Laparoscopic right hemicolectomy with CME: standardization using the "critical view" concept

Preoperative angio-CT colonography improves the quality of lymph node dissection during minimally invasive right hemicolectomy: a propensity score-matched study

BACKGROUND

Minimally invasive right hemicolectomy for cancer with complete mesocolic excision is a difficult procedure to perform. The aim of this single-center prospective study was to evaluate whether preoperative angio-CT colonography (A-CTC) improved the quality of lymph node dissection during this surgery.

METHODS

All patients undergoing elective minimally invasive right hemicolectomy for colon adenocarcinoma with complete mesocolic excision between 01/2020 and 12/2023 have been prospectively included. The primary endpoint was the number of lymph nodes examined in the surgical specimen, including the total number of lymph nodes and the percentage of patients with at least 12 lymph nodes examined. Secondary endpoints included operating time, intraoperative complications, overall postoperative morbidity, and length of hospital stay. A propensity score was constructed with groups matched 3:1 using nearest neighbor matching based on the propensity score.

RESULTS

Of the 161 patients included, 44 had A-CTC (27%) and 117 had conventional CT scans. After propensity score matching, patients in the A-CTC group had significantly more lymph nodes on the surgical specimen (24 vs. 20, p = 0.006) and a better quality of lymph node dissection (≥ 12 examined lymph nodes: 100% vs. 87%, p < 0.001). Median operative times were similar between the two groups (184 vs. 180 min, p = 0.07), but two patients (2%) in the conventional CT group experienced an intraoperative bleeding complication. Postoperative morbidity and length of hospital stay were comparable.

CONCLUSIONS

Preoperative 3D reconstruction of vascular anatomy with A-CTC is useful and improves the quality of lymph node dissection during minimally invasive right hemicolectomy for cancer.

Artificial intelligence-enhanced video-based assessment of surgical quality for training in laparoscopic right hemicolectomy: The "Marginal Gains" pilot study

INTRODUCTION

The study aims to propose a standardised workflow with critical views for surgical quality assessment (SQA) in laparoscopic right hemicolectomy (LRH), to disseminate it through a "Marginal Gains" course, and to evaluate its impact through artificial intelligence (AI) enhanced video-based assessment (VBA).

MATERIALS AND METHODS

Expert colorectal surgeons proposed a protocol for SQA in LRH based on evidence and consensus. A course ("Marginal Gains") comprising remote e-learning and on-site clinical immersion was organised to disseminate the proposed approach to LRH. Videos of procedures performed by participants before and after the course were analysed by experts (SQA items) and AI (workflows). Descriptive and inferential statistic was used to study the applicability of the proposed protocol and the impact of the course.

RESULTS

A protocol with 21 SQA items over 9 phases for LRH was proposed. Four surgeons successfully completed the pilot "Marginal Gains" course. Across the 8 videos uploaded, VBA showed that the proposed SQA items were appliable in 82.7 % (139/168 items) of the cases. Three out of 4 of the participants had higher SQA scores after the course, with an overall improvement of 30 % (20.75 ± 13.2 vs 32.75 ± 2.99 points; p = 0.126). All participants performed intracorporeal anastomosis after the course, with a significant quality improvement (1.5 ± 1.73 vs 3.75 ± 0.5 points; +56 %; p = 0.046). Overall, mean operative times increased by 00:23:38 after the course (01:36:03 ± 00:10:43 vs 01:59:41 ± 00:48:02; p = 0.465).

CONCLUSION

This study advocates for a paradigm shift in surgical education and practice by proposing, piloting, and measuring the impact of a structured, step-based approach to LRH.

[Extended Complete Mesocolic Excision in right-sided Colon Cancer - An Overview]

Surgical resection with systematic lymphadenectomy remains the standard of care for non-metastasised colon cancer. After the article of Hohenberger et al. in 2009 describing the surgical technique of complete mesocolic excision (CME), D2 lymphadenectomy has been called into doubt after the finding of a better oncological outcome. However, there has been also a controversial discussion about the oncological value of CME, since intraoperative complications may increase. Additional evidence has been provided in recent years from randomised controlled multicentre studies showing that the reported improved oncological long-term outcome after CME is more than questionable. The reported increased rate of intraoperative (vascular) complications could be not confirmed.

European multicentre analysis of the implementation of robotic complete mesocolic excision for right-sided colon tumours

AIM

Complete mesocolic excision (CME) is an oncologically driven technique for treating right colon cancer. While laparoscopic CME is technically demanding and has been associated with more complications, the robotic approach might reduce morbidity. The aim of this study was to assess the safety of stepwise implementation of robotic CME.

METHOD

A multicentre retrospective analysis of prospectively collected data on robotic right colectomy was performed at five European tertiary centres. Patients were classified for type of surgery: R-RHC (standard right colectomy), R-impCME (learning cases towards robotic CME defined as R-RHC with one but not all the hallmarks of CME) or R-CME (robotic CME). Primary outcomes were overall and severe 30-day complication rates before and after propensity score matching (PSM) analysis.

RESULTS

Five hundred and fifty-one consecutive patients undergoing robotic surgery for (pre)malignant lesions of the right colon between 2010 and 2020 were included: R-RHC (n = 101), R-impCME (n = 135) and R-CME (n = 315). Baseline characteristics differed for American Society of Anesthesiologists score (p = 0.0012) and preoperative diagnosis of adenocarcinoma (p < 0.001). Procedure time increased by surgical complexity (p < 0.001). Vascular event rates did not differ, with no superior mesenteric vein injuries. Conversion, complication and anastomotic leak rates, time to flatus/soft diet and length of stay (LOS) did not differ. While R-RHC was performed for a lower rate of malignancies (p < 0.001), lymph node yield was significantly higher in R-CME (p < 0.001). After PSM, analyses on 186 patients documented no differences in overall and severe 30-day complication rate, conversion rate, LOS or 30-day mortality.

CONCLUSION

R-CME can be implemented without increasing the overall or 30-day severe complication rate.

