[Optimizing the laparoscopic steps in right colectomy with complete mesocolic excision to reduce the intraoperative...

Laparoscopic right colectomy by the rule of complete mesocolic excision is becoming a standard operation for right colon cancer. Intraoperative iatrogenic vascular injuries are rare but disastrous complications. In addition to the dissection along the embryonic plane, reducing iatrogenic bleeding is of crucial importance to safeguard the surgical procedure. Keeping the operative field clear by gentle suction to have a good exposure is essential to identify the origin of bleeding, and then to make decision how to control the bleeding by bipolar coagulation, clipping and transection, suturing or conversion to open surgery. For small bleeding, the grasping forceps with bipolar coagulation or clipping would usually be effective. When there is laceration locating on the stem of superior mesenteric vein or Henle trunk, suturing with 4-0 or 5-0 prolene monofilament is suggested. Self-saphenous graft or bridge is advised for stem stricture after suturing. The ileocolic vessels are most anatomically constant, but with a different relationship between the artery and the vein. The tributaries to form the Henle trunk vary quite often, and they usually have close relation to the middle colic vein. Right colic artery rarely arises from the superior mesenteric artery, and the right colic vein seldom drains into the superior mesenteric vein. Anatomical variations are commonly observed in the pancreaticoduodenal area, where bleeding happens frequently. Selecting an optimal laparoscopic approach and dissecting order, awareness of vascular variation, and understanding the anatomical configuration of superior mesenteric vessels and their tributaries are important to minimize the intraoperative iatrogenic injuries during the meticulous dissections.