Vascular Anatomy in Laparoscopic Colectomy for Right Colon Cancer

A SICE (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie) observational prospective multicenter study on anatomical variants of the superior mesenteric artery: intraoperative analysis during laparoscopic right hemicolectomy-CoDIG 2 database (ColonDx Italian Group)

Colorectal cancer, the third most common cancer worldwide, affects 40-45% of patients on the right side. Surgery, especially minimally invasive methods such as laparoscopic and robotic procedures, is the preferred treatment. However, these techniques present technical complications. The anatomical complexity and variations in vessel branching patterns pose challenges, particularly for less experienced surgeons. The CoDIG 2 is a nationwide observational study involving 76 specialized Italian general surgery departments focused on colorectal surgery. The centres were directed to maintain their standard surgical and clinical practices. The aim of this study was to analyse the intraoperative vascular anatomy of Italian patients who underwent laparoscopic right colectomy and explore the ligature techniques used by Italian surgeons. Surgeons reported information about vascularization of the right colon for 616 patients and about surgical anatomy of RCA for 368 patients. Fifty-three patients (10.8%) showed no RCA intraoperatively. The right colic artery (RCA) was categorized according to the Yada classification (types 1-4) during evaluation, and intraoperative assessments revealed that Yada type 1 was the most common type (55.2%), while radiologic evaluations revealed a higher prevalence of type 2. Furthermore, compared with the superior mesenteric vein (SMV), the RCA is more often located anteriorly according to intraoperative and contrast-enhanced CT examination; 59.9% were found in the anterior position during intraoperative examination, while 40.1% were found in the same position on preoperative contrast-enhanced CT. Vascularization of the right colon, including missing branches, additional branches, shared trunks, and retro-superior courses of the mesenteric vein, exhibited notable variations. To understand vascular variations, a preoperative radiological study is necessary; although there was no concordance between the intraoperative and radiological evaluations, this is a limitation of preinterventional radiological evaluation (PII) because it is always needed for oncological staging. This approach is especially critical for inexperienced surgeons to avoid potential complications, such as problematic bleeding.

Complete mesocolic excision for colon cancer: current status and controversies

According to Hohenberger's original description, complete mesocolic excision for colon cancer involves precise dissection of the avascular embryonic plane between the parietal retroperitoneum and visceral peritoneum of the mesocolon. This ensures mesocolic integrity, access to high ligation of the supplying vessels at their origin and an associated extended lymphadenectomy. Results from centres which have adopted this approach routinely have demonstrated that oncological outcomes can be improved by the rigorous implementation of established principles of cancer surgery. Meticulous anatomical dissection along embryonic planes is a well-established principle of precision cancer surgery used routinely by the specialist colorectal surgeon. Therefore, the real question concerns the need for true central vascular ligation and associated extended (D3) lymphadenectomy or otherwise, particularly along the superior mesenteric vessels when performing a right colectomy. Whether this approach results in improved overall or disease-free survival remains unclear and its role remains controversial particularly given the potential for significant morbidity associated with a more extensive central vascular dissection. Current literature is limited by considerable bias, as well as inconsistent and variable terminology, and the results of established randomized trials are awaited. As a result of the current state of equipoise, various national guidelines have disparate recommendations as to when complete mesocolic excision should be performed if at all. This article aims to review the rationale for and technical aspects of complete mesocolic excision, summarize available short and long term outcome data and address current controversies.

Variations of the double superior mesenteric vein are not rare: An observational study using computed tomography, three-dimensional image reconstruction, and surgery

INTRODUCTION

Few studies have evaluated variations of the main trunk of the superior mesenteric vessels. Particularly, the double superior mesenteric vein (DSMV) has not been described in detail. This study aimed to establish the definition, anatomical characteristics, and underlying clinical significance of the DSMV.

MATERIALS AND METHODS

A total of 115 patients with colorectal cancer were included in this retrospective study between March 2020 and March 2022. The anatomical characteristics were analyzed using computed tomography, three-dimensional image reconstructions, and surgical videos.

RESULTS

Among the patients enrolled, 22 (19.1%) had DSMVs. The median diameters of the right and left superior mesenteric veins were similar. The superior mesenteric artery was sandwiched between the right and the left superior mesenteric veins. The left superior mesenteric vein mainly crossed the ventral side of the superior mesenteric artery (63.6%). In 1 case, the right superior mesenteric vein was mistakenly resected intraoperatively. The DSMV was classified into types I and II based on whether the right and left trunks formed a common trunk; it was further classified into subtypes a and b based on the colonic vein confluence. The proportions of type I-a, I-b, II-a, and II-b were 4.5%, 27.3%, 9.1%, and 59.1%, respectively. The middle colic veins drained into the left superior mesenteric vein in 19 cases (86.4%).

CONCLUSIONS

The DSMV is more common than previously thought. For the first time, the definition and four types of the DSMV were proposed. The presence of a DSMV should be considered during right hemicolectomies.

Right colon cancer: The influence of specific location on recurrence and survival

AIM

This study aimed to investigate whether the site of the tumour within the right colon affects survival in patients who underwent right colectomy for colon cancer.

METHODS

An observational retrospective longitudinal study was performed in patients who underwent right colectomy for non-metastatic, invasive right-sided colon cancer. Patients were categorized into two groups based on tumour location: (i) caecum and ascending colon; (ii) hepatic flexure and proximal transverse colon. Demographic and clinical features were characterized, and a survival analysis was performed.

RESULTS

Of the 198 patients enroled in the study, 134 (67.8%) had caecal or ascending colon cancer and 64 (32.3%) had hepatic flexure or transverse colon cancer. Seventy (35.4%) were female and the mean age at the time of surgery was 71.6 (SD 11.4). The groups were comparable with respect to the number of lymph nodes sampled, the pTNM stage, the histological differentiation grade and the likelihood of patients receiving adjuvant chemotherapy. Recurrence rate was nearly twice as high in the hepatic flexure and proximal transverse colon group (12.5% vs 6.7%), but this difference was not statistically significant (p = 0.174). Kaplan-Meier analysis showed no differences in disease-free (p = 0.255) and overall survival (p = 0.258) between the groups.

