of clinical outcome measures for recovery of gastrointestinal motility in postoperative ileus. Ann Surg 259:708–714CrossRefGoogle Scholar
  14. 14.
    Quirke P, Morris E (2007) Reporting colorectal cancer. Histopathology 50:103–112CrossRefGoogle Scholar
  15. 15.
    Scott N, Jamali A, Verbeke C, Ambrose NS, Botterill ID, Jayne DG (2008) Retroperitoneal margin involvement by adenocarcinoma of the caecum and ascending colon: what does it mean? Colorectal Dis 10:289–293CrossRefGoogle Scholar
  16. 16.
    West NP, Morris EJ, Rotimi O, Cairns A, Finan PJ, Quirke P (2008) Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study. Lancet Oncol 9:857–865CrossRefGoogle Scholar
  17. 17.
    Emmanuel A, Haji A (2016) Complete mesocolic excision and extended (D3) lymphadenectomy for colonic cancer: is it worth that extra effort? A review of the literature. Int J Colorectal Dis 31:797–804CrossRefGoogle Scholar
  18. 18.
    Ignjatovic D, Spasojevic M, Stimec B (2010) Can the gastrocolic trunk of Henle serve as an anatomical landmark in laparoscopic right colectomy? A postmortem anatomical study. Am J Surg 199:249–254CrossRefGoogle Scholar
  19. 19.
    Negoi I, Beuran M, Hostiuc S, Sartelli M, Coccolini F, Vartic M, Pinkney T (2018) Complete mesocolic excision for colon cancer is technically challenging but the most oncological appealing. Transl Gastroenterol Hepatol 22(3):79CrossRefGoogle Scholar
  20. 20.
    Freund MR, Edden Y, Reissman P, Dagan A (2016) Iatrogenic superior mesenteric vein injury: the perils of high ligation. Int J Colorectal Dis 31:1649–1651CrossRefGoogle Scholar
  21. 21.
    Jeong YJ, Cho BH, Kinugasa Y, Song CH, Hirai I, Kimura W et al (2009) Fetal topohistology of the mesocolon transversum with special reference to fusion with other mesenteries and fasciae. Clin Anat 22:716–729CrossRefGoogle Scholar
  22. 22.
    Cho BH, Kimura W, Song CH, Fujimiya M, Murakami G (2009) An investigation of the embryologic development of the fascia used as the basis for pancreaticoduodenal mobilization. J Hepatobiliary Pancreat Surg 16:824–831CrossRefGoogle Scholar
  23. 23.
    Ye K, Lin J, Sun Y, Wu Y, Xu J, He S (2018) Variation and treatment of vessels in laparoscopic right hemicolectomy. Surg Endosc 32:1583–1584CrossRefGoogle Scholar
  24. 24.
    Zhao L-Y, Liu H, Wang Y-N, Deng H-J, Xue Q, Li G-X (2014) Techniques and feasibility of laparoscopic extended right hemicolectomy with D3 lymphadenectomy. World J Gastroenterol 20:10531–10536CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Alvaro Garcia-Granero
    • 1
    • 2
  • Gianluca Pellino
    • 1
    • 3
    Email author
  • Matteo Frasson
    • 1
  • Delfina Fletcher-Sanfeliu
    • 4
  • Fernando Bonilla
    • 1
  • Luis Sánchez-Guillén
    • 1
  • Alberto Domenech Dolz
    • 1
  • Vicent Primo Romaguera
    • 1
  • Luis Sabater Ortí
    • 5
  • Francisco Martinez-Soriano
    • 2
  • Eduardo Garcia-Granero
    • 1
  • Alfonso A. Valverde-Navarro
    • 2
  1. 1.Colorectal Surgery UnitHospital Universitario y Politécnico “La Fe”ValenciaSpain
  2. 2.Department of Human Embryology and Anatomy DepartmentUniversity of ValenciaValenciaSpain
  3. 3.Department of Advanced Medical and Surgical SciencesUniversitá degli Studi della Campania “Luigi Vanvitelli”NaplesItaly
  4. 4.Cardiovascular SurgeryHospital Universitario Son EspasesMallorcaSpain
  5. 5.Hepatobiliopancreatic Surgery UnitHospital Clínico UniversitarioValenciaSpain

Personalised recommendations