1
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Chemtob A, Ignjatovic D, Stimec BV. Retrocolic Fascia-An Anatomical and Multidetector Computed Tomographic Angiography (MDCTA) Morphometric Analysis in Patients with Right Colon Cancer. Diagnostics (Basel) 2024; 14:1952. [PMID: 39272736 PMCID: PMC11393973 DOI: 10.3390/diagnostics14171952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 08/30/2024] [Accepted: 08/30/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND This study aims to delineate anatomical landmarks crucial for complete mesocolic excision, focusing on Gerota's fascia, which guides surgical dissection in right-sided colon cancer, forming the posterior limit. Employing a multimodal approach, the research aims to understand the fascial anatomy and its variations under pathological conditions. METHODS Three methods were applied: a pilot dissection on an embalmed cadaver for clear anatomical presentation of prerenal fascia, Mimics segmentation of the fascia and its relationship with the colon, and a retrospective analysis of MDCTA scans from 196 patients (mean age 65.73 y, 118 F/78 M). Systematic measurements of fascial thickness were taken at key renal levels-upper pole, hilum, lower pole, and infra-renal. Covariates analyzed included Body Mass Index, age, and sex. RESULTS The pilot dissection revealed the renal fascia of Gerota as the only true retrocolic compact connective tissue and the fusion fascia of Toldt as a mesh of strands of loose connective tissue and fat lobules. MDCTA showed clearer visualization of Gerota's fascia at the hilum and inferior renal pole, predominantly on the left. There were significant differences in fascial thickness between sides (1.30 mm on the right and 1.34 mm on the left) and a positive correlation with BMI, whereas age and sex showed no significant effects. CONCLUSION Gerota's fascia is a critical anatomical landmark in CME for right colon cancer. This study highlights the fascia's structural integrity, unaffected by the tumor, underscoring its importance in surgical navigation.
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Affiliation(s)
- Antoine Chemtob
- Anatomy Sector, Teaching Unit, Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, 1478 Lorenskog, Norway
- Institute of Clinical Medicine, University of Oslo, 0372 Oslo, Norway
| | - Bojan V Stimec
- Anatomy Sector, Teaching Unit, Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland
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2
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Garcia-Granero A, Martín-Martín GP, Dujovne-Lindenbaum P, Alvarez Laso CJ, Cerdán-Santacruz C, Flor-Lorente B, Biondo S. Standardization of the definition of the types of oncological colectomy. Delphi method for consensus of experts of the Spanish Association of Surgeons. Cir Esp 2024; 102:484-494. [PMID: 38851318 DOI: 10.1016/j.cireng.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 05/13/2024] [Indexed: 06/10/2024]
Abstract
There is no international consensus on the definition of the type of oncological resection that corresponds to each of the colectomies existing in the current literature. The objective is to define for each colectomy described in the literature: embryological dissection plane, vascular pedicles in which to perform central ligation, the extent of the colectomy, and the need for resection of the greater momentum. A consensus of experts is carried out through the Delphi methodology through two rounds from the Coloproctology Section of the Spanish Association of Surgeons. Study period: November 2021-January 2023. 120 experts were surveyed. Degrees of consensus: Very strong: >90%, Strong: 80%-90%, Moderate: 50%-80%, No consensus: <50%. The definition for each oncological colectomy was established by very strong, and strong recommendations. Each oncological colectomy was established as Right hemicolectomy (RHC), RHC with D3 lymphadenectomy, Extended-RHC, transverse colon segmental colectomy, splenic flexure segmental colectomy, subtotal colectomy, total colectomy, left hemicolectomy (LHC), extended-LHC, sigmoidectomy.
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Affiliation(s)
- Alvaro Garcia-Granero
- Unidad de Cirugía Colorrectal, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, Spain; Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Islas Baleares, Spain.
| | - Gonzalo P Martín-Martín
- Unidad Cirugía Colorrectal, Hospital Doctor Lopez Cano, Cadiz, Spain; Unidad Cirugía Colorrectal, Hospital La Janda, Vejer de la Frontera, Cadiz, Spain
| | | | - Carlos J Alvarez Laso
- Unidad de Cirugía Colorrectal, Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
| | | | - Blas Flor-Lorente
- Unidad de Cirugía Colorrectal, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Sebastiano Biondo
- Unidad de Cirugía Colorrectal, Hospital Universitario Bellvitge, Barcelona, Spain
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3
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Garcia-Granero Á, Gil-Catalán A, Jerí-McFarlane S, Sancho-Muriel J, Pellino G, Gamundí-Cuesta M, Garcia-Granero E, Gonzalez-Argenté FX. Proposal for standardization of laparoscopic D3 lymphadenectomy for right colon cancer. Tech Coloproctol 2024; 28:111. [PMID: 39162907 DOI: 10.1007/s10151-024-02974-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 07/11/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND This study presents a laparoscopic surgical protocol for right hemicolectomy and D3 lymphadenectomy (R-D3L) in right colon cancer and reports the oncological outcomes based on a prospective series. METHODS The study comprises two phases. In the first phase, a dynamic demonstration of the R-D3L surgical protocol is provided through textual explanation, illustrations, and edited surgical videos. The protocol emphasizes technical steps such as dissection of the embryological plane of the right mesocolon, high tie of ileocolic vessels, surgical trunk of Gillot dissection, and high tie of superior right colic vein (SRCV). In the second phase, a prospective observational study was conducted involving patients undergoing R-D3L surgery with this protocol between July 2015 and July 2021. Demographic, perioperative, and postoperative variables are analyzed, along with anatomopathological variables and oncological outcomes. RESULTS A total of 33 patients were analyzed. Median operative time was 202 min. Perioperative bleeding occurred in 6%. Postoperative complications were mild (Clavien-Dindo III in 2%). Postoperative ileus was observed in 15%. No anastomotic dehiscence was reported. The median postoperative stay was 7 days. The median number of resected lymph nodes was 26, with 27% having positive nodes and 70% were classified as stage T3 or T4. After a median follow-up of 45 months, local recurrence, distant recurrence, and carcinomatosis rates were 0%. Mortality rate from other causes was 9%. CONCLUSION The surgical protocol shown in the present study could help in the implementation of this technique in those units that consider it appropriate.
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Affiliation(s)
- Á Garcia-Granero
- Colorectal Unit, General and Digestive Surgery Department, Hospital Universitario Son Espases, Palma, Spain
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Human Embriology and Anatomy Department, University of Islas Baleares), Palma, Spain
| | - A Gil-Catalán
- Colorectal Unit, General and Digestive Surgery Department, Hospital Universitario Son Espases, Palma, Spain
| | - S Jerí-McFarlane
- Colorectal Unit, General and Digestive Surgery Department, Hospital Universitario Son Espases, Palma, Spain.
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain.
| | - J Sancho-Muriel
- Colorectal Unit, General and Digestive Surgery Department, Hospital Politécnico la Fe, Valencia, Spain
| | - G Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy
- Colorectal Surgery Unit, General and Digestive Surgery Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - M Gamundí-Cuesta
- Colorectal Unit, General and Digestive Surgery Department, Hospital Universitario Son Espases, Palma, Spain
| | - E Garcia-Granero
- Colorectal Unit, General and Digestive Surgery Department, Hospital Politécnico la Fe, Valencia, Spain
| | - F X Gonzalez-Argenté
- Colorectal Unit, General and Digestive Surgery Department, Hospital Universitario Son Espases, Palma, Spain
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4
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Lirici MM, Dapri G, Huescher CGS, Marks J. Laparoscopic right colectomy: correct technique based on key anatomical principles. MINIM INVASIV THER 2024; 33:187-199. [PMID: 38587468 DOI: 10.1080/13645706.2024.2332880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 02/18/2024] [Indexed: 04/09/2024]
Abstract
Since the early1990s, laparoscopic right colon resections have been the most performed advanced laparoscopic procedures just after laparoscopic left colectomies and sigmoid resections. Indications for laparoscopic right colectomies are either benign or malignant diseases. Despite its many indications, a laparoscopic right or extended right colectomy is mostly performed for cancer of the caecum, the ascending colon, the hepatic flexure or the proximal transverse colon. Worldwide, colorectal cancer is the third most diagnosed cancer: an estimated 1,880,725 people were diagnosed with colorectal cancer in 2020, out of which 1,148,515 were colon cancer cases and 40% were located in the right colon. These figures make an oncologic sound surgery for right colon cancer of the utmost relevance. More recently, complete mesocolic excision has been advocated as the optimal choice in term of radicality, especially in node-positive patients with right colon cancer. Laparoscopic standard right colectomy and extended right colectomy with or without CME should be performed according to defined principles based on a close knowledge of key anatomical landmarks. This knowledge will allow to trace anatomical structures and drive instruments along the correct surgical planes and has its foundations in teachings from surgeons and scientists of past and present time.