Laparoscopic right hemicolectomy with complete mesocolon excision and cranial approach

BACKGROUND

Complete mesocolon excision (CME) and D3-lymphadenectomy concepts have gained popularity for the surgical treatment of right colon cancer in comparison to the conventional laparoscopic right hemicolectomy (CLRH). The rationale of CME is to dissect the embryological planes between the mesenteric plane and the parietal fascia to remove the mesentery within a complete envelope of mesenteric fascia and visceral peritoneum that contains lymph nodes, the central vascular ligation, and adequate bowel length to remove involved pericolic lymph nodes in the longitudinal direction, having as the main goal to improve the oncological results. CME with D3-lymphadenectomy is challenge since involves the excision of the lymph adipose tissue covering the medial edge of the superior mesenteric vein (SMV) (trunk of Gillot, TG), and the gastrocolic trunk of Henle (GTH). We describe a LRH with CME using a cranial approach allowing an easier central vessels origin identification.

TECHNIQUE

Through the supramesocolic approach, gastrocolic ligament is opened and the GTH and the middle colic artery (MCA) and vein (MCV) origins are identified. Hepatic flexure is mobilized, and a gauze is placed above the mesenteric vessels. Then, the SMV is identified, dividing the ileocolic vessels origin. The plane between the Gerota and Toldt fascias is opened, identifying duodenum, pancreas, and the gauze previously placed. Following this plane and the SMV along the TG, the GTH and its branches are identified. The superior right colic vein, and the MCA and MCV right branches are divided. After that, colon is fully mobilized laterally opening the parietocolic gutter and an intracorporeal anastomosis is performed.

CONCLUSION

CME could lead to an improvement of oncological results due to a wider mesocolic excision in comparison to conventional D2-lymphadenectomy. Cranial approach facilitates the vessels origin identification to perform a true central ligation.

Simplified and reproducible laparoscopic complete mesocolic excision with D3 right hemicolectomy

AIM

Laparoscopic complete mesocolic excision (CME) with D3 lymphadenectomy for right colon cancer is gaining acceptance. However, this procedure has not yet been standardized like total mesorectal excision. Ergonomics is very important in this surgery (e.g. patient positioning, port placement) and identification of vascular anatomy is a critical step. The aim of this work is to present ten procedural steps that are simple and reproducible.

METHOD

The French position is adopted. The surgeon stands between the patient's legs. Four ports are placed: a camera port 2.5 cm to the left of the umbilicus; two working ports-a 12 mm right-hand port 5-7 cm below the umbilicus in the midline and a 5 mm left-hand port 2.5 cm medial and at the level of anterior superior iliac spine-and an assistant port at the level of the umbilicus at the pararectal line. This is most comfortable position in the 'caudal to cranial approach' for CME dissection. The right-hand instrument always dissects parallel to the superior mesenteric artery (SMA) axis so there is less chance of injury to major vascular structures. When clipping the ileocolic, right colic and gastrocolic trunk (GCT) branches, the instrument is always perpendicular to these structures, giving ease of clipping and division. An intentional attempt is made to dissect all tributaries of the GCT. This avoids inadvertent injury and bleeding. Identifying the SMA/superior mesenteric vein (SMV) axis and ileocolic pedicle is the most crucial step. We use surface landmarks for this-the ligamentum teres and SMA/SMV are both midline structures. Giving traction on the transverse mesocolon just below the ligamentum makes the pulsatile SMA visible irrespective of the patient's body mass index. Giving traction at the ileocaecal junction mesentery makes the ileocolic pedicle prominent. These two landmarks for identification of the vascular anatomy make this technique unique and reproducible. CME dissection is done caudal to cranial and lateral to medial. Supracolic and lateral mobilization of the colon is simple. While starting dissection in the right paracolic gutter the already dissected CME plane make this step easier. Anastomosis can be made intracorporeal or extracorporeal.

CONCLUSION

Ergonomics and landmarks for identification of the vascular anatomy make this technique simple and reproducible.

Laparoscopic Left Side Duodenum Adenocarcinoma Resection (III-IV Segment): A Step-By-Step Surgical Technique

INTRODUCTION

Nonampullary duodenal adenocarcinoma (NDA) accounts for approximately 5% of all gastrointestinal cancers. Complete surgical resection (R0) with regional draining lymph node removal is mandatory as treatment to potentially cure nonampullary duodenal cancer or to achieve long-term survival.

METHODS

According to existing literature, minimally invasive surgery has been reported to be safe and oncologically equivalent in pancreaticoduodenectomy for pancreatic and duodenal cancer. We describe a fully laparoscopic approach for the left-side adenocarcinoma of the duodenum "left-side" is defined with reference to the mesenteric vessels (III-IV segment).

RESULTS

For the first time in literature, this multimedia paper describes a fully laparoscopic complete resection (R0) of the left side of the duodenum (III-IV segment) with locoregional lymph node resection. The main steps of the procedure are described using the concept of the critical view of safety. Reconstruction of intestinal continuity was ensured by full intracorporeal anastomosis.

CONCLUSIONS

Through the tips and indications presented in this article, we supply a guide to the minimally invasive approach and increase operating surgeons' familiarity with such a complex procedure.

A nomogram prediction model for the risk of intra-abdominal infection after endoscopic full-thick resection of gastric submucosal tumors

Background

This study aimed to investigate the risk factors for complication of intra-abdominal infection (IAI) after endoscopic full-thickness resection of gastric submucosal tumors (GSMT) and to establish a nomogram prediction model for the occurrence of IAI.

Methods

Clinical data of patients with GSMT who underwent endoscopic full-thick resection (EFR) from January 2018 to July 2023 were retrospectively analyzed. The patients were divided into IAI and non-IAI groups according to whether IAI occurred during postoperative hospitalization. Univariate and multivariate logistic regression analyses were performed on the relevant clinical data of patients in the two groups to screen the independent influencing factors for the occurrence of IAI. The nomogram model was constructed based on the independent influencing factors. Model discrimination was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. The consistency of model-predicted risk with actual risk was evaluated using the Hosmer-Lemeshow goodness-of-fit test. The clinical performance of the nomogram model was evaluated using decision curve analysis.

Results

A total of 240 GSMT patients who underwent EFR procedures were finally included in this study, including 14 patients (5.83 %) in the IAI group and 226 patients in the non-IAI group. Univariate and multivariate logistic regression analyses showed that age (OR = 1.283, 95 % CI = 1.029-1.600), preoperative albumin (OR = 0.575, 95 % CI = 0.395-0.837), duration of operation (OR = 1.222, 95 % CI = 1.060-1.409), and hospitalization time (OR = 4.089, 95 % CI = 1.190-14.043) were independent influencing factors for the incidence of IAI in GSMT patients undergoing EFR surgery (P < 0.05). A Nomogram model was established based on the above factors. The Hosmer ⁃ Lemeshow test value of this model was 4.230 (P = 0.836). The AUC value of the predictive model was 0.992 (95 % CI: 0.983 to 1.000), with a C-index of 0.992 (95 % CI: 0.983-1.000), indicating that the nomogram model had good accuracy and discrimination. Decision curve analysis showed that the nomogram model had a good predictive performance.

