Laparoscopic top-down right hemicolectomy: a new surgical technique to complete mesocolic excision

In the present study we describe our top-down approach as a suitable, safe, and reproducible alternative technique for complete mesocolic excision (CME) in right hemicolectomy. The Top-down technique permits the correct identification and resection of gastrocolic trunk vessels at a safe distance from the pancreas and mesenteric vessels. This is possible thanks to the previous creation of two opened windows at Treves' avascular area and at the transverse mesocolon that lifts the lymphovascular tissue from the pancreas. This gentle dissection, avoiding major vascular trauma, reduces the complications related to traditional CME. The top-down technique was performed at "Guglielmo da Saliceto" Hospital in Piacenza, Italy. Thirty-two consecutive patients who underwent right hemicolectomy for cancer by the same surgeon were included, 16 with medial-to-lateral approach and 16 with the new top-down technique. Top-down CME showed a shorter surgical time, 178.3±41.9 vs. 222.1±35.6 minutes of bottom-up approach (P=0.003). The number of retrieved lymph nodes was slightly higher in top-down CME, 25.7±11.6 vs. 22.0±7.2 in the standard procedure. A similar postoperative course was observed between the two techniques. Severe complications (Clavien-Dindo > 3b) were not observed in the top-down group. The results of this preliminary analysis show a safe approach to laparoscopic CME, avoiding vascular injuries and prolonged surgical time.