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Affiliation(s)
- Marco Maria Lirici
- Center of Advanced Laparoscopic Surgery and Multidisciplinary Obesity Unit Nuova Clinica Annunziatella, Rome, Italy
| | - Giovanni Dapri
- Minimally Invasive General & Oncologic Surgery Center, Humanitas Gavazzeni University Hospital, Bergamo, Italy
| | - Cristiano G S Huescher
- Department of Surgery, Surgical Oncology Robotic and New Technology Cobellis Clinic, Vallo della Lucania, Italy
| | - John Marks
- Colorectal Surgery Center, Section of Colorectal Surgery, The Main Line Health System and The Lankenau Hospital, Lankenau Institute for Medical Research, Wynnewood, PA, USA
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5
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Boekestijn B, Wasser MNJM, Mieog JSD, DeRuiter MC. Retroperitoneum revisited: a review of radiological literature and updated concept of retroperitoneal fascial anatomy with imaging features and correlating anatomy. Surg Radiol Anat 2024; 46:1165-1175. [PMID: 38963431 PMCID: PMC11246311 DOI: 10.1007/s00276-024-03432-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 06/26/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE Spread of disease in the retroperitoneum is dictated by the complex anatomy of retroperitoneal fasciae and is still incompletely understood. Conflicting reports have led to insufficient and incorrect anatomical concepts in radiological literature. METHODS This review will discuss previous concepts prevalent in radiological literature and their shortcomings will be highlighted. New insights from recent anatomical and embryological research, together with imaging examples, will be used to clarify patterns of disease spread in the retroperitoneum that remain unexplained by these concepts. RESULTS The fusion fascia and the renal fascia in particular give rise to planes and spaces that act as vectors for spread of disease in the retroperitoneum. Some of these planes and structures, such as the caudal extension of the renal fascia, have previously not been described in radiological literature. CONCLUSION New insights, including the various fasciae, potential spaces and planes, are incorporated into an updated combined retroperitoneal fascial concept.
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Affiliation(s)
- B Boekestijn
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, The Netherlands.
| | - M N J M Wasser
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, The Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - M C DeRuiter
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
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6
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Vega EA, Martí-Cruchaga P, Salehi O, Benito A, Zozaya G, López-Olaondo L, Lapuente F, Rotellar F. Enucleation of Sporadic Insulinoma in the Posterior Side of the Head of the Pancreas: The Retrolaparoscopic Approach. Ann Surg Oncol 2024; 31:4635-4636. [PMID: 38565752 DOI: 10.1245/s10434-024-15215-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
| | - Pablo Martí-Cruchaga
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Alberto Benito
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
| | - Gabriel Zozaya
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
| | - Luis López-Olaondo
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
| | - Fernando Lapuente
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
| | - Fernando Rotellar
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain.
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7
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Yadav K. Laparoscopic right radical hemicolectomy: Central vascular ligation and complete mesocolon excision vs D3 lymphadenectomy - How I do it? World J Gastrointest Surg 2024; 16:1521-1526. [PMID: 38983361 PMCID: PMC11229996 DOI: 10.4240/wjgs.v16.i6.1521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 04/22/2024] [Accepted: 05/08/2024] [Indexed: 06/27/2024] Open
Abstract
In colon cancer surgery, ensuring the complete removal of the primary tumor and draining lymph nodes is crucial. Lymphatic drainage in the colon follows the vascular supply, typically progressing from pericolic to paraaortic lymph nodes. While NCCN guidelines recommend the removal of 10-12 lymph nodes for adequate oncological resection, achieving complete oncological resection involves more than just meeting these numerical targets. Various techniques have been developed and studied over time to attain optimal oncological outcomes. A key technique central to this goal is identifying the ileocolic vessels at their origin from the superior mesenteric vessels. Complete excision of the visceral and parietal mesocolon ensures the intact removal of the specimen, while D3 lymphadenectomy targets all draining regional lymph nodes. Although these principles emphasize different aspects, they ultimately converge to achieve the same goal of complete oncological resection. This article aims to simplify the surgical steps that align with the principle of central vascular ligation and mesocolon mobilization while ensuring adequate D3 dissection.
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Affiliation(s)
- Kaushal Yadav
- Department of Surgical Oncology, Max Hospital, Gurugram 122001, Haryana, India
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8
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Zizzo M, Morini A, Zanelli M, Fabozzi M. Surgical management of splenic flexure cancer: an open question in need of recommendations based on strong evidences. Minerva Surg 2024; 79:228-230. [PMID: 37930086 DOI: 10.23736/s2724-5691.23.10019-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Maurizio Zizzo
- Unit of Surgical Oncology, Azienda AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy -
| | - Andrea Morini
- Unit of Surgical Oncology, Azienda AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Magda Zanelli
- Unit of Pathology, Azienda AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Massimiliano Fabozzi
- Unit of Surgical Oncology, Azienda AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy
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9
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Kostov S, Selçuk I, Watrowski R, Dineva S, Kornovski Y, Slavchev S, Ivanova Y, Yordanov A. Neglected Anatomical Areas in Ovarian Cancer: Significance for Optimal Debulking Surgery. Cancers (Basel) 2024; 16:285. [PMID: 38254777 PMCID: PMC10813817 DOI: 10.3390/cancers16020285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/31/2023] [Accepted: 01/06/2024] [Indexed: 01/24/2024] Open
Abstract
Ovarian cancer (OC), the most lethal gynecological malignancy, usually presents in advanced stages. Characterized by peritoneal and lymphatic dissemination, OC necessitates a complex surgical approach usually involving the upper abdomen with the aim of achieving optimal cytoreduction without visible macroscopic disease (R0). Failures in optimal cytoreduction, essential for prognosis, often stem from overlooking anatomical neglected sites that harbor residual tumor. Concealed OC metastases may be found in anatomical locations such as the omental bursa; Morison's pouch; the base of the round ligament and hepatic bridge; the splenic hilum; and suprarenal, retrocrural, cardiophrenic and inguinal lymph nodes. Hence, mastery of anatomy is crucial, given the necessity for maneuvers like liver mobilization, diaphragmatic peritonectomy and splenectomy, as well as dissection of suprarenal, celiac, and cardiophrenic lymph nodes in most cases. This article provides a meticulous anatomical description of neglected anatomical areas during OC surgery and describes surgical steps essential for the dissection of these "neglected" areas. This knowledge should equip clinicians with the tools needed for safe and complete cytoreduction in OC patients.
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Affiliation(s)
- Stoyan Kostov
- Research Institute, Medical University Pleven, 5800 Pleven, Bulgaria;
- Department of Gynecology, Hospital “Saint Anna”, Medical University—“Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (S.S.)
| | - Ilker Selçuk
- Department of Gynecologic Oncology, Ankara Bilkent City Hospital, Maternity Hospital, 06800 Ankara, Turkey;
| | - Rafał Watrowski
- Department of Obstetrics and Gynecology, Helios Hospital Müllheim, 79379 Müllheim, Germany;
- Faculty Associate, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Svetla Dineva
- Diagnostic Imaging Department, Medical University of Sofia, 1431 Sofia, Bulgaria;
- National Cardiology Hospital, 1309 Sofia, Bulgaria
| | - Yavor Kornovski
- Department of Gynecology, Hospital “Saint Anna”, Medical University—“Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (S.S.)
| | - Stanislav Slavchev
- Department of Gynecology, Hospital “Saint Anna”, Medical University—“Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (S.S.)
| | - Yonka Ivanova
- Department of Gynecology, Hospital “Saint Anna”, Medical University—“Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (S.S.)
| | - Angel Yordanov
- Department of Gynecologic Oncology, Medical University Pleven, 5800 Pleven, Bulgaria
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David G, Cantore F, Morabito M, Antonucci A, Papis D, Misitano P. Full robotic right colectomy for colon cancer: step-by-step suprapubic bottom-to-up technique with complete mesocolic excision-a video vignette. Tech Coloproctol 2024; 28:22. [PMID: 38193934 DOI: 10.1007/s10151-023-02884-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/17/2023] [Indexed: 01/10/2024]
Affiliation(s)
- G David
- UO Chirurgia Generale, Ospedale Sant'Anna, Asst Lariana, San Fermo della Battaglia, Como, Italy.
