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Laparoscopic Complete Mesocolic Excision with Central Vascular Ligation (CME + CVL) for Right-Sided Colon Cancer: A New “Superior Mesenteric Artery First” Approach

  • Colorectal Cancer
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Purpose

It remains a technical challenge to perform “superior mesenteric artery (SMA) first” approach for laparoscopic right hemicolectomy with complete mesocolon excision (CME) as the vascular anatomy of the right colon varies a lot, which may cause difficulty in early location of SMA and the risk of vascular damage during central vascular ligation (CVL). The purpose of this study was to describe a new “SMA first” approach for laparoscopic CME with CVL in right hemicolectomy with Treitz’s ligament and ileocolic vascular pedicle as the anatomical landmarks for early identification of and exposure of SMA.

Methods

This procedure was performed on 21 patients with right colon cancer between March 2020 and August 2021. To start, the transverse mesocolon was retracted to expose the ligament of Treitz, and the pedicle of ileocolic vessels was anteriorly grasped. Next, the peritoneum near the right border of the ligament of Treitz was divided along the left side of SMA until the peritoneum below the ileocolic vessels. Next, the mesenteric lymphatic adipose tissue outside of the sheath of SMA was dissected from medial to lateral. Then, laparoscopic right hemicolectomy with complete mesocolic excision (CME) was performed. Patients’ preoperative baseline characteristics and intraoperative and postoperative complications were examined.

Results

The median operative time was 180 min, and the median intraoperative blood loss was 50 ml (interquartile range 40–90). Chylous leakage occurred in four patients, and all the patients resolved with percutaneous drainage. The total harvested lymph nodes was 21.0 (range 16–27). The median times to first flatus and liquid diet intake were both 3.0 days. The median number of postoperative hospital days was 10.0 days. No severe postoperative complications, such as abdominal infection, anastomotic leakage, or bleeding, were observed.

Conclusions

This new “SMA first” approach is safe and technically feasible for laparoscopic CME with CVL in right hemicolectomy.

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References

  1. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery: the clue to pelvic recurrence? Br J Surg. 1982;69(10):613–6.

    Article  CAS  Google Scholar 

  2. Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation: technical notes and outcome. Colorectal Dis. 2009;11:354–64.

    Article  CAS  Google Scholar 

  3. West NP, Morris EJ, Rotimi O, Cairns A, Finan PJ, Quirke P. Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study. Lancet Oncol. 2008;9:857–65.

    Article  Google Scholar 

  4. West NP, Hohenberger W, Weber K, Perrakis A, Finan PJ, Quirke P. Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol. 2010;28:272–8.

    Article  Google Scholar 

  5. Storli KE, Søndenaa K, Furnes B, Eide GE. Outcome after introduction of complete mesocolic excision for colon cancer is similar for open and laparoscopic surgical treatments. Dig Surg. 2013;30:317–27.

    Article  Google Scholar 

  6. Galizia G, Lieto E, De Vita F, Ferraraccio F, Zamboli A, Mabilia A, et al. Is complete mesocolic excision with central vascular ligation safe and effective in the surgical treatment of right-sided colon cancers? A prospective study. Int J Colorectal Dis. 2014;29:89–97.

    Article  Google Scholar 

  7. Matsuda T, Iwasaki T, Sumi Y, Yamashita K, Hasegawa H, Yamamoto M, et al. Laparoscopic complete mesocolic excision for right-sided colon cancer using a cranial approach: anatomical and embryological consideration. Int J Colorectal Dis. 2017;32(1):139–41.

    Article  Google Scholar 

  8. Higuchi T, Sugihara K. Complete mesocolic excision (CME) with central vascular ligation (CLV) as standardised surgical technique for colonic cancer: a Japanese multicentre study. Dis Colon Rectum. 2010;53:abstr176.

    Google Scholar 

  9. Hashiguchi Y, Muro K, Saito Y, Ito Y, Ajioka Y, Hamaguchi T, et al. Japanese Society for Cancer of the Colon and Rectum. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol. 2020;25(1):1–42.

    Article  Google Scholar 

  10. Schmoll HJ, Van Cutsem E, Stein A, Valentini V, Glimelius B, Haustermans K, et al. ESMO Consensus Guidelines for management of patients with colon and rectal cancer. A personalized approach to clinical decision making. Ann Oncol. 2012;23(10):2479–516.

    Article  CAS  Google Scholar 

  11. Benson AB 3rd, Venook AP, Cederquist L, Chan E, Chen YJ, Cooper HS, et al. Colon cancer, Version 1.2017, NCCN clinical practice guidelines in oncology. J Natl Compr Cancer Network JNCCN. 2017;15(3):370–98.

    Article  CAS  Google Scholar 

  12. Lee SD, Lim SB. D3 lymphadenectomy using a medial to lateral approach for curable right-sided colon cancer. Int J Colorectal Dis. 2009;24(3):295–300.

    Article  Google Scholar 

  13. Spasojevic M, Stimec BV, Gronvold LB, Nesgaard JM, Edwin B, Ignjatovic D. The anatomical and surgical consequences of right colectomy for cancer. Dis Colon Rectum. 2011;54(12):1503–9.