Conclusions

Age, preoperative albumin, duration of operation, and hospitalization time were independent influences on the occurrence of IAI in GSMT patients undergoing EFR surgery. A nomogram model based on these factors had a high predictive efficacy and may provide a guiding intervention for the prevention of postoperative IAI in GSMT patients.

Deep learning-based surgical step recognition for laparoscopic right-sided colectomy

PURPOSE

Understanding the complex anatomy and surgical steps involved in laparoscopic right-sided colectomy (LAP-RC) is essential for standardizing the surgical procedure. Deep-learning (DL)-based computer vision can achieve this. This study aimed to develop a step recognition model for LAP-RC using a dataset of surgical videos with annotated step information and evaluate its recognition performance.

METHODS

This single-center retrospective study utilized a video dataset of laparoscopic ileocecal resection (LAP-ICR) and laparoscopic right-sided hemicolectomy (LAP-RHC) for right-sided colon cancer performed between January 2018 and March 2022. The videos were split into still images, which were divided into training, validation, and test sets using 66%, 17%, and 17% of the data, respectively. Videos were manually classified into eight main steps: 1) medial mobilization, 2) central vascular ligation, 3) dissection of the superior mesenteric vein, 4) retroperitoneal mobilization, 5) lateral mobilization, 6) cranial mobilization, 7) mesocolon resection, and 8) intracorporeal anastomosis. In a simpler version, consecutive surgical steps were combined, resulting in five steps. Precision, recall, F1 scores, and overall accuracy were assessed to evaluate the model's performance in the surgical step classification task.

RESULTS

Seventy-eight patients were included; LAP-ICR and LAP-RHC were performed in 35 (44%) and 44 (56%) patients, respectively. The overall accuracy was 72.1% and 82.9% for the eight-step and combined five-step classification tasks, respectively.

CONCLUSIONS

The automatic surgical step-recognition model for LAP-RCs, developed using a DL algorithm, exhibited a fairly high classification performance. A model that understands the complex steps of LAP-RC will aid the standardization of the surgical procedure.

Evaluating the Adequacy of YouTube Videos for Learning Laparoscopic Right Hemicolectomy With Complete Mesocolic Excision

AIM

 Complete mesocolic excision (CME) is becoming an oncological surgical principle day by day for right hemicolectomy. However, the procedure is technically difficult and carries a higher risk of complications than open surgery. In this study, the adequacy of YouTube videos that facilitate education for laparoscopic right hemicolectomy with complete mesocolic excision (LRHCME) was investigated.

METHODS

In July 2024, in the search bar of the YouTube platform, the term "laparoscopic right hemicolectomy complete mesocolic excision" was searched. The first 100 videos in each search were evaluated. Animations, advertisements, lectures, non-surgical videos (pre-surgery, post-surgery vlog, etc.), and non-English videos were excluded from the study. Steps identified in the Delphi consensus were used to determine the reliability of the videos. The quality of the videos was measured using the Global Quality Scale (GQS) and the modified DISCERN score.

RESULTS

Seventy videos were included in the evaluation. While 28 (40%) of these videos were classified as reliable, 42 (60%) were not found reliable. In reliable videos, video description, HD resolution, GQS, modified DISCERN, and duration were significantly higher (p-value <0.001, 0.012, <0.001, <0.001, 0.041 respectively). Reliable videos had a better rank than unreliable videos (p=0.046).

CONCLUSION

When evaluated according to Delphi consensus, the most of LRHCME videos on the YouTube platform were unreliable. We conclude that YouTube alone is insufficient for learning LRHCME without a professional instructor.

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.

Cranial-first approach for laparoscopic extended right hemicolectomy

Complete mesocolic excision and central vascular ligation with D3 lymphadenectomy are important surgical principles for improving oncological outcomes in colon cancer. The cranial-first approach is a colonic mobilization-first approach to radical right hemicolectomy, which has several advantages, including early feasibility assessment, safe dissection from surrounding organs, preestablished inferior margin of lymph node dissection, and revelation of the tangible anatomy of the tributaries of the gastrocolic trunk. This video demonstrates the cranial-first approach to radical right hemicolectomy in a 66-year-old man with locally advanced cecal cancer.

[Minimally Invasive Techniques for Anastomosis in the Gastrointestinal Tract]

Aufgrund des zunehmenden Einsatzes der Robotik im Bereich der Chirurgie des Gastrointestinaltraktes bietet dieser Beitrag einen Leitfaden zu unterschiedlichen Anastomosentechniken bei der robotisch assistierten transthorakalen Ivor-Lewis-Ösophagektomie (RAMIE), der robotisch assistierten onkologischen Gastrektomie (RAMIG) sowie der robotischen Hemikolektomie rechts. Es werden die relevanten Operationsschritte dargestellt mit Fokus auf die verschiedenen Rekonstruktionen mittels robotisch assistierter Naht oder Verwendung eines Stapler Devices.

Die onkologische Entscheidungsfindung und insbesondere die Wahl der chirurgischen Therapie und das Ausmaß der Resektion hängen immer von der Lokalisation des Tumors, der Histologie und den individuellen Risikofaktoren des Patienten ab. Beim Magenkarzinom im Stadium ≥ IB wird ein multimodales Vorgehen empfohlen, das eine perioperative Chemotherapie in Kombination mit einer chirurgischen Resektion mit kurativer Absicht umfasst. Für Patienten mit lokal fortgeschrittenen Adenokarzinomen oder Plattenepithelkarzinomen des Ösophagus ist die multimodale Behandlung heute ebenfalls der Goldstandard. Nach Abschluss der neoadjuvanten Vorbehandlung sowie Durchführung eines Re-Stagings erfolgt komplettierend die operative Resektion.

Bei dem nicht metastasierten Kolonkarzinom ist eine primäre radikale onkologische Resektion im Sinne eines kurativen Therapiekonzeptes durchzuführen, gefolgt von einer adjuvanten Therapie bei fortgeschrittenem Befund.

