Laparoscopic Radical Extended Right Hemicolectomy Using a Caudal-to-Cranial Approach

Due to the emphasis of oncologic principle, a medial-to-lateral approach for laparoscopic right hemicolectomy was recommended.1 (,) 2 This approach, however, is technically challenging and involves several limitations with overweight patients, whose mesocolon may be too thick for identification of the vessel landmarks. Moreover, it is difficult for inexperienced surgeons to enter the retroperitoneum space accurately. This report describes a caudal-to-cranial approach for laparoscopic radical extended right hemicolectomy.

First, a "yellow-white borderline" between the right mesostenium and retroperitoneum in the right iliac fossa is dissected as the entry for separation of the fusion fascial space between the visceral and parietal peritoneum.3 The right Toldt's fascia is dissected and expanded medial to the periphery of the superior mesenteric vein (SMV), cranial to the pancreas head, and lateral to the ascending colon. The posterior paries of ileocolic vessels (ICVs), right colic vessels (RCVs), and Henle's trunk are exposed. Second, the mesocolon between the ICV and SMV is dissected safely, and the ICV, RCV, and right gastroepiploic vessels as well as the right branch of the middle colic vessel are divided and ligated easily because of the separated retroperitoneal space. The lymph nodes along the SMV are dissected using a caudal-to-cranial approach. Third, the greater omental is dissected for full mobilization of the mesocolon containing 10 cm of normal colon distal to the lesion followed by complete mobilization of the lateral attachments of the ascending colon.

In this study, 10 men and 8 women with hepatic flexure cancer underwent laparoscopic extended right hemicolectomy using a caudal-to-cranial approach. No conversion was recorded. The overall complication rate was 11.2 %, including one case of pulmonary infection and one case of urinary tract infection, both of which were cured with conservative measures. The mean age of the patients was 61.3 ± 12.7 years, and the mean body mass index was 22.1 ± 4.5 kg/m(2). The mean operative time was 187.5 ± 47.7 min, and the mean blood loss was 100.4 ± 45.2 ml. The mean first time of flatus was 57.7 ± 26.3 h, and the time of fluid intake was 62.9 ± 29.2 h. The hospital stay was 8.5 ± 4.2 days. The mean number of lymph nodes retrieved was 37.3 ± 12.8.

The initial results suggest that the reported approach may be a safe alternative to the conventional medial-to-lateral approach, especially for inexperienced surgeons. The main advantages of the current approach are easy access to the retroperitoneal space by protection of the ureter, safe dissection of lymph nodes along the SMV, and a potentially shortened learning curve.