CONCLUSION

In our population, specific location of right-sided colon cancers does not appear to have an influence on survival. Further investigation is needed to determine if tumour subsite has an impact on the recurrence rate, and whether it should be considered in defining prognosis and treatment.

"Caudal to cranial" versus "medial to lateral" approach in laparoscopic right hemicolectomy with complete mesocolic excision for the treatment of stage II and III colon cancer: perioperative outcomes and 5-year prognosis

The purpose of this study was to compare the "caudal to cranial" (CC) versus "medial to lateral" (ML) approach for laparoscopic right hemicolectomy. Pertinent data from all patients with stage II and III between January 2015 and August 2017 were entered into a retrospective database. A total of 175 patients underwent the ML (N = 109) or CC approach (N = 66). Patient characteristics were equivalent between groups. The CC group showed a shorter surgical time 170.00 (145.00, 210.00) vs. (206.50 (178.75, 226.25) min) than the ML group (p < 0.001). The time to oral intake was shorter in the CC group than in the ML group ((3.00 (1.00, 4.00) vs. 3.00 (2.00, 5.00) days; p = 0.007). For the total harvested lymph nodes, there was no statistical significance between the CC group 16.50 (14.00, 21.25) and the ML group 18.00 (15.00, 22.00) (p = 0.327), and no difference was found in the positive harvested lymph nodes (0 (0, 2.00) vs. 0 (0, 1.50); p = 0.753). Meanwhile, no differences were found in other perioperative or pathological outcomes, including blood loss and complications. For 5-year prognosis, overall survival rates were 75.76% in the CC group and 82.57% in the ML group (HR 0.654, 95% CI 0.336-1.273, p = 0.207); disease-free survival rates were 80.30% in the CC group and 85.32% in the ML group (HR 0.683, 95% CI 0.328-1.422, p = 0.305). Both approaches were safe and feasible and resulted in excellent survival. The CC approach was beneficial in terms of the surgical time and time to oral intake.

Cadaveric and CT angiography study of vessels around the transverse colon mesentery

BACKGROUND

Laparoscopic and robotic surgery for transverse colon cancer are difficult due to complex fusion of the foregut and midgut and variation of the vessels of the transverse colon. Although the vessels of the right colon have been investigated, middle colic artery (MCA) variation and the relationship with vessels around the transvers colon are unknown. We investigated variation of the MCA using computed tomography angiography (CTA) and cadaver specimen and the relationship between the superior mesenteric vein (SMV) and MCA using CTA. The classification of vessels around the transverse colon may lead to safer and reliable surgery.

METHODS

This study included 505 consecutive patients who underwent CTA in our institution from 2014 to 2020 and 44 cadaver specimens. Vascular anatomical classifications and relationships were analyzed using CT images.

RESULTS

The MCA was defined as the arteries arising from the superior mesenteric artery (SMA) that flowed into the transverse colon at the distal ends. The classifications were as follows: type I, branching right and left from common trunk; type II, the right and left branches bifurcated separately from the SMA; and type III, the MCA branched from a vessel other than the SMA. Type II was subclassified into two subtypes, type IIa with one left branch and type IIb with two or more left branches from SMA. In the CTA and cadaver studies, respectively, the classifications were as follows: type I, n = 290 and n = 31; type IIa, n = 211 and n = 13; type IIb, n = 3 and n = 0; and type III, n = 1 and n = 0. We classified the relationship between the MCA and left side of the SMV into three types: type A, a common trunk runs along the left edge of the SMV (n = 173; 59.7%); type B, a right branch of the MCA runs along the left edge of the SMV (n = 116; 40.0%); and type C, the MCA runs dorsal of the SMV (n = 1; 0.3%).

CONCLUSIONS

This study revealed that The MCA branching classifications and relationship between the SMV and MCA. Preoperative CT angiography may be able to reliably identify vessel variation, which may be useful in clinical practice.

Frequencies and Injury Analysis of Small Anterior Branch of Gastrocolic Trunk

Objective: Small anterior branch of gastrocolic trunk (SABGT) can be occasionally observed during transverse colectomy and right hemicolectomy. Improperly dealing with the branch may lead to unwanted bleeding and affect the operation process. The purposes of this study are to analyze the frequencies and injury of SABGT. Methods: Intact operation data were collected retrospectively from 39 colon cancer patients who underwent curative laparoscopic transverse colectomy or right hemicolectomy. Frequencies and injury of SABGT were analyzed. Results: Eight cases had SABGT, the frequencies of which is 20.5%. Injury of SABGT occurred intraoperatively in 2 patients. Conclusion: We suggest that SABGT should be considered in surgical management. Consciously looking for and properly dealing with the branch can minimize the influence on the operation process.

Laparoscopic extended right hemicolectomy with superior-to-inferior dissection: a mentee's initial experience

Laparoscopic right hemicolectomy is a widely accepted procedure for right colon cancer. Among the various approaches, the superior approach has potential benefits in that it exposes the gastrocolic trunk early and consistently allows for D3 lymph node dissection along superior mesenteric vessels. In this video, we present a beginner performing a laparoscopic extended right hemicolectomy using a superior approach without an assistant.

Anatomic patterns and clinical significance of gastrocolic trunk of Henlé in laparoscopic right colectomy for colon cancer: Results of the HeLaRC trial

BACKGROUND

Recent interest in laparoscopic right colectomy with D3 lymphadenectomy for right colon cancer, has raised renewed attention to the anatomic variations of the gastrocolic trunk of Henlé (GTH). Understanding the vascular structure of the GTH region for individual patients should improve surgical outcomes. The goal of this nationwide multicenter study (Anatomical Classification of Henlé's Trunk in Laparoscopic Right Hemi-colectomy (HeLaRC) trial) was to study the anatomic patterns of the GTH region, to clarify the implications of GTH in laparoscopic right colectomy with D3 lymphadenectomy (D3-RC) and analyze their clinical significance.

METHODS

We enrolled 583 patients from 26 centers across China who underwent D3-RC. The number of tributaries, length and types of GTH constitutions and their influence on intra-operative data were investigated. A nomogram score (based on the length of GTH, body mass index (BMI), tumor location, T stage and type of GTH (type I vs. non-type I) was established to assess the potential hazard of bleeding.