Dieses Manuskript sowie das begleitende Video erläutern die Rekonstruktionstechnik nach RAMIG sowohl als robotisch genähte Technik mittels V-Lock-3–0-Nähten als auch die Rekonstruktion mittels Linearstapler als alternative Technik. Für die RAMIE wird die Rekonstruktion mittels Zirkularstapler und intrathorakaler Anastomose als Standard gezeigt. Für die robotische Hemikolektomie wird eine Rekonstruktion mittels Linearstapler gezeigt.

Verschiedene Möglichkeiten der robotischen Rekonstruktion sowohl nach robotischer Gastrektomie, nach robotischer Hemikolektomie als auch nach robotischer Ösophagektomie beinhalten robotisch genähte Techniken sowie die Anwendung von Stapler Devices. Eine Evidenz zum Vergleich der verschiedenen Techniken, insbesondere in der robotischen Chirurgie im Gastrointestinaltrakt, fehlt bislang, die Methoden zeigen sich in der klinischen Anwendung jedoch sicher durchführbar mit guten postoperativen Ergebnissen. Kommende Studien werden sich einem Vergleich der unterschiedlichen Rekonstruktionsmethoden in der robotischen Chirurgie widmen.

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.

Developing a phantom for simulating robotic-assisted complete mesocolic excision using 3D printing and medical imaging

BACKGROUND

Robotic-assisted complete mesocolic excision is an advanced procedure mainly because of the great variability in anatomy. Phantoms can be used for simulation-based training and assessment of competency when learning new surgical procedures. However, no phantoms for robotic complete mesocolic excision have previously been described. This study aimed to develop an anatomically true-to-life phantom, which can be used for training with a robotic system situated in the clinical setting and can be used for the assessment of surgical competency.

METHODS

Established pathology and surgical assessment tools for complete mesocolic excision and specimens were used for the phantom development. Each assessment item was translated into an engineering development task and evaluated for relevance. Anatomical realism was obtained by extracting relevant organs from preoperative patient scans and 3D printing casting moulds for each organ. Each element of the phantom was evaluated by two experienced complete mesocolic excision surgeons without influencing each other's answers and their feedback was used in an iterative process of prototype development and testing.

RESULTS

It was possible to integrate 35 out of 48 procedure-specific items from the surgical assessment tool and all elements from the pathological evaluation tool. By adding fluorophores to the mesocolic tissue, we developed an easy way to assess the integrity of the mesocolon using ultraviolet light. The phantom was built using silicone, is easy to store, and can be used in robotic systems designated for patient procedures as it does not contain animal-derived parts.

CONCLUSIONS

The newly developed phantom could be used for training and competency assessment for robotic-assisted complete mesocolic excision surgery in a simulated setting.

[Robotic Assisted Proctocolectomy with Ileal Pouch-anal Anastomosis in Familial Adenomatous Polyposis - a Video Vignette]

Das kolorektale Karzinom (KRK) ist eines der häufigsten Malignome, bei dem in den letzten Jahren eine signifikante Zunahme hereditärer Fälle beobachtet werden konnte. Die zweithäufigste Ursache für ein hereditäres KRK ist die familiäre adenomatöse Polyposis, eine obligate Präkanzerose. Sinnvollster Therapieansatz ist eine prophylaktische laparoskopische Proktokolektomie mit Ileumpouch-analer Anastomose (IPAA) im jungen Erwachsenenalter. Mit der zunehmenden Etablierung robotischer Verfahren stellt sich die Frage, ob die Vorteile der robotischen Operationen, wie bspw. vereinfachtes Operieren und bessere Visualisierung in engen Räumen, insbesondere bei der prophylaktischen Proktokolektomie, sinnvoll sein kann. Problematisch ist allerdings die Notwendigkeit, in allen 4 Quadranten des Abdomens operieren zu müssen, was bei robotischen Eingriffen ein limitierender Faktor sein kann. Ziel dieser Arbeit war es daher, die Machbarkeit der robotisch assistierten Proktokolektomie mit IPAA zu demonstrieren und Tipps für eine Anwendung in der klinischen Praxis zu geben.

A Systematic Review of Varying Definitions and the Clinical Significance of Fredet's Fascia in the Era of Complete Mesocolic Excision

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".

Automatic Surgical Skill Assessment System Based on Concordance of Standardized Surgical Field Development Using Artificial Intelligence

Importance

Automatic surgical skill assessment with artificial intelligence (AI) is more objective than manual video review-based skill assessment and can reduce human burden. Standardization of surgical field development is an important aspect of this skill assessment.

Objective

To develop a deep learning model that can recognize the standardized surgical fields in laparoscopic sigmoid colon resection and to evaluate the feasibility of automatic surgical skill assessment based on the concordance of the standardized surgical field development using the proposed deep learning model.

Design, Setting, and Participants

This retrospective diagnostic study used intraoperative videos of laparoscopic colorectal surgery submitted to the Japan Society for Endoscopic Surgery between August 2016 and November 2017. Data were analyzed from April 2020 to September 2022.

Interventions

Videos of surgery performed by expert surgeons with Endoscopic Surgical Skill Qualification System (ESSQS) scores higher than 75 were used to construct a deep learning model able to recognize a standardized surgical field and output its similarity to standardized surgical field development as an AI confidence score (AICS). Other videos were extracted as the validation set.

Main Outcomes and Measures

Videos with scores less than or greater than 2 SDs from the mean were defined as the low- and high-score groups, respectively. The correlation between AICS and ESSQS score and the screening performance using AICS for low- and high-score groups were analyzed.

Results

The sample included 650 intraoperative videos, 60 of which were used for model construction and 60 for validation. The Spearman rank correlation coefficient between the AICS and ESSQS score was 0.81. The receiver operating characteristic (ROC) curves for the screening of the low- and high-score groups were plotted, and the areas under the ROC curve for the low- and high-score group screening were 0.93 and 0.94, respectively.

Conclusions and Relevance

The AICS from the developed model strongly correlated with the ESSQS score, demonstrating the model's feasibility for use as a method of automatic surgical skill assessment. The findings also suggest the feasibility of the proposed model for creating an automated screening system for surgical skills and its potential application to other types of endoscopic procedures.

Critical View of Safety in Laparoscopic Cholecystectomy: A Systematic Review of Current Evidence and Future Perspectives

BACKGROUND

The Critical View of Safety (CVS) has been increasingly recognised as the standard method for identification of the cystic structures, to prevent vasculobiliary injuries during laparoscopic cholecystectomy, however, its adoption has been anything but universal. A significant proportion of surgeons has a poor understanding of the three requirements. To bridge this gap between theory and practice, we aimed to summarise the available evidence on CVS, emphasising on current debates and future perspectives.

