Abstract
Background
Current evidence suggests that complete mesocolic excision (CME) for right-sided colon cancer could be beneficial in terms of long-term survival. However, CME is a considerably more complex operation than standard right hemicolectomy; this is especially true for the laparoscopic approach. Consequently, we have explored a new laparoscopic approach that provides surgical radicality at the mesenteric root on the one hand and maximum safety on the other hand.
Methods
The key feature of the uncinate process first approach (UFA) is the commencement of the dissection at the fourth part of the duodenum using a medial to lateral approach, thus mobilizing the whole mesenteric root posteriorly before the central parts of the mesenteric vessels are accessed. Twenty-eight selected patients with right-sided colon cancer underwent surgery using the UFA and were compared with 51 patients who underwent an open CME procedure (CON). In 11/28 and 51/51 patients in the UFA and CON groups, respectively, a planimetric assessment of the specimen was performed.
Results
Surgical time was longer (144.8 vs. 202.5 min; p < 0.000) and postoperative stay shorter (8.0 vs. 10.5 days; p < 0.01) for the laparoscopic approach. The area of the resected mesentery (UFA, 15,097 mm2; CON, 15,788 mm2; p = 0.47) and the lymph node count (UFA, 59.0; CON, 51.0; p = 0.09) was not significantly different; additionally, no difference was observed regarding anastomotic leakage (both n = 0) and postoperative mortality (UFA, 0/28; CON, 1/51; p = 1.0).
Conclusion
Laparoscopic right hemicolectomy with CME using the UFA provides adequate radicality according to the CME principles and seems feasible and as safe as an open technique. However, future trails will have to demonstrate whether the theoretical advantages of the UFA, with a higher degree of mobility and accessibility of the mesenteric root, translate into a significant clinical benefit, especially relative to the other laparoscopic techniques.
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References
Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S (2009) Standardized surgery for colonic cancer: complete mesocolic excision and central ligation–technical notes and outcome. Colorectal Dis 11(4):354–364. doi:10.1111/j.1463-1318.2008.01735.x (discussion 364–355)
Culligan K, Walsh S, Dunne C, Walsh M, Ryan S, Quondamatteo F, Dockery P, Coffey JC (2014) The mesocolon: a histological and electron microscopic characterization of the mesenteric attachment of the colon prior to and after surgical mobilization. Ann Surg 260(6):1048–1056. doi:10.1097/SLA.0000000000000323
Bokey EL, Chapuis PH, Dent OF, Mander BJ, Bissett IP, Newland RC (2003) Surgical technique and survival in patients having a curative resection for colon cancer. Dis Colon Rectum 46(7):860–866. doi:10.1097/01.DCR.0000074731.78773.BB
Gillot C, Hureau J, Aaron C, Martini R, Thaler G, Michels NA (1964) The Superior mesenteric vein, an anatomic and surgical study of eighty-one subjects. J Int Coll Surg 41:339–369
Toyota S, Ohta H, Anazawa S (1995) Rationale for extent of lymph node dissection for right colon cancer. Dis Colon Rectum 38(7):705–711
Benz SR, Tannapfel A, Tam Y, Stricker I (2014) [Complete mesocolic excision for right-sided colon cancer—the role of central lymph nodes]. Zentralblatt fur Chirurgie. doi:10.1055/s-0034-1383133
West NP, Hohenberger W, Weber K, Perrakis A, Finan PJ, Quirke P (2010) Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon. J Clin Oncol 28(2):272–278. doi:10.1200/JCO.2009.24.1448
