Skip to main content
SpringerLink
Log in

Defining minimal clearances for adequate lymphatic resection relevant to right colectomy for cancer: a post-mortem study

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

There has been a lengthy discussion on the extent of lymphatic resection for right-sided colon cancer and the central borders of the mesentery that are not yet defined. The objectives of this study are to define minimal clearances for adequate lymphatic resection in regard to colic artery origins and the superior mesenteric artery (SMA) and vein (SMV) relevant to right colectomy.

Methods

Central mesenteric lymph vessels, nodes, and blood vessels were dissected in 16 cadavers. Cranial–caudal clearances were defined as distances between an individual colic artery origin (ileocolic, right colic, and median colic artery) and the outermost lymphatic vessel within its lymphovascular bundle, cranial and caudal along the SMA. Long lymphatic vessels crossing the SMV between arterial bundles were counted and they constituted the medial clearances. An arbitrary watershed between small bowel and colonic lymph was localized. Immunohistochemistry was performed to histologically verify lymphatic vessels.

Results

Cranial–caudal clearances were ileocolic 3.6 ± 1.9 and 5.7 ± 1.9; right colic 2.8 ± 1.6 and 3.3 ± 1.0; middle colic artery bundle 6.3 ± 2.7 and 5.9 ± 2.4 mm, respectively. Long lymphatic vessels crossing the SMV between arterial buntles and approaching the SMA were found in all cadavers (antero/posteriorly in 12, only anteriorly in 4), median 3.5 (1–7) long lymphatic vessels anteriorly, and 1.5 (0–5) posteriorly per cadaver.

Conclusions

Right colonic lymphovascular bundles are volumes of mesenteric tissue that surround the superior mesenteric vessels anteriorly and posteriorly. Long lymphatic vessels traverse the superior mesenteric vein anteriorly/posteriorly approaching the superior mesenteric artery between arterial bundles and placing the medial clearance on the left side of the artery. These do not correlate to arterial crossing patterns. Cranial–caudal clearances determine the tissue to be removed superior/inferior to arterial origins together with long lymphatic vessels transversing independently between the lymphovascular bundles placing the weight of lymphatic resection on the mesenteric tissue and not on the level of vessel division (High tie).

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Culligan K, Sehgal R, Mulligan D, Dunne C, Walsh S, Quondamatteo F et al (2014) A detailed appraisal of mesocolic lymphangiology—an immunohistochemical and stereological analysis. J Anat 225(4):463–472

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  2. Jamieson JK, Dobson JF (1909) Lymphatics of the colon: with special reference to the operative treatment of cancer of the colon. Ann Surg 50(6):1077–1090

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  3. Jinnai A (1983) General rules for clinical and pathological studies on cancer of the colon, rectum and anus. Part I. Clinical classification. Japanese Research Society for Cancer of the Colon and Rectum. Jpn J Surg 13(6):557–573

    Article  Google Scholar 

  4. 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

    Article  PubMed  CAS  Google Scholar 

  5. 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 (discussion 64–65)

    Article  PubMed  CAS  Google Scholar 

  6. Munkedal DLE, Rosenkilde M, Tonner Nielsen D, Sommer T, West NP, Laurberg S (2017) Radiological and pathological evaluation of the level of arterial division after colon cancer surgery. Colorectal Dis 19(7):O238–O245

    Article  PubMed  CAS  Google Scholar 

  7. Weber K, Hohenberger W (2012) Right hemicolectomy with central vascular ligation in colon cancer. Surg Endosc 26(1):282

    Article  PubMed  Google Scholar 

  8. Hirche C, Mohr Z, Kneif S, Doniga S, Murawa D, Strik M et al (2012) Ultrastaging of colon cancer by sentinel node biopsy using fluorescence navigation with indocyanine green. Int J Colorectal Dis 27(3):319–324

    Article  PubMed  Google Scholar 

  9. Soltesz EG, Kim S, Kim SW, Laurence RG, De Grand AM, Parungo CP et al (2006) Sentinel lymph node mapping of the gastrointestinal tract by using invisible light. Ann Surg Oncol 13(3):386–396

    Article  PubMed  Google Scholar 

  10. Cahill RA, Perretta S, Leroy J, Dallemagne B, Marescaux J (2008) Lymphatic mapping and sentinel node biopsy in the colonic mesentery by natural orifice transluminal endoscopic surgery (NOTES). Ann Surg Oncol 15(10):2677–2683

