Total Medial Approach for Complete Mesocolic Excision of Advanced Transverse Colon Cancer; How To Approach Easily Ensuring Oncological Safety

Masato Kondo. Kobe City Medical Center General Hospital

INTRODUCTION

The laparoscopic surgery for advanced transverse colon cancer is still controversial in terms of technical difficulty caused by anatomical complexity around duodenum and pancreas including vascular abnormalities of middle colic vessels.

We aim to describe in detail our ordered, sequential laparoscopic approach for advanced transverse colon cancer under total medial approach ensuring the theory of complete mesocolic excision and central vessels ligation.

PROCEDURES

We place five trocars, one is umbilical endoscopy port, and other four ports are placed at the square under modified lithotomy position with both arms alongside the body.

At first, we expose superior mesenteric vein at the root of ileocolic vessels, and continuing to dissect and visualize the anterior side of the duodenum, pancreas head, and gastrocolic trunk along superior mesenteric vessels under medial approach. After accessory right colic vein is cut, right gastroepiploic vein can be easily taken down and separated from the transverse mosocolic fascia using ultrasonic coagulating devices on the right side of middle colic vessels.

Secondly, we cut the transverse mesocolic fascia at the lower edge of the pancreas body just above Treitz ligament, and open omental bursa on the left side of middle colic vessels.

Then we can do lymphadenectomy and cut the root of middle colic vessels easily and safely from the right and left side, that we call pinsers movement. Central vessels ligation is done under total medial approach before mobilizing the transverse colon without injuring the duodenum and pancreas head and body.

Finally, we mobilize the hepatic-flexure and splenic-flexure by almost medial-to-lateral approach and transect the greater omentum. The transverse colon can be mobilized, cut, and anastomosed intracorporeally or extracorporeally.

RESULTS

From November 2012 to April 2014, There were 138 patients with colon cancer operated laparoscopically, and 20 cases of advanced transverse colon cancer were all operated under this method. There was no conversion to open surgery and no postoperative complications more than Grade 3 in the Clavien-Dindo classification.

CONCLUSIONS

This approach leads to early ligation of tumor feeding vessels and complete mesocolic excision can be done preventing exposure of potentially positive lymph nodes before mobilizing the transverse colon. We believe this method is easy to learn, established, and also safe and feasible in oncology as a non-touch isolation technique for advanced transverse colon cancer.