Laparoscopic Right Colectomy plus Complete Excision of the Mesocolon and Central Vascular Ligation.

Abstract

Introduction.

Oncological right colectomy is the surgical treatment of choice for right colon cancer. However, for several years now, with the publication of Hohenberger on the standardization of the right colectomy, the necessary extension in lymphadenectomy has been discussed, when one performs surgery with curative intent. Today, the concept of D3 lymphadenectomy is accompanied by complete excision of the mesocolon and central vascular ligation of the pedicles of the right colon. The first ensures the inclusion of the entire right mesocolon and the right part of the transverse mesocolon, between its peritoneal sheets, when dissecting the embryological planes, mainly the right Toldt's fascia and the preduodenopancreatic Fredet's fascia. On the other hand, the central vascular ligation allows at least the ganglionic harvesting of all the ganglia up to the origin of the right colic vessels (D2) and eventually of those that are in front of the superior mesenteric vessels (D3).

Description.

We present the clinical case of a 69-year-old patient, hypothyroid, polycythemia vera treated with 100mg daily of acetylsalicylic acid. Diarrhea for months of evolution, positive fecal occult blood test. Colonoscopy showed a vegetating and ulcerated 30mm lesion occupying 1/3 of the circumference in the ascending colon. CEA and CA 19-9 were in the normal range. The computed tomography showed the parietal thickening of the ascending colon and lymphadenopathy in the meso. Absence of systemic spread.

It was decided to perform an oncological right colectomy with complete excision of the mesocolon and central vascular ligation.

The patient is placed in a 30º left lateral Trendelenburg position. Pneumoperitoneum with optic trocar up to 12mmHg. 3 operative trocars, 1 of 12mm in the left iliac fossa midclavicular line, another of 5mm in the midline equidistant from the pubis and umbilicus, and another of 5mm in the right flank anterior axillary line. Examination confirms the topography of the lesion and rules out liver and peritoneal disease. Medial approach to the right mesocolon starting below the ileus colic pedicle through the right Toldt's fascia. Clipping and sectioning of the ileocolic pedicle, vein and artery were carried out separately, at their origin. Dissection of the right border of the superior mesenteric vein. Clipping and sectioning of the right superior colic pedicle at its origin (the artery had a common trunk and two branches, clipped and sectioned separately), identifying and respecting the venous trunk of Henle. The section of the greater omentum was completed over the section boundary in the transverse colon. Section of the gastrocolic ligament from medial to lateral. Section of the right parietocolic ligament, mobilization of the last ileal loop and the ascending colon until they are completely liberated. Perfusion of the ileal and colonic section ends with immunofluorescence (indocyanine green) was verified. The transverse colon and distal ileum were sectioned with 60mm violet EndoGIAÒ. Intracorporeal isoperistaltic latero-lateral ileotransverse anastomosis was made with EndoGIAÒ of 60mm purple, and closure of the ostomy in 2 planes with V-LocÒ 3-0. The pathological anatomy confirmed a moderately differentiated adenocarcinoma T4aN0M0. Under a multimodal ERAS protocol, the patient had an excellent postoperative evolution, and was discharged 72 hours after surgery.

After 5 months postoperatively, the patient is asymptomatic, receiving adjuvant Capecitabine indicated by oncology.

Conclusions.

Oncological right colectomy remains the gold standard for curative treatment of right colon cancer.

The complete excision of the mesocolon and the central vascular ligation represent today the standardized and safe way for a surgery with curative intention.

The decision to perform extended D3 lymphadenectomy must be individualized for each patient, and must be made by a team trained in such surgery.