    Article  PubMed  CAS  Google Scholar 

  11. Lo Dico R, Lasser P, Goere D, Malka D, Boige V, Pocard M (2010) Lymph road mapping obtained via blue sentinel node detection to avoid middle colic artery resection for highly selected colon cancer cases: proof of a concept? Tech Coloproctol 14(3):237–240

    Article  PubMed  CAS  Google Scholar 

  12. Kimura W (2000) Surgical anatomy of the pancreas for limited resection. J Hepatobiliary Pancreat Surg 7(5):473–479

    Article  PubMed  CAS  Google Scholar 

  13. Nesgaard JM, Stimec BV, Bakka AO, Edwin B, Ignjatovic D (2015) Navigating the mesentery: a comparative pre- and per-operative visualization of the vascular anatomy. Colorectal Dis 17(9):810–818

    Article  PubMed  CAS  Google Scholar 

  14. Banerji S, Ni J, Wang SX, Clasper S, Su J, Tammi R et al (1999) LYVE-1, a new homologue of the CD44 glycoprotein, is a lymph-specific receptor for hyaluronan. J Cell Biol 144(4):789–801

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  15. Liersch R, Hirakawa S, Berdel WE, Mesters RM, Detmar M (2012) Induced lymphatic sinus hyperplasia in sentinel lymph nodes by VEGF-C as the earliest premetastatic indicator. Int J Oncol 41(6):2073–2078

    Article  PubMed  PubMed Central  Google Scholar 

  16. Viamonte M Jr, Ruttiman A (1980) Atlas of lymphography. Georg Thieme Verlag, New York

    Google Scholar 

  17. Spasojevic M, Stimec BV, Dyrbekk AP, Tepavcevic Z, Edwin B, Bakka A et al (2013) Lymph node distribution in the d3 area of the right mesocolon: implications for an anatomically correct cancer resection. A postmortem study. Dis Colon Rectum 56(12):1381–1387

    Article  PubMed  Google Scholar 

  18. Soerenson RL (2008) Atlas of human histology, 2nd edn. Academic Press, New York

    Google Scholar 

  19. Bertelsen CA, Neuenschwander AU, Jansen JE, Wilhelmsen M, Kirkegaard-Klitbo A, Tenma JR et al (2015) Disease-free survival after complete mesocolic excision compared with conventional colon cancer surgery: a retrospective, population-based study. Lancet Oncol 16(2):161–168

    Article  PubMed  Google Scholar 

  20. Ignjatovic D (ed) Laparoscopic D3 lymphadenectomy for right colon cancer. A videopresentation. 25th International EAES Congress; 2017 15th of June 2017; Frankfurt, Germany. Room 1: Auditorium

  21. Thorsen Y, Stimec B, Andersen SN, Lindstrom JC, Pfeffer F, Oresland T et al (2016) Bowel function and quality of life after superior mesenteric nerve plexus transection in right colectomy with D3 extended mesenterectomy. Tech Coloproctol 20(7):445–453

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Digestive Surgery, Vestfold Hospital Trust, Postbox 2168, 3103, Tønsberg, Norway

    Jens Marius Nesgaard

  2. Department of Cellular Physiology and Metabolism, Faculty of Medicine, University of Geneva, Geneva, Switzerland

    Bojan V. Stimec

  3. Histology Core Facility, Faculty of Medicine, University of Geneva, Geneva, Switzerland

    Pricilla Soulie

  4. Interventional Centre, Gastrointestinal and Pediatric Surgery, Oslo University Hospital–Rikshospitalet, Oslo, Norway

    Bjørn Edwin

  5. Institute of Clinical Medicine, University of Oslo, Oslo, Norway

    Bjørn Edwin, Arne Bakka & Dejan Ignjatovic

  6. Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lorenskog, Norway

    Arne Bakka & Dejan Ignjatovic

Authors
  1. Jens Marius Nesgaard
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bojan V. Stimec
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pricilla Soulie
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Bjørn Edwin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Arne Bakka
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Dejan Ignjatovic
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jens Marius Nesgaard.

Ethics declarations

Disclosures

Jens Marius Nesgaard, Bojan V. Stimec, Bjørn Edwin, Pricilla Soulie, Arne O. Bakka, and Dejan Ignjatovic have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nesgaard, J.M., Stimec, B.V., Soulie, P. et al. Defining minimal clearances for adequate lymphatic resection relevant to right colectomy for cancer: a post-mortem study. Surg Endosc 32, 3806–3812 (2018). https://doi.org/10.1007/s00464-018-6106-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-018-6106-3

Keywords

Search

Navigation