COMPLETELY MEDIAL ACCESS BY PAGE-TURNING APPROACH FOR LAPAROSCOPIC RIGHT HEMI-COLECTOMY: 6-YEAR-EXPERIENCE IN SINGLE CENTER

Zirui He, Sen Zhang, Pei Xue, Minhua Zheng, FRCS, Bo Feng. Shanghai Minimally Invasive Surgery Center, Ruijin Hospital

Objective: To investigate the feasibility and surgical strategy of complete mesocolic excision (CME) with completely medial access by “page-turning” approach (CMAPA) for the laparoscopic right hemi-colectomy.

Methods and procedures: The CMAPA is a modified medial approach of CME, which focus on the exploration of surgical plane instead of the recognition of vessels.

Surgical procedures: (1) Start point: the anatomy projection of ileocolic vessel; (2) Expose the whole trunk of SMV to the level of inferior edge of pancreas before ligating any branches, for the purpose of high tie and verifying their location;(3) Enter the intermesenteric space (IMS) and right retrocolic space (RRCS) with cranial and right extension through transverse retrocolic space (TRCS); (4) Complete mobilize the mesocolon and remove the tumor en-bloc. See Figure 1?2.

Results:

Clinical outcome:

From September 2011 to March 2017,there were 72 patients underwent CMAPA in Shanghai Ruijin Hospital. The average operation time was 135.9 ± 28.3 minutes, average blood loss was 63.2 ± 32.2ml, number of lymph node was 20.6 ± 7.7, average specimen length was 23.9 ± 4.7cm, flatus time was 2.5 ± 0.8days, fluid intake time was 3.2 ± 0.8 days and average hospital stay was 8.9 ± 4.7days. The overall complications rate was 6.94%(5/72). Compared to traditional medial approach of CME performed in our center, the blood loss, operation time and hospital stay were significantly reduced by performing CMAPA for laparoscopic right hemi-colectomy.

Conclusion: The advantage of the CMAPA

(1)To avoid the laparoscopic “leverage effect” and “tunnel effect”.

(2)To make the branches of superior mesenteric vessels more easily recognized.

(3)To offer surgeons an alternative route entering the TRCS, IMS and RRCS.

(4)To avoid repetitive flipping of the colon complying with the “no touch” principle, and to lower the requirements of assistants.

Figure1: Anatomy and surgical planes concerning CMAPA

Figure 2: The surgical procedures of CMAPA. A: Start point; B: Dissection of the surgical trunk; C: Exploring the TRCS and RRCS; D: Dissection of lymph nodes and vessels.