| | - F Cantore
- UO Chirurgia Generale, Ospedale Sant'Anna, Asst Lariana, San Fermo della Battaglia, Como, Italy
| | - M Morabito
- UO Chirurgia Generale, Ospedale Sant'Anna, Asst Lariana, San Fermo della Battaglia, Como, Italy
- Università degli Studi dell'Insubria, Varese, Italy
| | - A Antonucci
- UO Chirurgia Generale, Ospedale Sant'Anna, Asst Lariana, San Fermo della Battaglia, Como, Italy
| | - D Papis
- UO Chirurgia Generale, Ospedale Sant'Anna, Asst Lariana, San Fermo della Battaglia, Como, Italy
| | - P Misitano
- UO Chirurgia Generale, Ospedale Sant'Anna, Asst Lariana, San Fermo della Battaglia, Como, Italy
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11
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Brachini G, Cirillo B, Matteucci M, Cirocchi R, Tebala GD, Cavaliere D, Giacobbi L, Papa V, Solaini L, Avenia S, D’Andrea V, Davies J, Fedeli P, De Santis E. A Systematic Review of Varying Definitions and the Clinical Significance of Fredet's Fascia in the Era of Complete Mesocolic Excision. J Clin Med 2023; 12:6233. [PMID: 37834876 PMCID: PMC10573991 DOI: 10.3390/jcm12196233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Fredet's fascia represents a crucial landmark for vascular surgical anatomy, especially in minimally invasive complete mesocolic excision (CME) for right-sided colon adenocarcinoma. Fredet's fascia allows access to the gastrocolic trunk of Henle (GCTH), the most critical step in both open and minimally invasive right-sided CME techniques. Despite this, a recent workshop of expert surgeons on the standardization of the laparoscopic right hemicolectomy with CME did not recognize or include the term of Fredet's fascia or area. Hence, we undertook a systematic review of articles that include the terms "Fredet's fascia or area", or synonyms thereof, with special emphasis on the types of articles published, the nationality, and the relevance of this area to surgical treatments. METHODS We conducted a systematic review up to 15 July 2022 on PubMed, WOS, SCOPUS, and Google Scholar. RESULTS The results of the study revealed that the term "Fredet's fascia" is poorly used in the English language medical literature. In addition, the study found controversial and conflicting data among authors regarding the definition of "Fredet's fascia" and its topographical limits. CONCLUSIONS Knowledge of Fredet's fascia's surgical relevance is essential for colorectal surgeons to avoid accidental injuries to the superior mesenteric vascular pedicle during minimally invasive right hemicolectomies with CME. In order to avoid confusion and clarify this fascia for future use, we suggest moving beyond the use of the eponymous term by using a "descriptive term" instead, based on the fascia's anatomic structure. Fredet's fascia could, therefore, be more appropriately renamed "sub-mesocolic pre-duodenopancreatic fascia".
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Affiliation(s)
- Gioia Brachini
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy; (G.B.); (V.D.); (E.D.S.)
| | - Bruno Cirillo
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy; (G.B.); (V.D.); (E.D.S.)
| | - Matteo Matteucci
- Department of Medicine and Surgery, University of Milan, 20122 Milan, Italy;
| | - Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (L.G.); (S.A.)
| | | | - Davide Cavaliere
- General Surgical Department, Ospedale Degli Infermi Faenza, 48018 Faenza, Italy;
| | - Lorenza Giacobbi
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (L.G.); (S.A.)
| | - Veronica Papa
- Department of Motor Sciences and Wellness, University of Naples “Parthenope”, 80132 Napoli, Italy;
| | - Leonardo Solaini
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, 47121 Forlì, Italy;
| | - Stefano Avenia
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (L.G.); (S.A.)
| | - Vito D’Andrea
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy; (G.B.); (V.D.); (E.D.S.)
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University, Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK;
- University of Cambridge, Cambridge CB2 0QQ, UK
| | - Piergiorgio Fedeli
- School of Law, Legal Medicine, University of Camerino, 62032 Camerino, Italy;
| | - Elena De Santis
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy; (G.B.); (V.D.); (E.D.S.)
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12
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Zenger S, Gurbuz B, Can U, Erginoz E, Ozata IH, Kulle CB, Balik E, Bugra D. Reply. Dis Colon Rectum 2023; 66:e315. [PMID: 36940303 DOI: 10.1097/dcr.0000000000002867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Affiliation(s)
- Serkan Zenger
- VKF American Hospital, General Surgery, Istanbul, Turkey
| | - Bulent Gurbuz
- Department of General Surgery, VKF American Hospital, Istanbul, Turkey
| | - Ugur Can
- Department of General Surgery, VKF American Hospital, Istanbul, Turkey
| | - Ergin Erginoz
- Department of General Surgery, Istanbul University, Cerrahpaşa School of Medicine, Istanbul, Turkey
| | - Ibrahim Halil Ozata
- Department of General Surgery, Koc University, School of Medicine, Istanbul, Turkey
| | - Cemil Burak Kulle
- Department of General Surgery, Istanbul University, School of Medicine, Istanbul, Turkey
| | - Emre Balik
- Department of General Surgery, Koc University, School of Medicine, Istanbul, Turkey
| | - Dursun Bugra
- Department of General Surgery, Koc University, School of Medicine, Istanbul, Turkey
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13
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Andersen BT, Kazaryan AМ, Stimec BV, Ignjatovic D. The Long Tale of the Famous Herr Toldt and the Less-Known Monsieur Fredet. Dis Colon Rectum 2023; 66:e314. [PMID: 36940297 DOI: 10.1097/dcr.0000000000002868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Affiliation(s)
- Bjarte T Andersen
- Department of Gastrointestinal Surgery, Østfold Hospital Trust, Grålum, Norway, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Airazat М Kazaryan
- Department of Gastrointestinal Surgery, Østfold Hospital Trust, Grålum, Norway, Institute for Clinical Medicine, University of Oslo, Oslo, Norway, Interventional Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway, Department of Surgery, Fonna Hospital Trust, Odda, Norway, Department of Faculty Surgery N 2, I.M. Sechenov First Moscow State Medical University, Moscow, Russia, Department of Surgery N 2, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia
| | - Bojan V Stimec
- Anatomy Sector, Teaching Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dejan Ignjatovic
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway, Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
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14
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Wang L, Song B, Chen Y, Hirano Y. D3 lymph node dissection improves the survival outcome in patients with pT2 colorectal cancer. Int J Colorectal Dis 2023; 38:30. [PMID: 36757433 DOI: 10.1007/s00384-023-04326-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND The extent of lymphadenectomy in patients with pT2 colorectal cancer (CRC) remains controversial. This study aimed to elucidate the effects of D3 and D2 lymph node dissection (LND) on survival in patients diagnosed with pT2 CRC. METHODS This was a retrospective cohort study from a high-volume cancer center in Japan. From April 2007 to December 2020, 6273 patients with primary CRC were included in the study; among these, 616 patients diagnosed with pT2 CRC underwent radical colorectal resection. Propensity score matching (PSM) was applied to balance potential confounding factors, and a total of 104 matched pairs were extracted from the entire cohort. Independent risk factors associated with prognosis were determined by Cox regression analysis. The main outcome measures were overall survival (OS) and cancer-specific survival (CSS). RESULTS Before PSM, there was a statistically significant difference across the cohort in OS and CSS (p = 0.000 and 0.013) between D3 and D2 LND groups; the estimated hazard ratio (HR) was 2.2 (95% confidence interval (CI), 1.1-4.4, p = 0.031) for OS in the D3 LND and 4.4 (95% CI, 1.7 to 11, p = 0.0027) for CSS (p = 0.013). There was also a significant difference (p = 0.024) in OS between the D3 and D2 LND groups in the matched cohort, with an estimated HR for OS of 3.3 (95% CI, 1.2 to 9.1, p = 0.024) and an estimated HR for CSS of 7.2 (95% CI, 1.6 to 33, p = 0.011). CONCLUSIONS D3 LND had a significant survival advantage in the treatment of pT2 CRC. The results of this study provide a theoretical basis for the application of D3 LND in radical surgery for preoperative T2 CRC.
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Affiliation(s)
- Liming Wang
- Department of Gastrointestinal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China.
- Division of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
| | - Bolun Song
- Department of Gastrointestinal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China
| | - Yinggang Chen
- Department of Gastrointestinal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China
| | - Yasumitsu Hirano
- Division of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
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15
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Sica GS, Vinci D, Siragusa L, Sensi B, Guida AM, Bellato V, García-Granero Á, Pellino G. Definition and reporting of lymphadenectomy and complete mesocolic excision for radical right colectomy: a systematic review. Surg Endosc 2023; 37:846-861. [PMID: 36097099 PMCID: PMC9944740 DOI: 10.1007/s00464-022-09548-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/07/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several procedures have been proposed to reduce the rates of recurrence in patients with right-sided colon cancer. Different procedures for a radical right colectomy (RRC), including extended D3 lymphadenectomy, complete mesocolic excision and central vascular ligation have been associated with survival benefits by some authors, but results are inconsistent. The aim of this study was to assess the variability in definition and reporting of RRC, which might be responsible for significant differences in outcome evaluation. METHODS PRISMA-compliant systematic literature review to identify the definitions of RRC. Primary aims were to identify surgical steps and different nomenclature for RRC. Secondary aims were description of heterogeneity and overlap among different RRC techniques. RESULTS Ninety-nine articles satisfied inclusion criteria. Eight surgical steps were identified and recorded as specific to RRC: Central arterial ligation was described in 100% of the included studies; preservation of mesocolic integrity in 73% and dissection along the SMV plane in 67%. Other surgical steps were inconstantly reported. Six differently named techniques for RRC have been identified. There were 35 definitions for the 6 techniques and 40% of these were used to identify more than one technique. CONCLUSIONS The only universally adopted surgical step for RRC is central arterial ligation. There is great heterogeneity and consistent overlap among definitions of all RRC techniques. This is likely to jeopardise the interpretation of the outcomes of studies on the topic. Consistent use of definitions and reporting of procedures are needed to obtain reliable conclusions in future trials. PROSPERO CRD42021241650.