METHOD

We systematically reviewed the literature (1995-2021), to identify studies reporting on the CVS. Eligible articles were classified according to methodology and key idea. A quantitative analysis was performed to evaluate effectiveness of the CVS in preventing bile duct injury (BDI).

RESULTS

150 relevant articles were identified, focusing on six main points, (1) safety and effectiveness, (2) intraoperative documentation, (3) complementary imaging techniques, (4) bail-out alternatives, (5) adoption among surgeons, and (6) education and training. The quantitative analysis included 11 studies, with 10,938 cases. Overall, the CVS was achieved in 92.5%. Conversion rate was 4.8%. CVS-related BDI was 0.09% (0.05% technical errors and 0.04% misidentification errors).

CONCLUSION

Routine application of the CVS reduces BDI, but does not eliminate them altogether. Besides operative notes, the CVS should be documented by an imaging modality of sufficient quality. When the CVS cannot be safely established, the threshold for bail-out alternatives or complementary imaging should be low. Adoption by the surgical community worldwide shows great variability and focus should be placed on training through structured educational modules.

Robotic colectomy with CME versus laparoscopic colon resection with or without CME for colon cancer: a systematic review and meta-analysis

INTRODUCTION

This systematic review with meta-analysis aimed to compare the robotic complete mesocolon excision (RCME) to laparoscopic colectomy (LC) with (LCME) or without CME (LC non-CME) in postoperative outcomes, harvested lymph nodes and disease-free survival.

METHODS

We performed a systematic review with meta-analysis according to PRISMA 2020 and AMSTAR 2 guidelines.

RESULTS

The literature search yielded seven comparative studies including 677 patients: 269 patients in the RCME group and 408 in the LC group. The pooled analysis concluded to a lower conversion rate in the RCME group (OR=0.17; 95% CI [0.04, 0.74], p=0.02). There was no difference between the two groups in terms of morbidity (OR=1.03; 95% CI [0.70, 1.53], p=0.87), anastomosis leakage (OR=0.83; 95% CI [0.18, 3.72], p=0.81), bleeding (OR=1.90; 95% CI [0.64, 5.58], p=0.25), wound infection (OR=1.37; 95% CI [0.51, 3.68], p=0.53), operative time (mean difference (MD)=36.32; 95% CI [-24.30, 96.93], p=0.24), hospital stay (MD=-0.94; 95% CI [-2.03, 0.15], p=0.09) and disease-free survival (OR=1.29; 95% CI [0.71, 2.35], p=0.41). In the subgroup analysis, the operative time was significantly shorter in the LCME group than RCME group (MD=50.93; 95% CI [40.05, 61.81], p<0.01) and we noticed a greater number of harvested lymph nodes in the RCME group compared with LC non-CME group (MD=8.96; 95% CI [5.98, 11.93], p<0.01).

CONCLUSIONS

The robotic approach for CME ensures a lower conversion rate than the LC. RCME had a longer operative time than the LCME subgroup and a higher number of harvested lymph nodes than the LC non-CME group.

Robotic CME in obese patients: advantage of robotic ultrasound scan for vascular dissection

Complete mesocolic excision (CME) in right-sided colon cancers appears to confer oncological benefits compared to conventional colectomy. Identification of the superior mesenteric vein (SMV) remains challenging. We describe the novel use of intra-operative robotic ultrasound scan (rUSS) in obese patients (BMI ≥ 29). All consecutive patients having robotic CME for colon cancer between 2014 and 2017 were included in this retrospective cohort study. Data were recorded on an ethics approved prospective database and included patient demographics, clinical and oncological outcomes. Patients were divided into group 1 (BMI ≤ 28) and group 2 (BMI ≥ 29). SMV first approach was employed in all cases and SMV detection was aided using rUSS in group 2. Primary outcome was postoperative morbidity. Secondary outcomes included conversion rate, operative time and length of stay (LOS). 41 (group 1, median 66 years) were compared to 32 patients (group 2, median 63 years). There were no conversions to laparoscopy or laparotomy. Median operative times for group 2 were 30 min longer (186 vs. 216 min, p = 0.05). Overall morbidity was similar (20% vs. 19% in group 1 and 2, p = 0.26). There was no significant difference between the two groups with regard to LOS (median 7 vs. 6 days, p = 0.48), readmissions (2 vs. 5, p = 0.13), R0 resection rate (98% vs. 94%, p = 0.43) and lymph node harvest (median 31 vs. 30, p = 0.28).CME can be technically more challenging than conventional colectomy in obese patients and is associated with longer operative times. The use of rUSS in obese patients can help to identify SMV and allow safer dissection.

Inferior versus medial approach in laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer: A propensity-score-matched analysis

AIM

In laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer, either an inferior approach (IA) or a medial approach (MA) is selected in our institution based on the surgeon's preference. The present study compared the treatment outcomes between IA and MA.

METHOD

This retrospective, single-centre study using propensity score matching analysed the short- and long-term outcomes of laparoscopic surgery in patients with right-sided colon cancer from 2010 to 2019 at Cancer Institute Hospital.

RESULTS

After patient selection, 1011 patients remained for the analysis, of which 67% underwent IA surgery and 33% underwent MA surgery. After propensity score matching (1:1), 325 patients in each group were analysed. Regarding the short-term outcomes, there were no significant differences in the operation time, rate of conversion to open surgery or postoperative complication rate (Clavien-Dindo Grade ≥ III) between the two groups, although the intra-operative median blood loss was significantly less in the IA group than in the MA group (IA, 13 ml vs. MA, 20 ml, P < 0.0001). Regarding the long-term outcomes, the relapse-free survival, liver-relapse-free survival, cancer-specific survival and overall survival were all similar between groups.

CONCLUSION

Both the IA and MA in laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer are safe and feasible approaches; the IA may have an advantage over the MA in terms of reduced intra-operative blood loss. Based on their similar oncological outcomes, either the IA or MA can be selected, based on one's preference.

Potential benefit of superior to inferior dissection during laparoscopic extended right hemicolectomy

Various approaches can be used for performing laparoscopic right hemicolectomy for right-sided colon cancer. However, laparoscopic complete mesocolic excision with central vessel ligation using these approaches may sometimes present with difficulties of various factors. This video article presents a laparoscopic extended right hemicolectomy using a superior-to-inferior approach. The superior approach has potential benefits in that it exposes the superior mesenteric vessels and gastrocolic trunk.

