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Updated: May 9, 2026
Caudal-to-cranial Approach in Laparoscopic Right Hemicolectomy with Complete Mesocolon Excision and D3 Lymph Node Dissection
Published on: January 9, 2026
Short-term impact of the 'Marginal Gains' standardised workflow for laparoscopic right hemicolectomy with complete
Salvador Morales-Conde1,2, Andrea Scammon Duran1, Javier Valdes-Hernandez1
1Department of General and Digestive Surgery, University Hospital Virgen Macarena, University of Sevilla, Sevilla, Spain.
Background:
To evaluate the implementation and clinical impact of a standardised workflow for laparoscopic right hemicolectomy (LRH) with complete mesocolon excision (CME) using a cranial approach in colon cancer, the so-called 'Marginal Gains' project.
Methods:
This is a single-centre retrospective before-and-after cohort study of prospectively collected data. Outcomes of 29 patients undergoing LRH from 2022 to 2023 (control group) were compared with 34 patients treated between 2023 and 2024, after implementation of a structured CME-oriented workflow (intervention group). The primary outcome was the rate of workflow application and its clinical impact (secondary outcomes) in terms of CME rate (performed when clinically indicated), intraoperative events, 30-day postoperative complications, and lymph nodes harvested.
Results:
Baseline characteristics were comparable between groups. Workflow was applied in all cases. CME, performed according to predefined clinical criteria, was more frequent in the intervention group (13/34, 38.2%) than in the control group (1/29, 3.4%; p = .001), reflecting structured workflow adoption and potentially introducing selection bias. Overall postoperative complications occurred in 6/34 (17.6%) patients in the intervention group and 13/29 (44.8%) in the control group (p = .027), mainly driven by low-grade (Clavien I-II) events, particularly paralytic ileus (0 vs. 4 cases) and minor anastomotic bleeding (0 vs. 4 cases). One anastomotic leak occurred in the intervention group (2.9%), requiring reoperation with redo anastomosis (Clavien III-b). No significant differences were observed in tumour stage. The mean number of harvested lymph nodes was higher in the intervention group (22.18 ± 6 vs. 18.83 ± 6.50; p = .021).
Conclusions:
Implementation of the standardised CME-oriented workflow was feasible and associated with lower short-term postoperative morbidity and higher lymph node harvest. Given the non-randomised before-and-after design and limited sample size, these findings should be considered exploratory and hypothesis-generating rather than evidence of definitive improvement in surgical or oncological outcomes. Prospective multicentre validation is warranted.