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Affiliation(s)
- Giuseppe S Sica
- Minimally Invasive Unit, Department of Surgical Science, University Tor Vergata, Rome, Italy. .,Department of Surgical Science, Policlinico Tor Vergata - University Tor Vergata, Rome, Italy.
| | - Danilo Vinci
- Department of Surgical Science, Policlinico Tor Vergata - University Tor Vergata, Rome, Italy
| | - Leandro Siragusa
- Minimally Invasive Unit, Department of Surgical Science, University Tor Vergata, Rome, Italy.,Department of Surgical Science, Policlinico Tor Vergata - University Tor Vergata, Rome, Italy
| | - Bruno Sensi
- Minimally Invasive Unit, Department of Surgical Science, University Tor Vergata, Rome, Italy.,Department of Surgical Science, Policlinico Tor Vergata - University Tor Vergata, Rome, Italy
| | - Andrea M Guida
- Department of Surgical Science, Policlinico Tor Vergata - University Tor Vergata, Rome, Italy
| | - Vittoria Bellato
- Department of Surgical Science, Policlinico Tor Vergata - University Tor Vergata, Rome, Italy.,Ospedale IRCCS San Raffaele, Milan, Italy
| | - Álvaro García-Granero
- Colorectal Unit, Hospital Universitario Son Espases, Palma, Spain.,Applied Surgical Anatomy Unit, Human Embryology and Anatomy Department, University of Valencia, Valencia, Spain.,Human Embryology and Anatomy Department, University of Islas Baleares, Palma, Spain
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Naples, Italy.,Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
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16
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Garcia-Granero A, Jerí Mc-Farlane S, Gamundí Cuesta M, González-Argente FX. Application of 3D-reconstruction and artificial intelligence for complete mesocolic excision and D3 lymphadenectomy in colon cancer. Cir Esp 2023; 101:359-368. [PMID: 36709852 DOI: 10.1016/j.cireng.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/29/2022] [Indexed: 01/28/2023]
Abstract
Mathematical algorithms 3D-reconstruction techniques and artificial intelligence are a current line of innovation in colorectal surgical oncology. The objective of this study is to show the initial experience of a 3D image processing and reconstruction system to perform complete mesocolic excision and D3-lymphadenectomy in colon cancer. It is applied to a splenic flexure neoplasm and in a right colon cancer with suspected retroperitoneal infiltration. 3D image processing and reconstruction was employed to delimit 10 cm proximal and distal intestinal margins to the tumor and define its corresponding vascularization. In right colon cancer it showed position and exact dimensions of D3-lymphadenectomy area and possible retroperitoneal fascia infiltration. 3D image processing and reconstruction allows to obtain valuable information from computerized tomography scan. It could be employed during surgical strategy planification to improve oncological results and reduce intraoperative complications.
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Affiliation(s)
- Alvaro Garcia-Granero
- Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Son Espases, Palma, Illes Balears, Spain; Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma, Illes Balears, Spain; Unidad de Reconstrucción-3D y Centro de Simulación, Hospital Universitario Son Espases, Palma, Illes Balears, Spain; Profesor Departamento de Anatomía y Embriología Humana, Universidad de Islas Baleares, Palma, Illes Balears, Spain; Coordinador Unidad de Anatomía Quirúrgica Aplicada, Universidad de Valencia, Valencia, Spain.
| | - Sebastían Jerí Mc-Farlane
- Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Son Espases, Palma, Illes Balears, Spain
| | - Margarita Gamundí Cuesta
- Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Son Espases, Palma, Illes Balears, Spain
| | - Francesc Xavier González-Argente
- Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Son Espases, Palma, Illes Balears, Spain
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17
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Romano G, Di Buono G, Galia M, Agnello F, Anania G, Guerrieri M, Milone M, Silecchia G, Buscemi S, Agrusa A. Role of preoperative CT angiography with multimodality imaging reconstruction to perform laparoscopic Complete Mesocolic Excision (CME) and Central Vascular Ligation (CVL) in right-sided colon cancer: Is it really useful? A prospective clinical study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:209-216. [PMID: 36002353 DOI: 10.1016/j.ejso.2022.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/01/2022] [Accepted: 08/10/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The concept of complete mesocolic excision (CME) and central vascular ligation (CVL) in right colonic resections appears to improve the oncological outcomes. The highest rate of complications reported in the literature in patients undergoing CME is related to difficult surgical manuevers and intraoperative bleeding due to the central vascular dissection. METHODS We used preoperative findings obtained with the CT angiography, multiplanar reformation (MPR), maximum intesity projection (MIP) and 3D volume rendering (VR) technique to verify if this preoperative radiological assessment had significant benefits regarding the difficulty of dissection of the embryological planes, the identification of vascular structures and central lymph nodes with reduction in mean operative time, intraoperative complications and better short-term outcomes versus standard contrast enhanced CT scan. We also have administered a questionnaire to investigate the subjective responses on the degree of difficulty of the surgical procedure both by the surgical team expert in CME and by a group of young surgeons. RESULTS Statistical analysis showed that overall operative time was significant shorter in patients underwent to radiological assessment (224,5 min; range 160-300 versus 252,6 min; range 200-340; p-value 0.023) with a significant lower rate of intraoperative complication (2.7% versus 4.2%; p-value 0.043). No differences were reported with respect to blood loss, conversion rate, anastomotic leakage or other surgical results. Analysis of the questionnaire underlined a progressive awareness of the correspondence between the radiological imaging and the surgical field. CONCLUSION The possibility of identifying the characteristics and course of the vascular structures along the axis of the superior mesenteric vessels certainly increases the surgeon's knowledge of the operating field, making him more confident with surgical maneuvers and significantly reducing the duration of the operating time and intraoperative complications.
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Affiliation(s)
- Giorgio Romano
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Giuseppe Di Buono
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy.
| | - Massimo Galia
- Department of Radiology, University of Palermo, Palermo, Italy
| | | | - Gabriele Anania
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Mario Guerrieri
- Department of General Surgery, Università Politecnica delle Marche, Ancona, Italy
| | - Marco Milone
- Department of Surgical Specialties, University "Federico II" of Naples, Naples, Italy
| | - Gianfranco Silecchia
- Division of General Surgery & Bariatric Center of Excellence IFSO EC, Department of Medico-Surgical Sciences and Biothecnologies, Sapienza University of Rome, Latina, Italy
| | - Salvatore Buscemi
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Antonino Agrusa
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
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18
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Wedel T, Heimke M, Fletcher J, Miskovic D, Benz S, Stelzner S, Heinze T. The retrocolic fascial system revisited for right hemicolectomy with complete mesocolic excision based on anatomical terminology: do we need the eponyms Toldt, Gerota, Fredet and Treitz? Colorectal Dis 2022; 25:764-774. [PMID: 36457274 DOI: 10.1111/codi.16436] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 12/04/2022]
Abstract
AIM Right hemicolectomy with complete mesocolic excision (CME) requires the removal of an intact mesocolic envelope. The study aimed to determine, on the basis of macroscopic and microscopic anatomical studies, the optimal surgical dissection planes for CME to preserve fascial integrity. Unequivocal anatomical nomenclature was applied to describe the retrocolic fascial system and compared to frequently used eponyms (Toldt, Gerota, Fredet, Treitz). METHOD Stepwise macroscopic dissections, cross-section studies and histological analysis were performed on body donors to identify the components of the retrocolic fascial system. Based on these anatomical findings, the optimal surgical dissection planes for CME were validated in laparoscopic training courses on body donors and in robot-assisted surgical procedures in patients. RESULTS The mesocolic tissue and lymphovascular pedicles were enveloped by the ventral and dorsal mesocolic leaf (mesocolic fascia). The mesocolic fascia was attached to the parietal peritoneal fascia ('fascia of Toldt') along the parieto-mesocolic interface, and further cranially to the pre-duodenopancreatic fascia along the mesocolic-duodenopancreatic interface ('space of Fredet'). Dorsally, the parietal peritoneal fascia was separated from the anterior renal fascia ('fascia of Gerota') by the parieto-renal interface. Dissection along this interface in front of the anterior renal fascia followed by incision of the parietal peritoneal fascia at the duodenal border and opening the mesocolic-duodenopancreatic interface yielded the best macroscopic appearance of specimens and was considered optimal for CME. CONCLUSION The retrocolic fascial system as well as the surgical dissection planes for CME can be described by clearly defined anatomical terms rather than potentially confusing eponyms.