Complete mesocolic excision for right colonic cancer: prospective multicentre study

BACKGROUND

Complete mesocolic excision (CME) for right colonic cancer is a more complex operation than standard right hemicolectomy but evidence to support its routine use is still limited. This prospective multicentre study evaluated the effect of CME on long-term survival in colorectal cancer centres in Germany (RESECTAT trial). The primary hypothesis was that 5-year disease-free survival would be higher after CME than non-CME surgery. A secondary hypothesis was that there would be improved survival of patients with a mesenteric area greater than 15 000 mm2.

METHODS

Centres were asked to continue their current surgical practices. The surgery was classified as CME if the superior mesenteric vein was dissected; otherwise it was assumed that no CME had been performed. All specimens were shipped to one institution for pathological analysis and documentation. Clinical data were recorded in an established registry for quality assurance. The primary endpoint was 5-year overall survival for stages I-III. Multivariable adjustment for group allocation was planned. Using a primary hypothesis of an increase in disease-free survival from 60 to 70 per cent, a sample size of 662 patients was calculated with a 50 per cent anticipated drop-out rate.

RESULTS

A total of 1004 patients from 53 centres were recruited for the final analysis (496 CME, 508 no CME). Most operations (88.4 per cent) were done by an open approach. Anastomotic leak occurred in 3.4 per cent in the CME and 1.8 per cent in the non-CME group. There were slightly more lymph nodes found in CME than non-CME specimens (mean 55.6 and 50.4 respectively). Positive central mesenteric nodes were detected more in non-CME than CME specimens (5.9 versus 4.0 per cent). One-fifth of patients had died at the time of study with recorded recurrences (63, 6.3 per cent), too few to calculate disease-free survival (the original primary outcome), so overall survival (not disease-specific) results are presented. Short-term and overall survival were similar in the CME and non-CME groups. Adjusted Cox regression indicated a possible benefit for overall survival with CME in stage III disease (HR 0.52, 95 per cent c.i. 0.31 to 0.85; P = 0.010) but less so for disease-free survival (HR 0.66; P = 0.068). The secondary outcome (15 000 mm2 mesenteric size) did not influence survival at any stage (removal of more mesentery did not alter survival).

CONCLUSION

No general benefit of CME could be established. The observation of better overall survival in stage III on unplanned exploratory analysis is of uncertain significance.

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?

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.

Could the top-down right hemicolectomy be an easier alternative to the classic medial-to-lateral approach in obese patients? A case report with video example

• Laparoscopic right hemicolectomy is performed only in 25% of cases in recent survey. • The medial-to-lateral and the bottom-to-up are the most frequent approaches used to perform surgery. • Top-to-down right hemicolectomy is an infrequent approach. • Obesity is an evident aspect complicating surgical dissection. • Top-to Down dissection could be an opportunity to use as alternative approach when classical dissection becomes intricate.

The Mesentery in Complete Mesocolic Excision

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.

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.

Laparoscopic Complete Mesocolic Excision Without Routine Gastro-Pancreatico-Colic Trunk Dissection: Survival Outcomes and Morbidity for 567 Cases

Purpose: It is unclear whether the principles of open complete mesocolic excision (CME) can be safely applied to laparoscopic surgery. Furthermore, definitions vary over how radical optimal CME surgery should be. We report morbidity and oncological outcomes for laparoscopic CME without routine gastro-pancreatico-colic trunk (GPCT) dissection. Materials and Methods: An observational study with consecutive data for patients with Union for International Cancer Control (UICC) stage I-III colon adenocarcinoma who underwent elective laparoscopic resection between 2006 and 2015. Data were retrieved for demographics, tumor characteristics, treatment, and histology from prospectively maintained databases. Standardized, routinely video recorded, laparoscopic resections were performed in two United Kingdom centers from The National Training Programme for Laparoscopic Colorectal Surgery. Overall survival and disease-free survival (DFS) were reported using Kaplan-Meier curves and Cox regression. Results: Laparoscopic CME was performed in 567 patients, 52.7% (288/546) women, median (interquartile range [IQR]) age 73 (65-80) years. Median (IQR) length of stay was 4 (3-5) days with 4.0 (2.2-5.7)-year follow-up. Significant DFS predictors (hazard ratio [HR]) by multivariable Cox regression were age >80 years (1.9), American Society of Anesthesiologists (ASA) 3 and 4 (HR = 1.1), right colon cancer (1.7), UICC stage III (3.4), and intramesocolic grade (2.2). Overall 4-year DFS (95% confidence interval) was 81.3% (77-85). Four-year DFS by UICC grades I, II, and III was 94.6% (89-99), 83.4% (77-88), and 72.2% (66-78), respectively (log-rank P = .001). Morbidity by Clavien-Dindo grade was III 18 (3.2%), IV 4 (0.7%) and V 7 (1.2%). Conclusion: This large series suggests standardized laparoscopic CME without routine GPCT dissection has a low morbidity and achieves equivalent outcomes to the most radical open CME techniques.

Reliability and Educational Value of YouTube Videos of Complete Meso-Colic Excision With Right Hemicolectomy in the COVID-19 Pandemic

Aim: To investigate the reliability and educational value of YouTube videos of minimally invasive complete mesocolic excision with right hemicolectomy procedures.

Materials and methods: We searched YouTube with the terms “Laparoscopic and Robotic Complete Mesocolic Excision with Right Hemicolectomy” on January 12, 2021. To assess the reliability of the videos, we evaluated nine steps in each video and scored the videos based on the key steps they contained. The videos were divided into three groups according to the source of the upload. The total number of views, length, time since upload, and the number of likes, dislikes, and comments were recorded for each video. Narration, the use of descriptive subtitles, and the upload status by an expert surgeon were also examined.

Results: Sixty-eight videos were included in the study. A positive significant correlation was identified between the comprehensiveness score (CS) and the number of views (p=0.025). The CSs of the videos accessed from academic channels, as well as those accessed from journals, congress, and association channels, recorded higher CSs than those obtained from the personal channels of consultants (p=0.003). It was also found that CSs were higher in the videos of expert surgeons (p<0.001) and narrated videos (p<0.001).

