Laparoscopic complete mesocolic excision conducted by combining medial and cranial approaches for transvers colon cancer

Shinichiro Mori, Yoshiaki Kita, Kenji Baba, Masayuki Yanagi, Yusuke Tsuruta, Takako Tanaka, Yuko Mataki, Kosei Maemura, Yasuto Uchikado, Shoji Natsugoe. Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima

Objective: We have evaluated the safety and feasibility of laparoscopic complete mesocolic excision (CME) conducted by combining medial and cranial (MC) approaches with lymph node dissection around the gastrocolic trunk (GCT) and the middle colic vessels for transvers colon cancer.

Patients and Methods: We retrospectively analyzed 18 consecutive patients with transverse colon cancer who had undergone laparoscopic complete mesocolic excision (CME) via combined medial and cranial (MC) approaches between July 2009 and June 2015 by studying video recordings of the procedure and assessing operative data, pathological findings, length of bowel resected, complications, and length of hospital stay.

Surgical procedure: The medial approach was performed by dissecting the peritoneum behind the the ileocolic vessels and separating between mesocolon and fusion fascia. The ileocolic vessels were then divided at their roots. Lymph node dissection proceeded along the SMV to expose the middle colic artery (MCA) and its branches. The MCA was identified arising from the SMA and these vessels were severed at the roots of their branches. Subsequently, the GCT and its branches were carefully and sufficiently exposed from the medial side. A wide separation of embryological tissue plane between the pancreatic head and transverse mesocolon was performed, and then the separation of the mesofascial plane was also performed. In patients with left transverse colon cancer, dissection of the peritoneum behind the inferior mesenteric vein was followed by performing mesofascial separation between the descending mesocolon and fusion fascia, and mobilizing the splenic flexure.

Next, a cranial approach was performed by dissecting the greater omentum, after which the fusion fascia between the omentum and transverse mesocolon was detached, exposing the SMV, and the hepatic flexure was mobilized in continuity. The accessory middle colic veins were carefully dissected with 3dimensional identification of the GCT via both of the MC approaches.

Results: Sixteen and two patients graded mesocolic and intra-mesocolic plane, respectively. Nine, two, four, and three patients had T1, T2, T3, and T4a tumors, respectively. The median number of lymph nodes retrieved was 17.2, no lymph node metastasis being identified. The mean length of large bowel resected was 23.3 cm. The mean operative time and intraoperative blood loss were 272 min and 41 mL, respectively. No intraoperative complications occurred in any patient. Two patients had postoperative complications. The median postoperative hospital stay was 15 days.

Conclusions: Laparoscopic CME via combined MC approaches is a safe and feasible procedure for transverse colon cancer.