RESULTS

The GTH was found in 567 patients (97.3%). The distribution of GTH types was 0 (14.1%, n = 80), I (53.3%, n = 302), II (27.0%, n = 153), III (5.6%, n = 32). Of note, the type I GTH, T1 stage and tumor location at ileocecal or ascending colon were correlated with shorter exposure time of the GTH region (P < 0.0001). Short length of GTH (P = 0.002) and tumor location (transverse colon vs. non transverse colon) (P = 0.003) were correlated with the amount of GTH bleeding during the surgery. Nomogram discrimination was good (C-index: 0.72 (95% CI: 0.64, 0.80)). The dissection plane was better in patients with type I GTH than with other types (P = 0.023).

CONCLUSION

GTH pattern variations may affect surgical outcomes in patients undergoing D3-RC. Better recognition of GTH anatomy might lead to a safer operation with better oncologic quality.

The SAGES MASTERS program presents: the 10 seminal articles for the Laparoscopic Right Colectomy Pathway

BACKGROUND

As one of the 12 clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, the Colorectal Pathway intends to deliver didactic content organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure (laparoscopic right colectomy, laparoscopic left/sigmoid colectomy, and intracorporeal anastomosis during minimally invasive (MIS) ileocecal or right colon resection). In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic right colectomy which surgeons should be familiar with.

METHODS

Using a systematic literature search of Web of Science, the most cited articles on laparoscopic right colectomy were identified, reviewed, and ranked by the SAGES Colorectal Task Force and invited subject experts. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, with emphasis on relevance and impact in the field, findings, strengths and limitations, and conclusions.

RESULTS

The top 10 seminal articles selected for the laparoscopic right colectomy anchoring procedure include articles on surgical techniques for benign and malignant disease, with anatomical and video illustrations, comparative outcomes of laparoscopic vs open colectomy, variations in technique with impact on clinical outcomes, and assessment of the learning curve.

CONCLUSIONS

The top 10 seminal articles selected for laparoscopic right colectomy illustrate the diversity both in content and format of the educational curriculum of the SAGES Masters Program to support practicing surgeon progression to mastery within the Colorectal Pathway.

Vascular Anatomy and Variants: Knowledge during Laparoscopic Right Colectomy

From the review of the literature and clinical data, it is clear that the anatomy of the vessels of the right colon is remarkably variable, especially those of Henle branch. This justifies why the laparoscopic colectomy (LRC) plus complete mesocolon excision (CME) is often difficult to perform with the conversion rate due to the lesion of the vessels. The objective of this study was to retrospectively review the videos and literature of the right laparoscopic colectomy plus CME to highlight the greatest number of vascular variations of the right colon, to record them, and to highlight the methods by which cope with these variations during surgery.

Vascular variants in laparoscopic extended right hemicolectomy with central vascular ligation for right colon cancer

PURPOSE

To evaluate the right colic vascularity, focusing on the confluences of veins.

METHODS

The subjects of this retrospective study were 100 patients who underwent laparoscopic extended right hemicolectomy (Lap-ERHC) between April 2015 and September 2020, at our hospitals. Veins draining into the superior mesenteric vein (SMV) included the ileocecal vein (ICV), the right colic vein (RCV), the middle colic vein (MCV), and the gastrocolic trunk of Henle (GCT). Veins draining into vessels other than the SMV were defined as accessory colic veins (aICV, aRCV or aMCV).

RESULTS

The GCT, aRCV, and aMCV were found in 86, 89, and 15 patients, respectively. In 66 patients with one aRCV, drainage was split as the anterior superior pancreaticoduodenal vein (ASPDV) in 12, the right gastroepiploic vein (RGEV) in 7, and the GCT in 47. In 23 patients with two aRCVs, drainage was split as the ASPDV in 4, the RGEV in 1, the GCT in 11, and the ASPDV and GCT in 7. In 14 patients with one aMCV, drainage was split as the GCT in 8, the splenic vein in 5, and the first jejunal vein (FJV) in 1. One patient had two aMCVs, draining into the GCT and the FJV.

CONCLUSIONS

The findings of our evaluation of vascular anatomy, focusing on confluences of the colic veins, provides useful information for colorectal surgeons.

Tunnel versus medial approach in laparoscopic radical right hemicolectomy for right colon cancer: a retrospective cohort study

PURPOSE

This study aimed to explore the feasibility and safety of the tunnel approach in laparoscopic radical right hemicolectomy for colon cancer.

METHODS

From July 2016 to October 2018, a total of 106 consecutive patients with colon cancer who underwent laparoscopic radical right hemicolectomy at the Affiliated Cancer Hospital of Zhengzhou University were enrolled. The patients were stratified into either a tunnel approach (TA) (n = 56) group or traditional medial approach (MA) (n = 50) group according to the surgical technique performed. The baseline demographics, perioperative outcomes and oncologic outcomes were compared between the two groups.

RESULTS

The baseline characteristics did not differ between groups. The TA group had significantly less blood loss [20.0 (10.0-40.0) vs. 100 (100.0-150.0) ml, p < 0.001] and a shorter operation time [128.4 ± 16.7 vs. 145.6 ± 20.3 min, p < 0.001] than the MA group. The time to first flatus and postoperative hospital stay were similar [3.0 (2.0-4.0) vs. 3.0 (3-4.0) days, p = 0.329; 10.4 ± 2.6 vs. 10.7 ± 3.0 days, p = 0.506] between the two groups. The conversion to laparotomy and complication rates were similar between groups (0 vs. 6.0%, p = 0.203; 14.3% vs. 18.0%, p = 0.603, respectively). No treatment-related deaths occurred in either group. The TA group did not have significantly better survival outcomes than the MA group (p = 0.372).

CONCLUSIONS

The TA seems to allow for more favourable results in terms of blood loss and operative time than the MA, with similar results regarding time to first flatus, hospital stay, postoperative complication rate, conversion rate and oncologic outcomes; moreover, the TA is easier for beginners to master.

International survey among surgeons on laparoscopic right hemicolectomy: the gap between guidelines and reality

Introduction

To assess the current approaches and perioperative treatments of laparoscopic right hemicolectomy (LRHC) and to highlight similarities and differences with international guidelines and scientific evidence, we conducted a survey for surgeons across the globe.