Conclusion: Not all YouTube videos on this subject have reliability and educational value. Surgical videos on YouTube may be evaluated by a video review commission formed by academic institutions, surgical associations, or expert surgeons, and videos suitable for education could be brought together and published via a free channel.

The Future in Standards of Care for Gynecologic Laparoscopic Surgery to Improve Training and Education

Standards of care offer doctors and patients the confidence that an established quality, evidence-based, care is provided, and represent a tool for optimal responding to the population’s needs. It is expected that they will increasingly express a multimodal relationship with gynecologic laparoscopy. Laparoscopy is, now, a standard procedure in operative gynecology, standards are embedded in many laparoscopic procedures, standardization of the skills/competency assessment has been progressively developed, and the proof of competency in laparoscopy may become a standard of care. A continuous development of surgical education includes standard equipment (that may bring value for future advance), standardized training, testing (and performance) assessment, educational process and outcome monitoring/evaluation, patients’ care, and protection, etc. Standards of care and training have a reciprocally sustaining relationship, as training is an essential component of standards of care while care is provided at higher standards after a structured training and as credentialing/certification reunites the two. It is envisaged that through development and implementation, the European wide standards of care in laparoscopic surgery (in close harmonization with personalized medicine) would lead to effective delivery of better clinical services and provide excellent training and education.

Does cranial-medial mixed dominant approach have a unique advantage for laparoscopic right hemicolectomy with complete mesocolic excision?

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.

Minimally invasive surgery vs laparotomy in patients with colon cancer residing in high-altitude areas

BACKGROUND

Colon cancer is associated with a higher incidence among residents in high-altitude areas. Hypoxic environment at high altitudes inhibits the phagocytic and oxygen-dependent killing function of phagocytes, thereby increasing the inflammatory factors, inhibiting the body’s innate immunity and increasing the risk of colon cancer.

AIM

To examine the effect of minimally invasive surgery vs laparotomy in patients with colon cancer residing in high-altitude areas.

METHODS

Ninety-two patients with colon cancer in our hospital from January 2019 to February 2021 were selected and divided into the minimally invasive surgery and laparotomy groups using the random number table method, with 46 patients in each group. Minimally invasive surgery was performed in the minimally invasive group and laparotomy in the laparotomy group. Operative conditions, inflammatory index pre- and post-surgery, immune function index and complication probability were measured.

RESULTS

Operative duration was significantly longer and intraoperative blood loss and recovery time of gastrointestinal function were significantly less (all P < 0.05) in the minimally invasive group than in the laparotomy group. The number of lymph nodes dissected was not significantly different. Before surgery, there were no significant differences in serum C-reactive protein, interleukin-6 and tumor necrosis factor-α levels between the groups, whereas after surgery, the levels were significantly higher in the minimally invasive group (26.98 ± 6.91 mg/L, 146.38 ± 11.23 ng/mL and 83.51 ± 8.69 pg/mL vs 41.15 ± 8.39 mg/L, 186.79 ± 15.36 ng/mL and 110.65 ± 12.84 pg/mL, respectively, P < 0.05). Furthermore, before surgery, there were no significant differences in CD3+, CD4+ and CD4+/CD8+ levels between the groups, whereas after surgery, the levels decreased in both groups, being significantly higher in the minimally invasive group (55.61% ± 4.39%, 35.45% ± 3.67% and 1.30 ± 0.35 vs 49.68% ± 5.33%, 31.21% ± 3.25% and 1.13 ± 0.30, respectively, P < 0.05). Complication probability was significantly lower in the minimally invasive group (4.35% vs 17.39%, P < 0.05).

CONCLUSION

Laparoscopic minimally invasive procedures reduce surgical trauma and alleviate the inflammatory response and immune dysfunction caused by invasive operation. It also shortens recovery time and reduces complication probability.

Disease recurrence after right hemicolectomy in Scotland: Is there rationale to adopt complete mesocolic excision (CME)?

AIMS

Complete mesocolic excision (CME) has been proposed as a way to improve the oncological outcomes in patients with colon cancer. To investigate whether there is rationale for adopting the technique in Scotland, our aim was to define the incidence of disease recurrence following standard right hemicolectomy and to compare this with published CME outcomes.

METHODS

Data was collected on consecutive patients undergoing right or extended right hemicolectomy for colonic adenocarcinoma (2012-2017) at three hospitals in Scotland (Raigmore Hospital, Aberdeen Royal Infirmary and Glasgow Royal Infirmary). Emergency or palliative surgery was excluded. Patients were followed up with CT scans and colonoscopy for a minimum of 3 years.

RESULTS

689 patients (M 340, F 349) were included. 30-day mortality was 1.6%. Final pathological stage was Stage I (14%), Stage II (49.8%) and Stage III (36.1%). During follow-up, 10.5% developed loco-regional recurrence and 12.2% developed distant metastases. The 1, 3 and 5-year disease-free survival (DFS) was 94%, 84% and 82% respectively. Primary determinants of recurrence were T stage (p < 0.001), N stage (p < 0.001), apical node involvement (p < 0.001) and EMVI (p < 0.001). When compared to the literature, 30-day mortality was lower than many published series and DFS rates were similar to the largest CME study to date (4 year DFS 85.8% versus 83%).

CONCLUSION

The outcomes of patients undergoing right hemicolectomy in Scotland compare favourably with many published CME studies. The technique demands further evaluation before it can be recommended for adoption into routine surgical practice.

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.

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

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.

Complete mesocolic excision and central vascular ligation in colorectal cancer in the era of minimally invasive surgery

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.

Mesenteric closure with polymer-ligating clips after right colectomy with complete mesocolic excision for cancer and mesentery-based ileocolic resection for Crohn's disease

Mesenteric closure following right colectomy remains controversial and, following the advent of laparoscopic surgery, many surgeons do not routinely close the mesentery after colorectal resection. Nevertheless, especially after the introduction of operations such as right colectomy with complete mesocolic excision and ileocolic resections with extensive mesentery removal for Crohn's disease, the wide mesenteric defect resulting from the dissections can certainly expose the patients to complications such as internal hernias or volvuli. In general, mesenteric closure requires intracorporeal suturing. We describe a simple technique for the closure of the mesentery after surgical resection using polymer-ligating clips. This novel technique seems to minimize the time, effort and risk inherent to the procedure, even after large mesenteric excisions.

Feasibility and Safety of Laparoscopic Complete Mesocolic Excision (CME) for Right-sided Colon Cancer: Short-term Outcomes. A Randomized Clinical Study

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.

