Laparoscopic complete mesocolic excision via combining median-to-lateral and anterior-to-median approaches for transvers colon cancer

Shinichiro Mori, Kenji Baba, Yoshiaki Kita, Masayuki Yanagi, Yasuto Uchikado, Takaaki Arigami, Yoshikazu Uenosono, Yuko Mataki, Hiroshi Okumura, Akihiro Nakajo, Kosei Maemura, Sumiya Ishigami, Shoji Natsugoe. Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima

INTRODUCTION

Many large randomized trials of laparoscopic colectomy have shown short-term benefits and oncologically safety for colon cancer excluded patients with transverse colon cancer. So laparoscopic colectomy for transvers colon cancer is still a surgically challenging procedure because of its complex anatomy, being few previously reports mentioned the surgical strategy. We have evaluated the safety and feasibility of laparoscopic complete mesocolic excision (CME) via combining median-to-lateral and anterior-to-median (MLAM) approaches based on embryology of mesocolon in the treatment of transvers colon cancer.

METHODS AND PROCEDURES

Patients

We retrospectively analyzed 11 consecutive patients with transvers colon cancer. Laparoscopic CME via combining MLAM approaches were performed between July 2010 and June 2014. We used video recordings of the procedure to assess the quality of the surgery and completeness of CME. We also assessed operative data, pathological findings, length of large bowel resected, complications, BMI, length of hospital stay.

Surgical procedure:

All patients were administered general anesthesia and placed in the lithotomy position. A pneumoperitoneum was maintained at 10 mm Hg using CO2. Median-to-lateral approach was performed by dissecting the mesocolon above SMV and proceeded along the duodenum. After the embryological tissue planes comprising Told’s and pre-renal fascia had been exposed, a wide separation between the pancreatic head and transverse mesocolon was achieved. Dissection proceeded along the SMV, exposing the gastrocolic trunk of Henle (GCT) from median. Then, the middle colic artery was identified arising SMA with dissecting lymph nodes, and the vessels were cut at the root of its branches. Next, an anterior-to-median approach was performed by dissecting the greater omentum of the greater omentum. The fusion fascia was detached between the omentum and transverse mesocolon based on embryology. And the hepatic and splenic flexures were mobilized. The accessory middle colic veins were carefully dissected with 3-D recognition of GCT or middle colic veins via combining MLAM approaches. The transverse mesocolon dissected below the lower edge of the pancreas. And then, a minilaparotomy was performed via the umbilicus, the incision being approximately 4 cm in diameter. The excised specimen was extracted through this incision with wound protection, after which extracorporeal functional end-to-end anastomosis was performed using linear staplers.

RESULTS

All patients had undergone en bloc resection of the enveloped parietal planes. Five and six patients graded mesocolic and intra-mesocolic plane, respectively. These 6 patients graded intra-mesocolic plane underwent high ligation of the root of its branches. Four, zero, four, and three patients had T1, T2, T3, and T4 tumors, respectively. The median number of lymph nodes retrieved was 21.8, lymph node metastasis being identified one patient. The mean length of large bowel resected was 21 cm. The mean operative time and intraoperative blood loss were 299 min and 41 mL, respectively. No intraoperative complications occurred in any patient. One patient had postoperative complication. The mean BMI was 23.6 kg/m2. The median postoperative hospital stay was 15 days.

CONCLUSIONS

Laparoscopic CME via MLAM approaches based on embryology is a safe and feasible procedure for transvers colon cancer.