Methods

All digestive and colorectal surgeons registered with the database of the Research Institute against Digestive Cancer (IRCAD) were invited to take part in the survey via email and through the social media networks of IRCAD.

Results

There were a total of 440 respondents from 78 countries. Most surgeons worked in the European region (38.6%) followed by the Americas (34.1%), the Eastern Mediterranean region (13.0%), the South-East Asian region (5.9%), the Western Pacific region (4.8%), and Africa (3.2%) respectively. Over half of the respondents performed less than 25% of right hemicolectomies laparoscopically where 4 ports are usually used by 68% of the surgeons. The medial-to-lateral, vessel-first approach is the approach most commonly used (74.1%). The most common extraction site was through a midline incision (53%) and an abdominal drain tube is routinely used by 52% of the surgeons after surgery. A total of 68.6% of the responding surgeons perform the majority of the anastomoses extracorporeally. Finally, we found that the majority of responders (60.7%) routinely used mechanical bowel preparations prior to LRHC.

Conclusion

Regarding several topics related to LRHC care, a discrepancy was observed between the current medical practice and the recommendations from RCTs and international guidelines and significant regional differences were observed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09044-w.

Is Laparoscopic Complete Mesocolic Excision and Central Vascular Ligation Really Necessary for All Patients With Right-Sided Colon Cancer?

Colon cancer treatment is on the way to evolution over several decades. The minimally invasive surgery has improved postoperative short-term outcomes. Adjuvant chemotherapy has prolonged the survival of advanced colon cancer patients. Hohenberger proposed the noble concept of complete mesocolic excision (CME) which consists of 3 components: plane surgery, sufficient longitudinal bowel resection, and central vascular ligation (CVL). Mesocolic plane surgery shares the same surgical principle of total mesorectal excision, which is maintaining the intact mesothelial envelope. However, there remain debates about the extent of bowel resection and the level of CVL for maximizing lymph node dissection. There is no solid clinical evidence for the oncological necessity and benefit of extended radical dissection in right hemicolectomy. CME with CVL based on open surgery has been adopted in laparoscopic surgery. So, it is also necessary to look at how the CME could be transformed and successfully implanted in the laparoscopic era. Recent rapid advances in surgical technology and cancer biology are preparing for fundamental changes in cancer surgery. In this study, we reviewed the history, oncological necessity, and compatibility of CME for the right hemicolectomy in the laparoscopic era and outline the new perspectives on the evolution of cancer surgery.

A systematic review and meta-analysis of variants of the branches of the superior mesenteric artery: the Achilles heel of right hemicolectomy with complete mesocolic excision?

AIM

Dissection with subsequent ligation and resection of arteries at their origin (central vascular ligation) is essential for adequate oncological resection during right hemicolectomy with complete mesocolic excision. This technique is technically demanding due to the highly variable arterial pattern of the right colon. Therefore, this study aims to provide a comprehensive evidence-based assessment of the arterial vascular anatomy of the right colon.

METHODS

A thorough systematic literature search through September 2020 was conducted on the electronic databases PubMed, Scopus and Web of Science to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using MetaXl software.

RESULTS

A total of 41 studies (n = 4691 patients) were included. The ileocolic artery (ICA), right colic artery (RCA) and middle colic artery (MCA) were present in 99.7% (95% CI 99.4%-99.8%), 72.6% (95% CI 61.3%-82.5%) and 96.9% (95% CI 94.2%-98.8%) respectively of patients. Supernumerary RCA and MCA were observed in 3.2% and 11.4% respectively of all cases. The RCA shared a common trunk with the ICA and MCA in 13.2% and 17.7% respectively of patients. A retro-superior mesenteric vein course of the ICA and RCA was observed in 55.1% and 11.4% respectively of all cases.

CONCLUSION

The vascular anatomy of the right colon displays several notable variations, namely the absence of some branches (RCA absent in 27.4% of cases), supernumerary branches, common trunks, and retro-superior mesenteric vein courses. These variations should be taken into consideration during right hemicolectomy with complete mesocolic excision to ensure adequate oncological resection while minimizing intra-operative complications.

A Study of the Right Colonic Vascular Anatomy: Correlations between Veins and Arteries

Objectives

Few studies have examined the correlations between the arteries and veins of the right colon. In this study, we aimed to use high-resolution CT scans to understand the vascular anatomy of Henle's gastrocolic trunk and review the terminology describing the arteries and veins of the right colon.

Methods

This retrospective study has examined patients who underwent laparoscopic colectomy for right colon cancer in a single institution in Japan. Scans from consecutive patients who underwent surgery between October 2017 and March 2020 (n = 165) were examined. Preoperative CT images were used to create multiplanar reformation images and volume rendering images.

Results

Among the 139 patients with Henle's gastrocolic trunk (GCT) present, arteries accompanying the accessory right colic vein (ARCV) were most common on the right branch of the middle colic artery (MCA) (71.2%), followed by the right colic artery (RCA) (19.4%); meanwhile, 9.4% of the patients had no accompanying arteries. Of patients with no accompanying arteries to the ARCV, RCA was present in 15.4%. Among the 26 patients with no GCT, the right colic vein (RCV) existed in 15 patients, with the artery accompanying the RCV most commonly being the right branch of the MCA (66.6%), followed by the RCA (33.3%).

Conclusions

Irrespective of the presence of GCT, approximately 70% of the arteries accompanying the drainage vein from the right colon were the right branch of the MCA. We suggest that vascular branch formation be considered preoperatively in surgical management for right colon cancer.

Predictive value of computed tomography with coronal reconstruction in right hemicolectomy with complete mesocolic excision for right colon cancers: a retrospective study

Background

Understanding the vascular anatomy is critical for performing central vascular ligation (CVL) in right hemicolectomy with complete mesocolic excision (CME). This study aimed to investigate the predictive value of multi-slice spiral computed tomography (MSCT) with coronal reconstruction in right hemicolectomy with CME.