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Affiliation(s)
- Thilo Wedel
- Center of Clinical Anatomy, Institute of Anatomy, Kurt-Semm Center for Minimally Invasive and Robotic Surgery, Kiel University, Kiel, Germany
| | - Marvin Heimke
- Center of Clinical Anatomy, Institute of Anatomy, Kurt-Semm Center for Minimally Invasive and Robotic Surgery, Kiel University, Kiel, Germany
| | | | | | - Stefan Benz
- Department for Abdominal and Pediatric Surgery, Klinikverbund-Suedwest, Kliniken Boeblingen, Boeblingen, Germany
| | - Sigmar Stelzner
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Tillmann Heinze
- Center of Clinical Anatomy, Institute of Anatomy, Kurt-Semm Center for Minimally Invasive and Robotic Surgery, Kiel University, Kiel, Germany
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19
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Garcia-Granero A, Jerí Mc-Farlane S, Gamundí Cuesta M, González-Argente FX. Aplicación de reconstrucción 3D e inteligencia artificial a la escisión completa de mesocolon y linfadenectomía D3 en el cáncer de colon. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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20
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Abstract
The following article summarizes technical aspects of how to operate in the mesentery during complete mesocolic excision (CME). Increasingly, CME is being adopted and as such it is important to establish the anatomical basis of the techniques involved. This review thus serves to provide that foundation and explains the surgical techniques built on it.
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Affiliation(s)
- Jordan Fletcher
- Department of Colorectal Surgery, St. Mark's Hospital, London, United Kingdom
| | - Danilo Miskovic
- Department of Colorectal Surgery, St. Mark's Hospital, London, United Kingdom
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21
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Pattern of recurrence and survival after D2 right colectomy for cancer: is there place for a routine more extended lymphadenectomy? Updates Surg 2022; 74:1327-1335. [PMID: 35778547 PMCID: PMC9338120 DOI: 10.1007/s13304-022-01317-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/14/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Conventional Right Colectomy with D2 lymphadenectomy (RC-D2) currently represent the most common surgical treatment of right-sided colon cancer (RCC). However, whether it should be still considered a standard of care, or replaced by a routine more extended D3 lymphadenectomy remains unclear. In the present study, we aim to critically review the patterns of relapse and the survival outcomes obtained from our 11-year experience of RC-D2. METHODS Clinical data of 489 patients who underwent RC-D2 for RCC at two centres, from January 2009 to January 2020, were retrospectively reviewed. Patients with synchronous distant metastases and/or widespread nodal involvement at diagnosis were excluded. Post-operative clinical-pathological characteristics and survival outcomes were evaluated including the pattern of disease relapse. RESULTS We enrolled a total of 400 patients with information follow-up. Postoperative morbidity was 14%. The median follow-up was 62 months. Cancer recurrence was observed in 55 patients (13.8%). Among them, 40 patients (72.7%) developed systemic metastases, and lymph-node involvement was found in 7 cases (12.8%). None developed isolated central lymph-node metastasis (CLM), in the D3 site. The estimated 3- and 5-year relapse-free survival were 86.1% and 84.4%, respectively. The estimated 3- and 5-year cancer-specific OS were 94.5% and 92.2%, respectively. CONCLUSIONS The absence of isolated CLM, as well as the cancer-specific OS reported in our series, support the routine use of RC-D2 for RCC. However, D3 lymphadenectomy may be recommended in selected patients, such as those with pre-operatively known CLM, or with lymph-node metastases close to the origin of the ileocolic vessels.
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22
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SEGURA MJ, LOZOYA R, ALARCÓN M, GÓMEZ M, SOLANA A, RUIZ MD, CHECA F. Intestinal occlusion and ileocolic invagination due to cecum adenocarcinoma. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.21.05279-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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Lin L, Yuan SB, Guo H. Does cranial-medial mixed dominant approach have a unique advantage for laparoscopic right hemicolectomy with complete mesocolic excision? World J Gastrointest Surg 2022; 14:221-235. [PMID: 35432765 PMCID: PMC8984517 DOI: 10.4240/wjgs.v14.i3.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/14/2021] [Accepted: 03/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Complete mesocolic excision (CME) with central vascular ligation (CVL) was proposed by Hohenberger in 2009. The CME principle has gradually become the technical standard for colon cancer surgery. How to achieve CME with CVL in laparoscopic right hemicolectomy (LRH) is controversial, and a unified standard approach is not yet available. In recent years, the authors’ team has integrated the theory of membrane anatomy, tried to combine the cephalic approach with the classic medial approach (MA) for technical optimization, and proposed a cranial-medial mixed dominant approach (CMA).
AIM To explore the feasibility of operational approaches for LRH with CME.
METHODS In this retrospective cohort study, the clinical data of 57 patients with right-sided colon cancer (TNM stage I, II, or III) who underwent LRH with CME from January 2016 to June 2020 were collected and summarized. There were 31 patients in the traditional MA group and 26 in the CMA group.
RESULTS There were no significant differences in baseline data between the two groups. The operation was shorter and the number of lymph nodes dissected was higher in the CMA group than in the MA group, but there was no significant difference in the number of positive lymph nodes, intraoperative blood loss, postoperative exhaust time, feeding time, postoperative hospital stay or postoperative complication incidence.
CONCLUSION Our study shows that the CMA is a safe and feasible procedure for LRH with CME and has a unique advantage.
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Affiliation(s)
- Li Lin
- Department of Gastrointestinal Surgery and Xiamen City Key Laboratory of Gastrointestinal Cancer, Zhongshan Hospital, Xiamen University, Xiamen 361000, Fujian Province, China
| | - Si-Bo Yuan
- Department of Gastrointestinal Surgery and Xiamen City Key Laboratory of Gastrointestinal Cancer, Zhongshan Hospital, Xiamen University, Xiamen 361000, Fujian Province, China
| | - Huan Guo
- Department of Gastrointestinal Surgery and Xiamen City Key Laboratory of Gastrointestinal Cancer, Zhongshan Hospital, Xiamen University, Xiamen 361000, Fujian Province, China
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Shinji S, Yamada T, Matsuda A, Sonoda H, Ohta R, Iwai T, Takeda K, Yonaga K, Masuda Y, Yoshida H. Recent advances in the treatment of colorectal cancer: A review. J NIPPON MED SCH 2022; 89:246-254. [DOI: 10.1272/jnms.jnms.2022_89-310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Seiichi Shinji
- Departments of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Takeshi Yamada
- Departments of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Akihisa Matsuda
- Departments of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Hiromichi Sonoda
- Departments of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Ryo Ohta
- Departments of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Takuma Iwai
- Departments of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Koki Takeda
- Departments of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Kazuhide Yonaga
- Departments of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Yuka Masuda
- Departments of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Hiroshi Yoshida
- Departments of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
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Anania G, Davies RJ, Bagolini F, Vettoretto N, Randolph J, Cirocchi R, Donini A. Right hemicolectomy with complete mesocolic excision is safe, leads to an increased lymph node yield and to increased survival: results of a systematic review and meta-analysis. Tech Coloproctol 2021; 25:1099-1113. [PMID: 34120270 PMCID: PMC8419145 DOI: 10.1007/s10151-021-02471-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 05/30/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND The introduction of complete mesocolic excision (CME) for right colon cancer has raised an important discussion in relation to the extent of colic and mesenteric resection, and the impact this may have on lymph node yield. As uncertainty remains regarding the usefulness of and indications for right hemicolectomy with CME and the benefits of CME compared with a traditional approach, the purpose of this meta-analysis is to compare the two procedures in terms of safety, lymph node yield and oncological outcome. METHODS We performed a systematic review of the literature from 2009 up to March 15th, 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two hundred eighty-one publications were evaluated, and 17 met the inclusion criteria and were included. Primary endpoints analysed were anastomotic leak rate, blood loss, number of harvested lymph nodes, 3- and 5-year oncologic outcomes. Secondary outcomes were operating time, conversion, intraoperative complications, reoperation rate, overall and Clavien-Dindo grade 3-4 postoperative complications. RESULTS In terms of safety, right hemicolectomy with CME is not inferior to the standard procedure when comparing rates of anastomotic leak (RR 0.82, 95% CI 0.38-1.79), blood loss (MD -32.48, 95% CI -98.54 to -33.58), overall postoperative complications (RR 0.82, 95% CI 0.67-1.00), Clavien-Dindo grade III-IV postoperative complications (RR 1.36, 95% CI 0.82-2.28) and reoperation rate (RR 0.65, 95% CI 0.26-1.75). Traditional surgery is associated with a shorter operating time (MD 16.43, 95% CI 4.27-28.60) and lower conversion from laparoscopic to open approach (RR 1.72, 95% CI 1.00-2.96). In terms of oncologic outcomes, right hemicolectomy with CME leads to a higher lymph node yield than traditional surgery (MD 7.05, 95% CI 4.06-10.04). Results of statistical analysis comparing 3-year overall survival and 5-year disease-free survival were better in the CME group, RR 0.42, 95% CI 0.27-0.66 and RR 0.36, 95% CI 0.17-0.56, respectively. CONCLUSIONS Right hemicolectomy with CME is not inferior to traditional surgery in terms of safety and has a greater lymph node yield when compared with traditional surgery. Moreover, right-sided CME is associated with better overall and disease-free survival.