Modified complete mesocolic excision with central vascular ligation by the squeezing approach in laparoscopic right colectomy

PURPOSE

Complete mesocolic excision (CME) and central vascular ligation (CVL) are becoming the standard procedure in laparoscopic right-sided colectomy. However, the approach to CME and CVL has not been established, although several useful approaches have been reported. The squeezing approach described herein is a novel procedure to perform modified CME and CVL in laparoscopic right colectomy.

METHODS

The squeezing approach features retroperitoneal mobilization followed by cranial mesocolic mobilization and lymph node dissection using a cranial approach followed by a caudal approach. Dissection of the regional lymph nodes along with central vascular ligation was performed along the anterior wall of the superior mesenteric vein. In total, 177 patients (mean age, 70.6 years; male-to-female ratio, 90:87) who underwent laparoscopic right-sided colectomy were retrospectively assessed. Descriptive statistics for patient characteristics were calculated.

RESULTS

The mean operative time and blood loss were 169 min and 37 mL, respectively. Seven patients (4.0%) required conversion to open surgery, and major postoperative complications occurred in five patients (2.8%) with no anastomotic leakage. Histological R0 resection was achieved in all cases of stages 0-III colon cancer. The 5-year recurrence-free survival rates were 100% (n = 19), 100% (n = 40), 87% (n = 46), and 81% (n = 43) in pathological stages 0, I, II, and III, respectively. Node recurrence occurred in one case near the root of the middle colic artery.

CONCLUSION

The novel squeezing approach in laparoscopic right colectomy could be safely performed in terms of the technical and oncological aspects.

Reduced port versus open right hemicolectomy for colorectal cancer: a retrospective comparison study of two centers

PURPOSE

The concept of complete mesocolic excision (CME) in right-sided colorectal cancer is well known for open and laparoscopic surgery. The aim of this study was to evaluate and compare perioperative and oncological outcomes of reduced port and open surgery for right-sided colorectal cancer.

METHODS

One hundred forty-one patients received elective surgery for right-sided colonic cancer between January 2015 and December 2019 and were included in a retrospective database.

RESULTS

We observed longer operation time in the RP-CME group (145 min vs. 119.43 min, p<0.01). Hospital stay (8 days vs. 14 days, p<0.01) and time to first intestinal passage (42 h. vs. 59 h, p<0.01) were significantly shorter in the reduced port group. Postoperative complications were more likely to be observed in the O-CME group (7.2% vs. 14.1%, p=0.28); anastomotic leakage rate was low in both groups (1.8% vs. 2.4%, p=1.00). Specimen scores (score 1= good: 93.8% vs. 91.7%, p=1.00) and average number of retrieved lymph nodes were comparable (24 vs. 23 p=0.69). In O-CME patients, we observed more advanced tumor stages (UICC III: 21.4% vs. 45.9%, p<0.01).

CONCLUSION

To our knowledge, this is the first study comparing reduced port to open surgery for right-sided colorectal cancer. We could demonstrate that this technique is feasible for oncological right hemicolectomy with observation of shorter hospital stay and lower morbidity rates compared to open surgery. The oncological outcome did not differ in the present study.

Prognostic value of preoperative circulating tumor cells counts in patients with UICC stage I-IV colorectal cancer

Colorectal cancer (CRC) is one of the leading causes of cancer death worldwide. There is an urgent need to identify prognostic markers for patients undergoing curative resection of CRC. The detection of circulating tumor cells in peripheral blood is a promising approach to identify high-risk patients with disseminated disease in colorectal cancer. This study aims to evaluate the prognostic relevance of preoperative CTCs using the Cellsearch® system (CS) in patients, who underwent resection with curative intent of different stages (UICC I-IV) of colorectal cancer. Out of 91 Patients who underwent colorectal resection, 68 patients were included in this study. CTC analysis was performed in patients with CRC UICC stages I-IV immediately before surgery. Data were correlated with clinicopathological parameters and patient outcomes. One or more CTCs/7.5 mL were detected in 45.6% (31/68) of patients. CTCs were detected in all stages of the Union of International Cancer Control (UICC), in stage I (1/4, 25%), in stage II (4/12, 33.3%), in stage III (5/19, 26.3%) and in stage IV (21/33, 63.6%). The detection of ≥ 1 CTCs/ 7.5ml correlated to the presence of distant overt metastases (p = 0.014) as well as with shorter progression-free (p = 0.008) and overall survival (p = 0.008). Multivariate analyses showed that the detection of ≥ 1 CTCs/ 7.5ml is an independent prognostic indicator for overall survival (HR, 3.14; 95% CI, 1.18-8.32; p = 0.021). The detection of CTCs is an independent and strong prognostic factor in CRC, which might improve the identification of high-risk patients in future clinical trials.

The use of ultrasound in central vascular ligation during laparoscopic right-sided colon cancer surgery: technical notes

BACKGROUND

Complete mesocolic excision (CME) with central vascular ligation (CVL) requires the surgeon to sharply dissect the mesocolon and approach the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) for ligation of the supplying vessels relating to right-sided colon cancer at their origin. Even with preoperative images, it can still be challenging to identify these structures during laparoscopic surgery because of various intraoperative conditions. The aim of this study was to assess the efficacy of intraoperative ultrasound (IOUS) for identification of blood vessels during right-sided colon cancer surgery.

METHODS

We performed IOUS on 19 patients diagnosed with right-sided colon cancer at our institution, in January-October 2020. Preoperatively, a three-dimensional computed tomography (3D-CT) angiogram was obtained for the majority of patients to visualize the SMA, SMV, and their respective branches. The running position of the ileocolic artery (ICA) and right colic artery (RCA) related to the SMV and the presence of the middle colic artery were identified and compared using preoperative 3D-CT, IOUS, and intraoperative findings.

RESULTS

Nineteen patients [seven men and 12 women with a mean age of 73.9 ± 8.4 years (range 58-82 years)] were studied, including some with a body mass index of > 30 kg/m², locally advanced cancer, and severe adhesion. There were IOUSs that detected the SMA, SMV, and their tributaries in all patients. The positional relationships between the SMV and the ICA and RCA revealed by IOUS were consistent with the preoperative and intraoperative findings.

CONCLUSION

IOUS is a safe, feasible, and reproducible technique that can assist in detecting the branching of the SMA and SMV during CME with CVL in laparoscopic right-sided colon cancer surgery, regardless of individual conditions.