Methods

This is a retrospective descriptive study. Eighty patients with right colon cancer who underwent right hemicolectomy from December 2015 to January 2020 were included. The intraoperative reports (including imaging data) and MSCT images with coronal reconstruction were analysed and compared. The detection rates of the ileocolic vein (ICV) and ileocolic artery (ICA) roots and the accuracy in predicting their anatomical relationship were analysed. The detection rate and accuracy in predicting the location of the gastrocolic trunk of Henle (GTH), middle colic artery (MCA) and middle colic vein (MCV) were analysed. The distance from the ICV root to the GTH root (ICV-GTH distance) was measured and analysed. The maximum distance from the left side of the superior mesenteric artery (SMA) to the right side of the superior mesenteric vein (SMV), named the ‘lsSMA-rsSMV distance’, was also measured and analysed.

Results

In seventy-four (92.5%) patients, both the ICV and ICA roots were located; their anatomical relationship was determined by MSCT, and the accuracy of the prediction was 97.2% (72/74). The GTH was located by MSCT in 75 (93.7%) patients, and the accuracy of the prediction was 97.33% (73/75). The MCA was located by MSCT in 47 (58.75%) patients, and the accuracy was 78.72% (37/47). The MCV was located by MSCT in 51 (63.75%) patients, and the accuracy of the prediction was 84.31% (43/51). The ICV-GTH distance was measured in 73 (91.2%) patients, and the mean distance was 4.28 ± 2.5 cm. The lsSMA-rsSMV distance was measured in 76 (95%) patients, and the mean distance was 2.21 ± 0.6 cm.

Conclusions

With its satisfactory accuracy in predicting and visualising the information of key anatomical sites, MSCT with coronary reconstruction has some predictive value in CME with CVL in right hemicolectomy.

Securing the surgical field for mobilization of right-sided colon cancer using the duodenum-first multidirectional approach in laparoscopic surgery

Background

The aim of this study was to compare the short-term outcomes of the duodenum-first multidirectional approach (DMA) in laparoscopic right colectomy with those of the conventional medial approach to assess its safety and feasibility.

Methods

This retrospective study enrolled 120 patients who had laparoscopic surgery for right-sided colon cancer in our institution between April 2013 and December 2019. Fifty-four patients underwent colectomy using the multidirectional approach; among these, 20 underwent the DMA and 34 underwent the caudal-first multidirectional approach (CMA). Sixty-six patients underwent the conventional medial approach. Complications within 30 days of surgery were compared between the groups.

Results

There were 54 patients in the multidirectional group [29 females, median age 72 years (range 36–91 years)] and 66 in the medial group [42 females, median age 72 years (range 41–91 years)]. Total operative time was significantly shorter in multidirectional approach patients than conventional medial approach patients (208 min vs. 271 min; p = 0.01) and significantly shorter in patients who underwent the DMA compared to the CMA (201 min vs. 269 min; p < 0.001). Operative time for the mobilization procedure was also significantly shorter in patients who underwent the DMA (131 min vs. 181 min; p < 0.001). Blood loss and incidence of postoperative complications did not differ. In 77 patients with advanced T3/T4 tumors, the DMA, CMA, and conventional medial approach were performed in 13, 21, and 43 patients, respectively. Total operative time and operative time of the mobilization procedure were significantly shorter in patients undergoing DMA. Blood loss and incidence of postoperative complications did not differ. R0 resection was achieved in all patients with advanced tumors.

Conclusions

The DMA in laparoscopic right colectomy is safe and feasible and can achieve R0 resection with a shorter operative time than the conventional medial approach, even in patients with advanced tumors.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-021-02444-5.

Robotic complete mesocolic excision versus conventional robotic right colectomy for right-sided colon cancer: a comparative study of perioperative outcomes

AIM

This study aims to compare the short-term outcomes of robotic complete mesocolic excision (RCME) versus conventional robotic right colectomy (RRC) for right-sided colon cancer.

METHODS

Consecutive patients who underwent robotic surgery for right-sided colon cancer in a public quaternary and a private tertiary healthcare centre between November 2018 and June 2020 were included. Clinical, perioperative and histopathological variables were collected and analysed.

RESULTS

Fifty-one patients were included; 25 (49%) of them had an RCME. The groups were evenly distributed in terms of demographic characteristics and tumour location. Operative time was similar between both groups, and no patients required conversion to open surgery. There were no differences in overall complications (16% in RCME vs. 26.9% in RRC; p = 0.499) or their profile between groups. There were no anastomotic leaks recorded, and the reoperation rates were similar (0% for RCME versus 3.8% for RRC; p = 1). In addition, the median length of hospital stay was similar in between the RCME and the RRC groups (4 [4-6] days versus 5 [3-8.5] days, respectively; p = 0.891). Whilst there were no differences in the TNM staging, the mean number of lymph nodes harvested with RCME was 37.7 (±12.9) compared to 21.8 (±7.5) with RCC (p < 0.001).

CONCLUSION

In our series, RCME was associated with a higher lymph node harvest and a similar morbidity profile compared to RCC. Further studies are required to validate these results and provide long-term oncologic outcomes.

Anomalous origin of the middle colic artery from the ileocecal artery affecting laparoscopic ascending colon cancer resection

The anomalies of the middle colic artery have rarely been reported and reviewed in literature. However, in case such anomalies are observed in clinical practice, surgery must still be performed safely. This report presents the case of a 78-years-old female who underwent ileocecal resection and hepatectomy due to ascending colon cancer with liver metastasis. Preoperative abdominal contrast-enhanced computed tomography showed an anomaly of the middle colic artery. Since such anomaly is extremely rare, preoperative evaluation of vascular structure is important for safely performing the surgery.

Anatomical characteristics and classifications of gastrocolic trunk of Henle in laparoscopic right colectomy: preliminary results of multicenter observational study

BACKGROUND

As a key landmark during laparoscopic right colectomy, the classification and variation of the gastrocolic trunk of Henle (GTH) remains to be clarified. The aim of this nationwide multicenter study was to describe the characteristics of the GTH intra-operatively during laparoscopic right colectomies.

METHODS

Three hundred seventy-one patients who underwent laparoscopic right colectomies from January 2018 to March 2019 in 25 hospitals across China were enrolled in the study. The length of the GTH, the classification with a precise description of confluent tributaries, and other variations were analyzed.

RESULTS

Of the 371 patients, 363 had a GTH. The proportion of type-0, type-I, type-II, and type-III was 15.2% (n = 55), 54.8% (n = 199), 25.3% (n = 92), and 4.7% (n = 17), respectively. The average length of the GTH was 8.5 mm, ranging from 2 to 30 mm.