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Affiliation(s)
- G Anania
- Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy
| | - R J Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - F Bagolini
- Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy
| | - N Vettoretto
- Montichiari Surgery, ASST Spedali Civili, Brescia, Italy
| | - J Randolph
- Georgia Baptist College of Nursing. Mercer University, Atlanta, GA, USA
| | - R Cirocchi
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy.
- Azienda Ospedaliera Di Terni, 05100, Terni, Italy.
| | - A Donini
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Fletcher-Sanfeliu D, García-Granero Á, Doménech Dolz A, Pellino G, Orbis F, Arroyo A, Valverde-Navarro AA, Sabater Ortí L, Martín-González I. Surgical anatomy applied to transperitoneal approaches of the abdominal aorta and visceral trunks. Dynamic article. Cir Esp 2021; 99:562-571. [PMID: 34538636 DOI: 10.1016/j.cireng.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 12/20/2020] [Indexed: 11/29/2022]
Abstract
Access to the abdominal aorta and its visceral trunks is possible through several approaches. Dissections of five cadavers performed during three National Surgical Anatomy courses applied to Aorta, Hepatobiliopancreatic and Digestive Surgery. Videos and pictures were taken throughout the dissections and showed different abdominal aorta approaches. Abdominal aorta and visceral trunks approaches: longitudinal inframesocolic access, supraceliac clamping, celiac trunk dissection, superior mesenteric artery approaches (retroperitoneal after Kocher menoeuvre, supramesocolic or inframesocolic), Cattell-Braasch manoeuvre and mattox manoeuvre: retrorenal and prerenal. Correct knowledge of the intraabdominal anatomy is necessary to perform all the abdominal aorta surgical approaches. Cadaveric dissection could help to achieve this objective. Cardiovascular and digestive surgeons need to know the possible strategies in order to choose the one which is best suited for each patient.
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Affiliation(s)
| | - Álvaro García-Granero
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, Spain; Departamento de Anatomía y Embriología Humana, Universidad de Valencia, Valencia, Spain.
| | | | - Gianluca Pellino
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Vall d́Hebrón, Barcelona, Spain
| | - Francisco Orbis
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Antonio Arroyo
- Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario de Elche, Alicante, Spain; Departamento de Patología y Cirugía, Facultad de Medicina, Universidad Miguel Hernández de Elche, Alicante, Spain
| | | | - Luis Sabater Ortí
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario, Valencia, Spain
| | - Iván Martín-González
- Servicio de Cirugía Cardiovascular, Hospital Universitario del Vinalopó, Elche, Alicante, Spain
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Franceschilli M, Di Carlo S, Vinci D, Sensi B, Siragusa L, Bellato V, Caronna R, Rossi P, Cavallaro G, Guida A, Sibio S. Complete mesocolic excision and central vascular ligation in colorectal cancer in the era of minimally invasive surgery. World J Clin Cases 2021; 9:7297-7305. [PMID: 34616795 PMCID: PMC8464444 DOI: 10.12998/wjcc.v9.i25.7297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/14/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
Since the 19th century, appropriate lymphadenectomy has been considered a cornerstone of oncologic surgery and one of the most important prognostic factors. This approach can be applied to any surgery for gastrointestinal cancer. During surgery for colon and rectal cancer, an adequate portion of the mesentery is removed together with the segment of bowel affected by the disease. The adequate number of lymph nodes to be removed is standardized and reported by several guidelines. It is mandatory to determine the appropriate extent of lymphadenectomy and to balance its oncological benefits with the increased morbidity associated with its execution in cancer patients. Our review focuses on the concept of “complete mesenteric excision (CME) with central vascular ligation (CVL),” a radical lymphadenectomy for colorectal cancer that has gained increasing interest in recent years. The aim of this study was to evaluate the evolution of this approach over the years, its potential oncologic benefits and potential risks, and the improvements offered by laparoscopic techniques. Theoretical advantages of CME are improved local-relapse rates due to complete removal of the intact mesocolic fascia and improved distance recurrence rates due to ligation of vessels at their origin (CVL) which guarantees removal of a larger number of lymph nodes. The development and worldwide diffusion of laparoscopic techniques minimized postoperative trauma in oncologic surgery, providing the same oncologic results as open surgery. This has been widely applied to colorectal cancer surgery; however, CME entails a technical complexity that can limit its wide minimally-invasive application. This review analyzes results of these procedures in terms of oncological outcomes, technical feasibility and complexity, especially within the context of minimally invasive surgery.
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Affiliation(s)
- Marzia Franceschilli
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Sara Di Carlo
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Danilo Vinci
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Bruno Sensi
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Leandro Siragusa
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Vittoria Bellato
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Roberto Caronna
- Department of Surgical Sciences, Unit of Pancreatic and Biliary Surgery, Sapienza University of Rome, Rome 00161, Italy
| | - Piero Rossi
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Giuseppe Cavallaro
- Department of Surgery P Valdoni, Unit of Oncologic and Minimally Invasive Surgery, Sapienza University of Rome, Rome 00161, Italy
| | - Andrea Guida
- Department of Surgery, Minimally Invasive Unit, Tor Vergata University of Rome, Rome 00133, Italy
| | - Simone Sibio
- Department of Surgery P Valdoni, Unit of Oncologic and Minimally Invasive Surgery, Sapienza University of Rome, Rome 00161, Italy
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[Is complete mesocolic excision in laparoscopic right hemicolectomy adequate and safe?]. Chirurg 2021; 92:846. [PMID: 34398257 DOI: 10.1007/s00104-021-01477-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
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Feasibility and Safety of Laparoscopic Complete Mesocolic Excision (CME) for Right-sided Colon Cancer: Short-term Outcomes. A Randomized Clinical Study. Ann Surg 2021; 274:57-62. [PMID: 33177355 DOI: 10.1097/sla.0000000000004557] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aim of this prospective clinical study is to compare short-term outcome of laparoscopic right hemicolectomy using the Complete Mesocolic Excision (CME group) with patients who underwent conventional right-sided colonic resection (NCME group). SUMMARY BACKGROUND DATA Although CME with central vascular ligation in laparoscopic right hemicolectomy is associated with a significant decrease in local recurrence rates and improvements in cancer-related 5-year survival, there may be additional risks associated with this technique because of increased surgical complications. As a result, there is controversy surrounding its use. METHODS In this randomized controlled trial, several primary endpoints (operative time, intraoperative blood loss, other complications, conversion rate, and anastomotic leak) and secondary endpoints (overall postoperative complications) were evaluated. In addition, we evaluated histopathologic data, including specimen length and the number of lymph nodes harvested, as objective signs of the quality of CME, related to oncological outcomes. RESULTS The CME group had a significantly longer mean operative time than the NCME group (216.3 minutes vs 191.5 minutes, P = 0.005). However, the CME group had a higher number of lymph nodes (23.8 vs 16.6; P < 0.001) and larger surgical specimens (34.3 cm vs 29.3 cm; P = 0.002). No differences were reported with respect to intraoperative blood loss, conversion rate, leakage, or other postoperative complications. CONCLUSIONS In this study laparoscopic CME were a safe and feasible technique with improvement in lymph nodes harvesting and length of surgical specimens with no increase of surgical intraoperative and postoperative complications.
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Franceschilli M, Vinci D, Di Carlo S, Sensi B, Siragusa L, Guida A, Rossi P, Bellato V, Caronna R, Sibio S. Central vascular ligation and mesentery based abdominal surgery. Discov Oncol 2021; 12:24. [PMID: 35201479 PMCID: PMC8777547 DOI: 10.1007/s12672-021-00419-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/20/2021] [Indexed: 12/14/2022] Open
Abstract
In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.
