The laparoscopic right hemi-colectomy CME with completely medial access by “page-tunrning” approach

Bo Feng, Min-Hua Zheng. Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

Objective:

To investigate the feasibility and technical strategies of laparoscopic complete mesocolic excision (CME) with completely medial access by “page-turning” approach (CMAPA) for the right hemi-colon cancer .

Description:

The laparoscopic CME with CMAPA is conducted in the “inside-to-outside” and “bottom-to up”  direction, which adopts the strategy of “point-to-line”  and “line-to-plane”.  Point: Taking the the anatomy projection of ileocolic vessel as starting point; Line: Dissecting the vessel along the superior mesenteric vein; Plane: Taking the transverse retrocolic space (TRCS) as surgical operation plane.

The operational procedures are conducted as following: (1) Take the the anatomy projection of ileocolic vessel as the starting point and confirming the accurate location of superior mesenteric vein(SMV); (2) Dissect the surgical trunk along the SMV, ligation at the origin of the central vessel and enter the lesser peritoneal sac by the inferior edge of the pancreas;(3) Enter the intermesenteric space (IMS) and right retrocolic space RRCS with cranial and right extension through TRCS; (4) Complete mobilize the mesocolon and remove the tumor package. See Figure 1?2.

Figure1: The anatomical diagram for the direction of CMAPA and related anatomy plane and tissues

Figure 2: The operational procedures of CMAPA. A: Initiation. B: Dissection of the surgical trunk. C: Entering the TRCS and extension. D Post lymph node resections.

The short-term outcome of the CMAPA:

During September 2011 and October 2015,there were 85 patients underwent surgeries by CMAPA. The operation time, blood loss volume, number of lymph node dissection and specimen length, time to anal exsufflation, time for fluid diet intake and duration of hospital stay were (126 ± 35) minutes, (75 ± 36)ml, 21 ± 5, (22 ± 5)cm, (2.7 ± 1.6)days, (3.7 ± 1.8)days and (12 ± 4)days. No meaningful difference was found between CMAPA and our study before.

The advantage of the CMAPA

(1)Reduce the “Leverage Effect” and “Tunnel Effect” effectively. Then, we can extend the operation field and avoid damaging the surrounding vessels and tissues during the surgery.
(2)Handle the variation of the right hemi-colon vessel more safely under direct vision, especially for the surgical trunk, which can lead to less blood loss and more clearly operation field.
(3)Because of the direction of “inside-to-outside” and “bottom-to up” combined with the strategy of “point-to-line” and “line-to-plane”, it’s easier for doctors to identify and enter the TRCS, then extend to the IMS and RRCS, which leads to complete mobilize and remove the intact mesocolon. All the operational approaches were performed just like the “page-turning”.
(4)Comply more with the “no touch isolation”. It starts with the dissection of the surgical trunk and ligation of the central vessel followed by the mobilization of the mesocolon, which greatly decreases the possibility of blood metastasis.
(5)Make it easier for the surgery cooperation. The procedures were conducted by a more “reasonable” direction, which avoid the repetitive flipping of the colon and mesocolon, and the demand lower requirements for assistants.