CONCLUSIONS

This is the first multicenter study with a large sample by which the GTH was classified based on laparoscopic intraoperative observation. Variations in the GTH were classified into four types based on the number of colic drainage veins (right colic, superior right colic, middle colic, accessory middle colic, and ileocolic veins), among which the right colic vein was the most common. The length of the GTH was relatively short, and thus might carry a risk of bleeding. Further clinical data should be correlated with the characteristics of the GTH.

3D Printing Technology Improves Medical Interns' Understanding of Anatomy of Gastrocolic Trunk

OBJECTIVE

Complex vascular anatomy has always been a difficult point for medical students. Gastrocolic trunk (Henle trunk) has many branches and variations, involving the venous reflux of the stomach, right colon, and pancreas. This study investigated the effects of 3 dimensional (3D) printing technology on medical interns' understanding of Henle trunk's variation, by comparing 2 dimensional (2D) images.

SETTING

Henle trunk modes were manufactured using 3D-CT angiography and 3D-printing technology.

PARTICIPANTS

Forty-seven interns from 2 medical schools (Nanjing Medical University and Medical College of Nantong University) participated in the study.

DESIGN

The interns were divided randomly allocated into 2 groups, where group 1 was the control group with a 2D image of Henle trunk plus surgical video (named 2D image group), and group 2 was the study group with a 3D printed model of Henle trunk plus surgical video (named 3D-printing group). Knowledge of interns on the Henle trunk was compared between 2 groups using a question test before and after the teaching intervention.

RESULTS

All interns had an improved overall assessment score as a result of attending the seminar, whether in the 2D image group or the 3D-printing group. The score of the 2D image group increased 32.57 ± 13.86, and the 3D-printing group increased 47.04 ± 12.99, showing significant difference (p = 0.001). There was no significant difference observed between postseminar scores between 2 medical schools (p = 0.975). There was a significant improvement in satisfaction among the 3D-printing group for education depth, novel and inspiring of teaching method, except for the interaction between teacher and interns (p = 0.215). Interns hope to have more teaching time for 3D printing, and not satisfied with the time of 3D printing teaching compared with those in the 2D image group (p = 0.021).

CONCLUSIONS

The 3-D printed Henle trunk model is a very effective teaching tool, which can help interns understand the anatomy of Henle trunk. The application of 3D printing technology in the teaching of interns of complex vascular anatomy is worth popularizing in teaching hospitals.

Robotic complete mesocolic excision and central vascular ligation for right-sided colon cancer: short-term outcomes from a case series

BACKGROUND

Despite conflicting data regarding oncological outcomes, studies demonstrate that complete mesocolic excision (CME) and central vascular ligation (CVL) for right-sided colon cancer removes significantly more tissue and yields higher lymph node counts when compared to conventional resection. This study aims to report the safety profile of CME and CVL in patients undergoing robotic surgery for right-sided colon cancer during the introduction of this technique across two institutions.

METHODS

Patients who underwent an elective robotic right colectomy with CME and CVL for right-sided colon cancer in a public quaternary and a private tertiary healthcare centre between November 2018 and April 2020 were included. Demographic, clinical, perioperative and histopathological variables were recorded and analysed.

RESULTS

Twenty patients (13 females) with a median age of 69 (23-83) years and median body mass index of 27 (19-46) were included. All of them had a pre-operative diagnosis of right-sided colon adenocarcinoma. Median operative time and blood loss were 140 (130-300) min and 30 (20-100) mL, respectively. There were no conversions or intra-operative complications. There were two post-operative complications recorded (one ileus and one intra-abdominal collection treated with intravenous antibiotics) and no re-interventions. Median length of stay was 4 (2-8) days. All patients had an R0 resection, and the median lymph node yield was 36 (22-80) lymph nodes.

CONCLUSION

This series demonstrates a safe introduction of robotic CME and CVL in patients with right-sided colon cancer. The lymph node harvest obtained with CME and CVL in this setting was high.

Arterial vascularization of the right colon with implications for surgery

PURPOSE

During right-sided colectomies, surgeons encounter major anatomical variations at the level of the right colon, leading to morbidity. Due to the confusion surrounding the colonic arterial vessels emerging from the superior mesenteric artery (SMA) to vascularize the right part of the colon, this review aimed to describe the arterial vessels found in the mesocolic structures of the ascending colon, the hepatic flexure and the right transverse colon.

METHODS

A review of the literature was performed using the MEDLINE database. Only human studies were included. All dissection, angiographic, arterial cast and corrosion studies were analyzed.

RESULTS

This review demonstrates that the right colon, the hepatic flexure and the right transverse colon are vascularized by three significant arteries emerging from the SMA and forming one peripheral paracolic arc: (1) the ileocolic artery (ICA), the most constant vessel (99.8%) with low variability; (2) the right colic artery (RCA), the most inconstant vessel (2/3 of cases) with high variability in its origin; and (3) the middle colic artery (MCA), a constant vessel (95%) with variation in its origin and its number. The marginal artery is almost constant (100%) and represents the only peripheral arterial arc at the level of the right side of the colon.

CONCLUSIONS

Three arteries emerging from the superior mesenteric artery exist: the ICA, the RCA and the MCA. The ICA and the MCA are the most constant. Knowledge of this vascular anatomy is essential for performing right-sided colectomies.

Gastrocolic trunk of Henle and its variants: review of the literature and clinical relevance in colectomy for right-sided colon cancer

PURPOSE

Venous vascular anatomy of the right colon presents a high degree of variability. Henle's Gastrocolic Trunk is considered an important anatomical landmark by colorectal surgeons. The classical description concerns a bipod vascular structure or tripod, but several variants are associated to it. The aim of this study is to merge the most updated literature on the anatomy knowledge of the Gastrocolic Trunk by evaluating all possible variants, as well as to underline its surgical importance due to its topographical relationships.

METHODS

Twelve studies describing the anatomy of the gastrocolic trunk were selected, each of them dealing with a more or less extensive series of cases. A distinction was drawn between the gastropancreatic trunk, devoid of the colonic component, and the gastrocolic trunk; and then the frequency of the different resulting variants was reported. The data obtained from cadavers and radiological studies were analyzed separately.