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Affiliation(s)
- M Franceschilli
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - D Vinci
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy.
| | - S Di Carlo
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - B Sensi
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - L Siragusa
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - A Guida
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - P Rossi
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - V Bellato
- Department of Surgical Sciences, Minimally Invasive Surgery Unit, University of Rome "Tor Vergata", Rome, Italy
| | - R Caronna
- Department of Surgery Pietro Valdoni Unit of Oncologic and Minimally Invasive Surgery, Rome, Italy
- Department of Surgical Science, Sapienza University of Rome, Rome, Italy
| | - S Sibio
- Department of Surgery Pietro Valdoni Unit of Oncologic and Minimally Invasive Surgery, Rome, Italy
- Department of Surgical Science, Sapienza University of Rome, Rome, Italy
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García-Granero A, Frasson M. Applied surgical anatomy is back (has it ever left?). Colorectal Dis 2021; 23:1299-1300. [PMID: 34128591 DOI: 10.1111/codi.15740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alvaro García-Granero
- Colorectal Unity, University Hospital Son Espasses, Mallorca, Spain.,Surgical Anatomy Unit, University of Valencia, Valencia, Spain.,Human Embryology and Anatomy Department, University Islas Baleares, Mallorca, Spain
| | - Matteo Frasson
- Surgical Anatomy Unit, University of Valencia, Valencia, Spain.,Colorectal Unity, University Hospital La Fe, Valencia, Spain
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Peltrini R, Di Nuzzo MM, Caricato C, Bracale U, Corcione F. The "complete common mesentery" and the agenesis of Toldt's and Fredet's fasciae. Surg Radiol Anat 2021; 43:1437-1439. [PMID: 34059926 DOI: 10.1007/s00276-021-02775-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Roberto Peltrini
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy.
| | - Maria Michela Di Nuzzo
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Chiara Caricato
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Umberto Bracale
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
| | - Francesco Corcione
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
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Zizzo M, Zanelli M, Sanguedolce F, Castro Ruiz C, Biolchini F, Giunta A. Complete mesocolic excision (CME) and D3-lymphadenectomy (D3) for right-sided colon cancers: a potentially prognostic surgical approach. Surg Today 2021; 51:1723-1724. [PMID: 34021799 DOI: 10.1007/s00595-021-02306-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Maurizio Zizzo
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy. .,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.
| | - Magda Zanelli
- Pathology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Francesca Sanguedolce
- Pathology Unit, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Foggia, Foggia, Italy
| | - Carolina Castro Ruiz
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Federico Biolchini
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Alessandro Giunta
- Surgical Oncology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
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34
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Mazzarella G, Muttillo EM, Picardi B, Rossi S, Muttillo IA. Complete mesocolic excision and D3 lymphadenectomy with central vascular ligation in right-sided colon cancer: a systematic review of postoperative outcomes, tumor recurrence and overall survival. Surg Endosc 2021; 35:4945-4955. [PMID: 33977376 DOI: 10.1007/s00464-021-08529-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/30/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND In right-sided colon cancer surgery, currently there is a great deal of discussion and debate regarding complete mesocolic excision (CME) versus conventional right hemicolectomy (CRH) on postoperative outcomes and oncological results. Our aim was to perform a systematic review of the short- and long-term outcomes of CME to standardize surgical approach in patients with right-sided colon cancer. METHODS A systematic review was performed examining available data on randomized and non-randomized studies evaluating the role of CME and D3 lymphadenectomy in the treatment of right-sided colon cancer, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards. RESULTS After literature search, 919 studies have been recorded, 110 studies underwent full-text reviews and 30 studies met inclusion criteria. The total number of CME procedures was 5931. Postoperative complications was reported in 28 studies with pooled overall complications of 1.88% for CME surgery. Six studies reported 0% of overall postoperative complications and they demonstrated a low incidence of complications following CME procedure. Anastomotic leak was reported in 27 studies with pooled proportion of 0.92% after CME resections. There were 16 papers reporting overall survival following CME procedure, with a mean of 85% of patients survived at 5 years. Mean 5-year overall survival was 93.05% in stage I patients, 89.76% in stage II patients and 79.65% in stage III patients. Local and distant recurrence were included in 21 studies, reporting tumor recurrence rate of 12.25% following CME. 5-year tumor recurrence was 5.8% in stage I patients, 7.68% in stage II patients and 15.69% in stage III patients. CONCLUSIONS CME does not increase the risk of postoperative complications and significantly improves the long-term oncological impact. Prospective multicentre studies results are needed to verify if CME could be considered standard surgery for right colon cancer.
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Affiliation(s)
- Gennaro Mazzarella
- Department of General and Emergency Surgery, San Filippo Neri Hospital, Rome, Italy. .,Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Edoardo Maria Muttillo
- Department of General and Emergency Surgery, San Filippo Neri Hospital, Rome, Italy.,Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Biagio Picardi
- Department of General and Emergency Surgery, San Filippo Neri Hospital, Rome, Italy
| | - Stefano Rossi
- Department of General and Emergency Surgery, San Filippo Neri Hospital, Rome, Italy
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Xiao Y, Lin C, Lu JY, Xu L, Hou WY, Sun R, Chang GJ, Zhang JJ. Short-term outcomes of pure transvaginal laparoscopic right colectomy: A novel surgery approach based on an Idea, Development, Exploration, Assessment, Long-term framework stage IIa study. J Surg Oncol 2021; 123 Suppl 1:S36-S42. [PMID: 33650688 DOI: 10.1002/jso.26363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/21/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES The application of pure natural orifice translumenal endoscopic surgery (NOTES) to intra-abdominal visceral resections remains limited due to the complexity of the dissection. This study aimed to assess the safety and feasibility of laparoscopic right colectomy using a purely transvaginal approach. METHODS The data of 12 continuous patients with colon neoplasia who underwent transvaginal right colectomy from November 2018 to July 2020 were prospectively collected, and their perioperative events were recorded. RESULTS The patients' median age was 70.4 years. Four were diagnosed with colon adenoma and eight with adenocarcinoma. The median operative time was 185 min, with a median blood loss of 25 ml. The median time to gas passing was 32.5 h after surgery. The median postoperative hospital stay was 6 days. One operation was converted to hybrid NOTES due to difficulty with the anastomosis, and one was converted to laparoscopic surgery because of vascular injury. Three cases were grades I, II, and III according to the Clavien-Dindo classification. CONCLUSION Pure NOTES right colectomy using the transvaginal approach is feasible and safe with good short-term outcomes. We recommend this novel technique for highly-selected patients with no more than a D2 dissection performed by experienced colorectal surgeons.
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Affiliation(s)
- Yi Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chen Lin
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jun-Yang Lu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Lai Xu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wen-Yun Hou
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Rui Sun
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Guo-Jing Chang
- Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jun-Ji Zhang
- Department of Obstetrics & Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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Gastric equivalent of the 'Holy Plane' to standardize the surgical concept of stomach cancer to mesogastric excision: updating Jamieson and Dobson's historic schema. Gastric Cancer 2021; 24:273-282. [PMID: 33387120 DOI: 10.1007/s10120-020-01142-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgery for curable gastric cancer has historically involved dissection of lymph nodes, depending on the risk of metastasis. By establishing the concept of mesogastric excision (MGE), we aim to make this approach compatible with that for colorectal cancer, where the standard is excision of the mesentery. METHODS Current advances in molecular embryology, visceral anatomy, and surgical techniques were integrated to update Jamieson and Dobson's schema, a historical reference for the mesogastrium. RESULTS The mesogastrium develops with a three-dimensional movement, involving multiple fusions with surrounding structures (retroperitoneum or other mesenteries) and imbedding parenchymal organs (pancreas, liver, and spleen) that grow within the mesentery. Meanwhile, the fusion fascia and the investing fascia interface with adjacent structures of different embryological origin, which we consider to be equivalent to the 'Holy Plane' in rectal surgery emphasized by Heald in the concept of total mesorectal excision. Dissecting these fasciae allows for oncologic MGE, consisting of removing lymph node-containing mesenteric adipose tissue with an intact fascial package. MGE is theoretically compatible with its colorectal counterpart, although complete removal of the mesogastrium is not possible due to the need to spare imbedded vital organs. The celiac axis is treated as the central artery of the mesogastrium, but is peripherally ligated by tributaries flowing into the stomach to feed the spared organs. CONCLUSION The obscure contour of the mesogastrium can be clarified by thinking of it as the gastric equivalent of the 'Holy Plane'. MGE could be a standard concept for surgical treatment of stomach cancer.
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D3-lymphadenectomy enhances oncological clearance in patients with right colon cancer. Results of a meta-analysis. Eur J Surg Oncol 2021; 47:1541-1551. [PMID: 33676793 DOI: 10.1016/j.ejso.2021.02.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/23/2021] [Accepted: 02/16/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND D3-Lymphadenectomy, together with complete mesocolic excision (CME), were introduced to provide oncological results after right colon cancer. The aim of this systematic review with meta-analysis was to assess the short and long-term outcomes of right-sided hemicolectomy with CME + D3 as compared with classic right hemicolectomy. Secondary aims included the prevalence of D3-metastasis and skip metastasis when performing CME + D3. MATERIAL AND METHODS A systematic review with meta-analysis was conducted, according to PRISMA methodology. RESULTS 29 studies were enrolled (2592 patients). No differences were accounted in morbidity variables associated with the measured techniques. CME + D3 was significantly associated with a greater distance between the tumour and the closest vascular tie, a longer colonic resection, a wider resection of mesentery and an increased number of harvested lymph nodes. Regarding to long-terms outcomes, we found a significant decrease in local recurrence in patients undergoing CME + D3 (HR:0.17) and a significant improvement in 3-year and 5-year overall survival rates (HR:0.53 vs. HR:0.57, respectively), as well as an improving survival in patients with stage II and III disease. Overall prevalence of patients with lymphatic metastases in D3-territory was of 8.6% and 2.2% of skip metastases. CONCLUSIONS CME + D3 is a feasible surgical procedure that allows to obtain specimens with higher quality oncological resection, without greater associated morbidity, thus improving survival in patients with stage II and III right colon cancer.