West NP, Morris EJ, Rotimi O, Cairns A, Finan PJ, Quirke P (2008) Pathology grading of colon cancer surgical resection and its association with survival: a retrospective observational study. Lancet Oncol 9(9):857–865. doi:10.1016/S1470-2045(08)70181-5
Juo YY, Hyder O, Haider AH, Camp M, Lidor A, Ahuja N (2014) Is minimally invasive colon resection better than traditional approaches? First comprehensive national examination with propensity score matching. JAMA Surg 149(2):177–184. doi:10.1001/jamasurg.2013.3660
Schwenk W, Neudecker J, Haase O (2014) Current evidence for laparoscopic surgery of colonic cancer. Der Chirurg Zeitschrift fur Alle Gebiete der Operativen Medizen 85(7):570–577. doi:10.1007/s00104-014-2742-x
Rondelli F, Trastulli S, Avenia N, Schillaci G, Cirocchi R, Gulla N, Mariani E, Bistoni G, Noya G (2012) Is laparoscopic right colectomy more effective than open resection? A meta-analysis of randomized and nonrandomized studies. Colorectal Dis 14(8):e447–469. doi:10.1111/j.1463-1318.2012.03054.x
Cho MS, Baek SJ, Hur H, Soh Min B, Baik SH, Kyu Kim N (2014) Modified complete mesocolic excision with central vascular ligation for the treatment of right-sided colon cancer: long-term outcomes and prognostic factors. Ann Surg. doi:10.1097/SLA.0000000000000831
Jacobs M, Verdeja JC, Goldstein HS (1991) Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1(3):144–150
Killeen S, Mannion M, Devaney A, Winter DC (2014) Complete mesocolic resection and extended lymphadenectomy for colon cancer: a systematic review. Colorectal Dis 16(8):577–594. doi:10.1111/codi.12616
Dijkstra FA, Bosker RJ, Veeger NJ, van Det MJ, Pierie JP (2014) Procedural key steps in laparoscopic colorectal surgery, consensus through Delphi methodology. Surg Endosc. doi:10.1007/s00464-014-3979-7
Hasegawa S, Kawamura J, Nagayama S, Nomura A, Kondo K, Sakai Y (2007) Medially approached radical lymph node dissection along the surgical trunk for advanced right-sided colon cancers. Surg Endosc 21(9):1657. doi:10.1007/s00464-007-9305-x
Mori S, Baba K, Yanagi M, Kita Y, Yanagita S, Uchikado Y, Arigami T, Uenosono Y, Okumura H, Nakajo A, Maemuras K, Ishigami S, Natsugoe S (2014) Laparoscopic complete mesocolic excision with radical lymph node dissection along the surgical trunk for right colon cancer. Surg Endosc. doi:10.1007/s00464-014-3650-3
Feng B, Sun J, Ling TL, Lu AG, Wang ML, Chen XY, Ma JJ, Li JW, Zang L, Han DP, Zheng MH (2012) Laparoscopic complete mesocolic excision (CME) with medial access for right-hemi colon cancer: feasibility and technical strategies. Surg Endosc 26(12):3669–3675. doi:10.1007/s00464-012-2435-9
Jin G, Tuo H, Sugiyama M, Oki A, Abe N, Mori T, Masaki T, Atomi Y (2006) Anatomic study of the superior right colic vein: its relevance to pancreatic and colonic surgery. Am J Surg 191(1):100–103. doi:10.1016/j.amjsurg.2005.10.009
Abraham NS, Young JM, Solomon MJ (2004) Meta-analysis of short-term outcomes after laparoscopic resection for colorectal cancer. Br J Surg 91(9):1111–1124. doi:10.1002/bjs.4640
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The contribution of Mrs Alexandra Gayer in managing the database is gratefully acknowledged.
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The authors, Professor Tannapfel, Dr. Stricker, Dr. Tam and Professor Benz, have no conflicts of interest or financial ties to disclose.
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Benz, S., Tam, Y., Tannapfel, A. et al. The uncinate process first approach: a novel technique for laparoscopic right hemicolectomy with complete mesocolic excision. Surg Endosc 30, 1930–1937 (2016). https://doi.org/10.1007/s00464-015-4417-1
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DOI: https://doi.org/10.1007/s00464-015-4417-1