RESULTS

The Gastrocolic Trunk is found in 74% of cadaver studies, and in 86% of radiological studies. Its most frequent configuration is represented by the union of right gastroepiploic vein + anterior superior pancreaticoduodenal vein + superior right colic vein, respectively, 32.5% and 42.5%, followed by the right colic vein which replaces (26.9%, 12.3%) or is added (10%, 20.1%) to the superior right colic vein.

CONCLUSIONS

The superior right colic vein joins the right gastroepiploic vein and the anterior superior pancreaticoduodenal vein thus forming, in most cases, the gastrocolic trunk. The anatomical knowledge of vascular structures forms the basis for both the interpretation of preoperative radiological images and the surgical procedure itself, despite the considerable anatomical variability of tributaries.

Vascular anatomical variation in laparoscopic right hemicolectomy

Laparoscopic complete mesocolic excision is gradually becoming the standard surgical approach in colon cancer therapy, the core element of which is central vascular ligation. However, this increases the difficulty for surgeons, particularly in the context of right colectomy, which encounters complex vascular anatomy. This study aimed to examine vascular variations that occur during laparoscopic right hemicolectomy through a review of the medical literature. We demonstrated that the ICA and MCA are evident in the majority of patients. The RCA was inconsistently present ranging from 12% to 45%. The ICA passed the SMV anteriorly or posteriorly at average rates. However, the RCA passed anterior to the SMV in most patients. Regarding intravenous, the ICV was consistently present, whereas the RCV was absent in up to 80% of patients. The GTH was present in nearly 80% of patients. We classified the vascular variations by the location of the branches instead of using numerical classification. The GCT and GPCT were common types whilst the GPT was relatively rare. In summary, detailed information on the vascular anatomical variations occurring on the right-side of the colon is vital. Failure to identify variations during surgical procedures can result in unwanted bleeding. Thus, we advocate for the use of the ICV as an anatomic marker during surgery.

Initial experience of laparoscopic right hemicolectomy with complete mesocolic excision in Singapore: a case series

INTRODUCTION

Laparoscopic colorectal surgery is increasingly performed worldwide due to its multiple advantages over traditional open surgery. In the surgical treatment of right-sided colonic tumours, the latest technique is laparoscopic right hemicolectomy with complete mesocolic excision (lapCME), which aims to lower the rate of local recurrence and maximise survival as compared to standard laparoscopic right hemicolectomy (lapS).

METHODS

We conducted a retrospective analysis of our initial experience with lapCME in Singapore General Hospital between 2012 and 2015. All procedures were performed by a single surgeon.

RESULTS

Nine patients underwent lapCME and 16 patients underwent lapS. Indication for lapCME was cancer in the right colon. None of the patients required conversion to open surgery, and all were discharged well. The number of lymph nodes resected in the lapCME group was significantly greater than in the lapS group (29 ± 15 vs. 19 ± 6; p = 0.02) during the study period, and the mean operation time was significantly longer for lapCME (237 ± 50 minutes vs. 156 ± 46 minutes; p = 0.0005). There were no statistically significant differences in terms of demographics, tumour stage, time taken for bowel to open postoperatively, time taken for patient to resume a solid diet postoperatively and length of hospital stay. Two patients who underwent lapS were re-admitted for intra-abdominal collections - one patient required radiology-guided drainage, while the other patient was managed conservatively.

CONCLUSION

Our initial experience with lapCME confirms the feasibility and safety of the procedure.

The venous trunk of henle (gastrocolic trunk): A systematic review and meta-analysis of its prevalence, dimensions, and tributary variations

Surgeons have recognized the clinical significance of the venous trunk of Henle during multiple pancreatic, colorectal, and hepatobiliary procedures. To date, no study has followed the principles of evidence-based anatomy to characterize it. Our aim was to find, gather, and systematize available anatomical data concerning this structure. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, and Web of Science databases were searched. The following data were extracted: prevalence of the trunk of Henle, its mean diameter and length, the organization of its tributaries, method of anatomical assessment (cadaveric, radiological, or intraoperative), geographical origin, study sample, and known health status. Our search identified 38 records that included data from 2,686 subjects. Overall, the prevalence of the trunk of Henle was 86.9% (95% CI, 0.81-0.92) and the mean diameter was 4.2 mm. Only one study reported the length of the trunk (10.7 mm). The most common type of venous trunk (56.1%) was a vessel comprising three tributaries: gastric (right gastro-epiploic vein), pancreatic (most commonly the anterior superior pancreaticoduodenal vein), and colic (most commonly the superior right colic vein). The trunk of Henle is a common variant in the anatomy of the portal circulation. It is a highly variable vessel, but the most common type is a gastro-pancreato-colic trunk. In surgical practice, the presence of this venous trunk poses a high risk for bleeding, but it can also be a useful landmark during various abdominal procedures. Clin. Anat. 31:1109-1121, 2018. © 2018 Wiley Periodicals, Inc.

Variations of Gastrocolic Trunk of Henle and Its Significance in Gastrocolic Surgery

Due to the increasing incidence of gastrointestinal (GI) tumors, more and more importance is attached to radical resection and patients' survival, which requires adequate extent of resection and radical lymph node dissection. Blood vessels around the gastrointestinal tract, as anatomical landmarks for tumor resection and lymph node dissection, play a key role in the successful surgery and curative treatment of gastrointestinal tumors. In the isolation of subpyloric area or hepatic flexure of the colon for gastrectomy or right hemicolectomy, lymph node dissection and ligation are often performed at the head of the pancreas and superior mesenteric vein, during which even a minor inadvertent error may lead to unwanted bleeding. Among these blood vessels, the venous system composed of Henle's trunk and its tributaries is the most complex, which has a direct influence on the outcome and postoperative recovery of the patients. There are many variations of Henle's trunk, with complicated courses and various locations, attracting more and more researchers to study it and tried to analyze the influence of its variations on gastrointestinal surgeries. We characterized various variants and tributaries of Henle's trunk using autopsy, vascular casting, 3D CT reconstruction, intraoperative anatomy, and Hisense CAS system and summarized and analyzed the tributaries of Henle's trunk, to determine its influence on GI surgeries.