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Surgical steps for right laparoscopic D3 lymphadenectomy in a patient with a giant duodenal diverticulum. Tech Coloproctol 2021; 25:597-598. [PMID: 33544259 DOI: 10.1007/s10151-020-02377-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/16/2020] [Indexed: 12/30/2022]
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39
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Fletcher-Sanfeliu D, García-Granero Á, Doménech Dolz A, Pellino G, Orbis F, Arroyo A, Valverde-Navarro AA, Ortí LS, Martín-González I. Surgical anatomy applied to transperitoneal approaches of the abdominal aorta and visceral trunks. Dynamic article. Cir Esp 2021; 99:S0009-739X(20)30425-5. [PMID: 33546883 DOI: 10.1016/j.ciresp.2020.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 11/08/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Access to the abdominal aorta and its visceral trunks is possible through several approaches. Dissections of five cadavers performed during three National Surgical Anatomy courses applied to Aorta, Hepatobiliopancreatic and Digestive Surgery. Videos and pictures were taken throughout the dissections and showed different abdominal aorta approaches. Abdominal aorta and visceral trunks approaches: longitudinal inframesocolic access, supraceliac clamping, celiac trunk dissection, superior mesenteric artery approaches (retroperitoneal after Kocher menoeuvre, supramesocolic or inframesocolic), Cattell-Braasch manoeuvre and mattox manoeuvre: retrorenal and prerenal. Correct knowledge of the intraabdominal anatomy is necessary to perform all the abdominal aorta surgical approaches. Cadaveric dissection could help to achieve this objective. Cardiovascular and digestive surgeons need to know the possible strategies in order to choose the one which is best suited for each patient.
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Affiliation(s)
| | - Álvaro García-Granero
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, España; Departamento de Anatomía y Embriología Humana, Universidad de Valencia, Valencia, España.
| | - Alberto Doménech Dolz
- Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario, Valencia, España
| | - Gianluca Pellino
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Vall d́Hebrón, Barcelona, España
| | - Francisco Orbis
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario y Politécnico la Fe, Valencia, España
| | - Antonio Arroyo
- Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario de Elche, Alicante, España; Departamento de Patología y Cirugía, Facultad de Medicina, Universidad Miguel Hernández de Elche, Alicante, España
| | | | - Luis Sabater Ortí
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario, Valencia, España
| | - Iván Martín-González
- Servicio de Cirugía Cardiovascular, Hospital Universitario del Vinalopó, Elche, Alicante, España
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Andersen BT, Stimec BV, Edwin B, Kazaryan AM, Maziarz PJ, Ignjatovic D. Re-interpreting mesenteric vascular anatomy on 3D virtual and/or physical models: positioning the middle colic artery bifurcation and its relevance to surgeons operating colon cancer. Surg Endosc 2021; 36:100-108. [PMID: 33492511 PMCID: PMC8741724 DOI: 10.1007/s00464-020-08242-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022]
Abstract
Background The impact of the position of the middle colic artery (MCA) bifurcation
and the trajectory of the accessory MCA (aMCA) on adequate lymphadenectomy when
operating colon cancer have as of yet not been described and/or analysed in the
literature. The aim of this study was to determine the MCA bifurcation position to
anatomical landmarks and to assess the trajectory of aMCA. Methods The colonic vascular anatomy was manually reconstructed in 3D from
high-resolution CT datasets using Osirix MD and 3-matic Medical and analysed. CT
datasets were exported as STL files and supplemented with 3D printed models when
required. Results Thirty-two datasets were analysed. The MCA bifurcation was left to the
superior mesenteric vein (SMV) in 4 (12.1%), in front of SMV in 17 (53.1%) and right
to SMV in 11 (34.4%) models. Median distances from the MCA origin to bifurcation were
3.21 (1.18–15.60) cm. A longer MCA bifurcated over or right to SMV, while a shorter
bifurcated left to SMV (r = 0.457, p = 0.009). The main MCA direction was towards right in
19 (59.4%) models. When initial directions included left, the bifurcation occurred
left to or anterior to SMV in all models. When the initial directions included right,
the bifurcation occurred anterior or right to SMV in all models. The aMCA was found
in 10 (31.3%) models, following the inferior mesenteric vein (IMV) in 5 near the
lower pancreatic border. The IMV confluence was into SMV in 18 (56.3%), splenic vein
in 11 (34.4%) and jejunal vein in 3 (9.4%) models. Conclusion Awareness of the wide range of MCA bifurcation positions reported is
crucial for the quality of lymphadenectomy performed. The aMCA occurs in 31.3% models
and its trajectory is in proximity to the lower pancreatic border in one half of
models, indicating that it needs to be considered when operating splenic flexure
cancer. Supplementary information The online version of this article (10.1007/s00464-020-08242-8) contains supplementary material, which is available to authorized
users.
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Affiliation(s)
- Bjarte T Andersen
- Department of Gastrointestinal Surgery, Østfold Hospital Trust, PO Box 300, 1714, Grålum, Norway.,Institute for Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Bojan V Stimec
- Anatomy Sector, Teaching Unit, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bjørn Edwin
- Intervention Centre and Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.,Institute for Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Airazat M Kazaryan
- Department of Gastrointestinal Surgery, Østfold Hospital Trust, PO Box 300, 1714, Grålum, Norway. .,Intervention Centre and Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway. .,Institute for Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway. .,Department of Faculty Surgery, I.M. Sechenov First Moscow State Medical University, Moscow, Russia. .,Department of Surgery N 2, Yerevan State Medical University After M.Heratsi, Yerevan, Armenia.
| | - Przemyslaw J Maziarz
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway.,Lancet Kirurgisk Praksis, Rolvsøy, Norway
| | - Dejan Ignjatovic
- Institute for Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.,Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway
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Matsuda T, Yamashita K, Hasegawa H, Utsumi M, Kakeji Y. Current status and trend of laparoscopic right hemicolectomy for colon cancer. Ann Gastroenterol Surg 2020; 4:521-527. [PMID: 33005847 PMCID: PMC7511568 DOI: 10.1002/ags3.12373] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/04/2020] [Accepted: 06/22/2020] [Indexed: 01/19/2023] Open
Abstract
Laparoscopic right hemicolectomy (LRH) is utilized worldwide as one of the standard surgical treatments for right-sided colon cancer. However, there have been issues concerning its applicability, techniques, and trend. The present study aimed to elucidate the current status and trend of LRH by reviewing literature focusing on important issues associated with this surgery. Based on previous studies, LRH most likely provides better short-term outcomes and similar oncological outcomes compared to open surgery. Despite the increasing use of robotic approach in this surgery, it seems to have always been associated with longer operative times and greater hospital cost with limited advantage. Intracorporeal anastomosis seems to improve short-term outcomes, such as quicker recovery of bowel function, compared to extracorporeal anastomosis. However, it does not contribute to shorter hospital stay. With regard to dissection technique, various approaches, and landmarks have been advocated to overcome the technical difficulty in LRH. This difficulty is likely to be caused by anatomical variation, especially in venous structures. The superiority of one approach or landmark over another is still argued about due to the lack of large-scale prospective studies. However, deep understanding both of anatomical variation and characteristics of each approach would be of extreme importance to minimize adverse effects and maximize patient benefit after LRH.
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Affiliation(s)
- Takeru Matsuda
- Division of Gastrointestinal SurgeryDepartment of SurgeryKobe University Graduate School of MedicineKobeJapan
- Division of Minimally Invasive SurgeryDepartment of SurgeryKobe University Graduate School of MedicineKobeJapan
| | - Kimihiro Yamashita
- Division of Gastrointestinal SurgeryDepartment of SurgeryKobe University Graduate School of MedicineKobeJapan
| | - Hiroshi Hasegawa
- Division of Gastrointestinal SurgeryDepartment of SurgeryKobe University Graduate School of MedicineKobeJapan
| | - Masako Utsumi
- Division of Gastrointestinal SurgeryDepartment of SurgeryKobe University Graduate School of MedicineKobeJapan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal SurgeryDepartment of SurgeryKobe University Graduate School of MedicineKobeJapan
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