    Article  Google Scholar 

  14. He Z, Su H, Ye K, Sun Y, Guo Y, Wang Q, et al. Anatomical characteristics and classifications of gastrocolic trunk of Henle in laparoscopic right colectomy: preliminary results of multicenter observational study. Surg Endosc. 2020;34(10):4655–61.

    Article  Google Scholar 

  15. Zhou L, Diao D, Ye K, Feng Y, Yi X, Tong W, et al. The Medial Border of Laparoscopic D3 lymphadenectomy for right colon cancer: results from an exploratory pilot study. Dis Colon Rectum. 2021;64(10):1286–96.

    Article  Google Scholar 

  16. Yi X, Li H, Lu X, Wan J, Diao D. “Caudal-to-cranial” plus “artery first” technique with beyond D3 lymph node dissection on the right midline of the superior mesenteric artery for the treatment of right colon cancer: is it more in line with the principle of oncology? Surg Endosc. 2020;34(9):4089–100.

    Article  Google Scholar 

  17. Luo W, Lu T, Xiao Y, Li F, Xu Z, Jia Y. A New Medial-to-lateral approach for laparoscopic D3 lymphadenectomy plus complete mesocolic excision (D3 + CME) for right-sided colon cancer. Ann Surg Oncol. 2021;28(6):3256–7.

    Article  Google Scholar 

  18. Nesgaard JM, Stimec BV, Bakka AO, Edwin B, Ignjatovic D, Group RCCs. Navigating the mesentery: a comparative pre- and per-operative visualization of the vascular anatomy. Colorectal Dis. 2015;17(9):810–8.

    Article  CAS  Google Scholar 

  19. Deng X, Hu T, Wei M, Wu Q, Yang T, Meng W, et al. Feasibility of a unidirectionally progressive, pancreas-oriented procedure for laparoscopic D3 right hemicolectomy. Langenbeck’s Arch Surg. 2018;403(6):761–8.

    Article  Google Scholar 

  20. Nesgaard JM, Stimec BV, Soulie P, Edwin B, Bakka A, Ignjatovic D. Defining minimal clearances for adequate lymphatic resection relevant to right colectomy for cancer: a post-mortem study. Surg Endosc. 2018;32(9):3806–12.

    Article  Google Scholar 

  21. Yi XJ, Lu XQ, Li HM, Wang W, Xiong WJ, et al. Feasibility and efficacy of laparoscopic radical right hemicolectomy with complete mesocolic excision using an “artery-first” approach. Gastroenterol Rep. 2019;7(3):199–204.

    Article  Google Scholar 

  22. Zhao LY, Li GX, Zhang C, Yu J, Deng HJ, Wang YN, et al. Vascular anatomy of the right colon and vascular complications during laparoscopic surgery. Zhonghua wei chang wai ke za zhi Chin J Gastrointest Surg. 2012;15(4):336–41.

    Google Scholar 

  23. Spasojevic M, Stimec BV, Fasel JF, Terraz S, Ignjatovic D. 3D relations between right colon arteries and the superior mesenteric vein: a preliminary study with multidetector computed tomography. Surg Endosc. 2011;25(6):1883–6.

    Article  CAS  Google Scholar 

  24. Skandalakis JE, Skandalakis LJ, Colborn GL, Pemberton LB, Gray SW. The duodenum. Surgical anatomy. Am Surg. 1989;55(5):291–8.

    CAS  PubMed  Google Scholar 

  25. Standring S. Grey’ anatomy, the anatomical basis of clinical practice, 41st edn. Am J Radiol. 2016;1088:1124.

    Google Scholar 

  26. Liu S, Liu C, Hu S. Clinical anatomical atlas of abdominal surgery. 2006;115:117.

  27. Le Voyer TE, Sigurdson ER, Hanlon AL, et al. Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol. 2003;21(15):2912–9.

    Article  Google Scholar 

Download references

Acknowledgment

The authors thank Jiaming Cao, who helped to prepare the video.

Funding

This study was funded by Scientific Research Project of Suining Central Hospital (Granted No. 2019y53) and Scientific Research Project of Suining City (Granted No. 2014s31).

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Authors and Affiliations

  1. Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China

    Wenjun Luo MD, Zhaolun Cai MD & Bo Zhang MD

  2. Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, Sichuan, China

    Wenjun Luo MD, Fugen Li MD, Tingting Lu MB, Zhengwen Xu MD & Yingdong Jia MD

Authors
  1. Wenjun Luo MD
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  2. Zhaolun Cai MD
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  3. Fugen Li MD
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  4. Tingting Lu MB
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  5. Zhengwen Xu MD
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  6. Yingdong Jia MD
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  7. Bo Zhang MD
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Correspondence to Wenjun Luo MD or Bo Zhang MD.

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Authors declare that they have no conflict of interest.

Ethical Approval

This study was approved by the ethics committee of Suining Central Hospital. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Luo, W., Cai, Z., Li, F. et al. Laparoscopic Complete Mesocolic Excision with Central Vascular Ligation (CME + CVL) for Right-Sided Colon Cancer: A New “Superior Mesenteric Artery First” Approach. Ann Surg Oncol 29, 5066–5073 (2022). https://doi.org/10.1245/s10434-022-11773-0

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