Retromesenteric course of the middle colic artery-challenges and pitfalls in D3 right colectomy for cancer

BACKGROUND

The middle colic artery (MCA) is of crucial importance in abdominal surgery, for laparoscopic or open right and transverse colectomies. Against this background, a high number of reports concerning anatomical variations of the MCA have been published intended to contribute to the improvement of operative techniques for the treatment of colon cancer. Despite this extensive literature, briefly reviewed in the present paper, a course of the MCA posterior to the superior mesenteric vein, called a retromesenteric trajectory, has been related to only once, to the best of our knowledge.

METHODS

A total series of 507 patients included in two prospective trials concerning laparoscopic or open right colectomy for cancer between 2011 and 2017 are reported. The investigation included preoperative or postoperative multidetector-computed tomography angiography.

RESULTS

We found four (0.79%) cases of retromesenteric MCA. They all underwent meticulous image analysis with mesenteric vessels' road mapping, detailed morphometry, and surgical validation which revealed that, apart from their course, those cases did not differ significantly from the rest of the series.

CONCLUSION

This paper therefore documents the worth-knowing behavior causing considerable confusion for the operating surgeon unaware of the abnormality and shows its concrete impact on patient-tailored surgical practice, in particular for laparoscopic D3 colectomy (including the "uncinated process first" approach).

Surgical Anatomy of the Superior Mesenteric Vessels Related to Colon and Pancreatic Surgery: A Systematic Review and Meta-Analysis

The surgeon dissecting the base of the mesenterium, around the superior mesenteric vein (SMV) and artery, is facing a complex tridimensional vascular anatomy and should be aware of the anatomical variants in this area. The aim of this systematic review is to propose a standardized terminology of the superior mesenteric vessels, with impact in colon and pancreatic resections. We conducted a systematic search in PubMed/MEDLINE and Google Scholar databases up to March 2017. Forty-five studies, involving a total of 6090 specimens were included in the present meta-analysis. The pooled prevalence of the ileocolic, right colic and middle colic arteries was 99.8%, 60.1%, and 94.6%, respectively. The superior right colic vein and Henle trunk were present in 73.9%, and 89.7% of specimens, respectively. In conclusion, the infra-pancreatic anatomy of the superior mesenteric vessels is widely variable. We propose the term Henle trunk to be used for any venous confluence between gastric, pancreatic and colic veins, which drains between the inferior border of the pancreas and up to 20 mm downward on the right-anterior aspect of the SMV. The term gastrocolic trunk should not be synonymous, but a subgroup of the Henle trunk, together with to gastropancreatocolic, gastropancreatic, or colopancreatic trunk.

Comparison between different approaches applied in laparoscopic right hemi-colectomy: A systematic review and network meta-analysis

AIM

Several different operative approaches have been applied nowadays in laparoscopic right hemi-colectomy. This study aims to evaluate the potential benefits of different approaches by conducting a network meta-analysis (NMA).

METHOD

A comprehensive literature research of the PubMed, Embase, Medline, the Cochrane Central Library, Wan Fang and China National Knowledge Infrastructure (CNKI) databases was performed. Original articles comparing two of three different approaches including medial to lateral (MtL) approach, lateral to medial (LtM) approach and cranial to caudal (CtC) approach of laparoscopic right colon resection for patients with both neoplastic and benign diseases were included.

RESULTS

3 RCTs and 3 NRCTs with a total of 571 patients were included in this NMA. The result revealed that LtM approach needs shorter postoperative flatus recovery time than both MtL approach with a WMD of 1.40 (95% CI: 0.13 to 2.67, P < 0.05) and CtC approach (WMD = -1.25, 95% CI: -1.90 to -0.61, P < 0.05). The length of hospital stay of LtM approach is shorter than that of MtL approach (WMD = 0.29, 95% CI: 0.08 to 0.50, P < 0.05). CtC approach can achieve less postoperative complications (OR = 3.37, 95% CI: 1.06 to 10.70, P < 0.05) compared with MtL approach.

CONCLUSION

All three approaches are safe and acceptable in laparoscopic right hemi-colectomy since the pooled evidence revealed that most aspects of different approaches are comparable in general. The postoperative flatus recovery time and hospitalization time of LtM approach is shorter compared with MtL approach. And CtC approach may have slight superiority in postoperative complications compared with MtL approach.

Variations in the Vascular Anatomy of the Right Colon and Implications for Right-Sided Colon Surgery

BACKGROUND

Knowledge of the normal pattern and variations of the blood supply of the right colon is crucial for better outcomes after colon surgery.

OBJECTIVE

The purpose of this study was to describe the precise vascular anatomy of the right colon according to surgical perspective.

DESIGN

Adult fresh cadavers were dissected between January 2013 and October 2015, focusing on the venous and arterial anatomy of the right side of the colon.

SETTINGS

Macroscopic anatomical dissections were performed on 111 adult fresh cadavers with emphasis on the vascular anatomy of the right colon. The colic tributaries of the superior mesenteric artery and vein were documented in writing. Furthermore, the dissections were recorded with a video camera.

RESULTS

The incidence of colic arteries arising from the superior mesenteric artery included ileocolic artery, 100%; right colic artery, 33.3%; middle colic artery, 100%; and accessory middle colic artery, 11,7%. All 111 cadavers had a single ileocolic vein, which drained into the superior mesenteric vein in 103 cases (92.8%), into the gastro-pancreatico-colic trunk in 7 cases (6.3%), and into the jejunal trunk in 1 case (0.9%). The drainage site of the ileocolic vein to the superior mesenteric vein varied, and in 9% of cases the ileocolic vein did not accompany the ileocolic artery. The gastro-pancreatico-colic trunk was detected in 87 cases (78.4%); with several forms of the origin of the respective branches, the gastropancreatic trunk was detected in 24 cases (21.6), and the classic gastrocolic trunk of Henle was not detected. Variations were found in the formation and drainage routes of other venous colic tributaries of the superior mesenteric vein.

LIMITATIONS

This study is limited by its use of cadavers in that it is impossible to trace each vessel to its origin in live surgery.

CONCLUSIONS

Surgeons must watch, observe, and bear in mind that vascular variations can occur. Awareness of these complex variations may improve the quality of surgery and may prevent devastating complications during right-sided colon resections.