The fusion fascia of Fredet: an important embryological landmark for complete mesocolic excision and D3-lymphadenectomy in right colon cancer

Laparoscopic right colectomy: correct technique based on key anatomical principles

Since the early1990s, laparoscopic right colon resections have been the most performed advanced laparoscopic procedures just after laparoscopic left colectomies and sigmoid resections. Indications for laparoscopic right colectomies are either benign or malignant diseases. Despite its many indications, a laparoscopic right or extended right colectomy is mostly performed for cancer of the caecum, the ascending colon, the hepatic flexure or the proximal transverse colon. Worldwide, colorectal cancer is the third most diagnosed cancer: an estimated 1,880,725 people were diagnosed with colorectal cancer in 2020, out of which 1,148,515 were colon cancer cases and 40% were located in the right colon. These figures make an oncologic sound surgery for right colon cancer of the utmost relevance. More recently, complete mesocolic excision has been advocated as the optimal choice in term of radicality, especially in node-positive patients with right colon cancer. Laparoscopic standard right colectomy and extended right colectomy with or without CME should be performed according to defined principles based on a close knowledge of key anatomical landmarks. This knowledge will allow to trace anatomical structures and drive instruments along the correct surgical planes and has its foundations in teachings from surgeons and scientists of past and present time.

Neglected Anatomical Areas in Ovarian Cancer: Significance for Optimal Debulking Surgery

Ovarian cancer (OC), the most lethal gynecological malignancy, usually presents in advanced stages. Characterized by peritoneal and lymphatic dissemination, OC necessitates a complex surgical approach usually involving the upper abdomen with the aim of achieving optimal cytoreduction without visible macroscopic disease (R0). Failures in optimal cytoreduction, essential for prognosis, often stem from overlooking anatomical neglected sites that harbor residual tumor. Concealed OC metastases may be found in anatomical locations such as the omental bursa; Morison's pouch; the base of the round ligament and hepatic bridge; the splenic hilum; and suprarenal, retrocrural, cardiophrenic and inguinal lymph nodes. Hence, mastery of anatomy is crucial, given the necessity for maneuvers like liver mobilization, diaphragmatic peritonectomy and splenectomy, as well as dissection of suprarenal, celiac, and cardiophrenic lymph nodes in most cases. This article provides a meticulous anatomical description of neglected anatomical areas during OC surgery and describes surgical steps essential for the dissection of these "neglected" areas. This knowledge should equip clinicians with the tools needed for safe and complete cytoreduction in OC patients.

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".

D3 lymph node dissection improves the survival outcome in patients with pT2 colorectal cancer

BACKGROUND

The extent of lymphadenectomy in patients with pT2 colorectal cancer (CRC) remains controversial. This study aimed to elucidate the effects of D3 and D2 lymph node dissection (LND) on survival in patients diagnosed with pT2 CRC.

METHODS

This was a retrospective cohort study from a high-volume cancer center in Japan. From April 2007 to December 2020, 6273 patients with primary CRC were included in the study; among these, 616 patients diagnosed with pT2 CRC underwent radical colorectal resection. Propensity score matching (PSM) was applied to balance potential confounding factors, and a total of 104 matched pairs were extracted from the entire cohort. Independent risk factors associated with prognosis were determined by Cox regression analysis. The main outcome measures were overall survival (OS) and cancer-specific survival (CSS).

RESULTS

Before PSM, there was a statistically significant difference across the cohort in OS and CSS (p = 0.000 and 0.013) between D3 and D2 LND groups; the estimated hazard ratio (HR) was 2.2 (95% confidence interval (CI), 1.1-4.4, p = 0.031) for OS in the D3 LND and 4.4 (95% CI, 1.7 to 11, p = 0.0027) for CSS (p = 0.013). There was also a significant difference (p = 0.024) in OS between the D3 and D2 LND groups in the matched cohort, with an estimated HR for OS of 3.3 (95% CI, 1.2 to 9.1, p = 0.024) and an estimated HR for CSS of 7.2 (95% CI, 1.6 to 33, p = 0.011).

CONCLUSIONS

D3 LND had a significant survival advantage in the treatment of pT2 CRC. The results of this study provide a theoretical basis for the application of D3 LND in radical surgery for preoperative T2 CRC.

Definition and reporting of lymphadenectomy and complete mesocolic excision for radical right colectomy: a systematic review

BACKGROUND

Several procedures have been proposed to reduce the rates of recurrence in patients with right-sided colon cancer. Different procedures for a radical right colectomy (RRC), including extended D3 lymphadenectomy, complete mesocolic excision and central vascular ligation have been associated with survival benefits by some authors, but results are inconsistent. The aim of this study was to assess the variability in definition and reporting of RRC, which might be responsible for significant differences in outcome evaluation.

METHODS

PRISMA-compliant systematic literature review to identify the definitions of RRC. Primary aims were to identify surgical steps and different nomenclature for RRC. Secondary aims were description of heterogeneity and overlap among different RRC techniques.

RESULTS

Ninety-nine articles satisfied inclusion criteria. Eight surgical steps were identified and recorded as specific to RRC: Central arterial ligation was described in 100% of the included studies; preservation of mesocolic integrity in 73% and dissection along the SMV plane in 67%. Other surgical steps were inconstantly reported. Six differently named techniques for RRC have been identified. There were 35 definitions for the 6 techniques and 40% of these were used to identify more than one technique.

CONCLUSIONS

The only universally adopted surgical step for RRC is central arterial ligation. There is great heterogeneity and consistent overlap among definitions of all RRC techniques. This is likely to jeopardise the interpretation of the outcomes of studies on the topic. Consistent use of definitions and reporting of procedures are needed to obtain reliable conclusions in future trials. PROSPERO CRD42021241650.

Application of 3D-reconstruction and artificial intelligence for complete mesocolic excision and D3 lymphadenectomy in colon cancer

Mathematical algorithms 3D-reconstruction techniques and artificial intelligence are a current line of innovation in colorectal surgical oncology. The objective of this study is to show the initial experience of a 3D image processing and reconstruction system to perform complete mesocolic excision and D3-lymphadenectomy in colon cancer. It is applied to a splenic flexure neoplasm and in a right colon cancer with suspected retroperitoneal infiltration. 3D image processing and reconstruction was employed to delimit 10 cm proximal and distal intestinal margins to the tumor and define its corresponding vascularization. In right colon cancer it showed position and exact dimensions of D3-lymphadenectomy area and possible retroperitoneal fascia infiltration. 3D image processing and reconstruction allows to obtain valuable information from computerized tomography scan. It could be employed during surgical strategy planification to improve oncological results and reduce intraoperative complications.

Role of preoperative CT angiography with multimodality imaging reconstruction to perform laparoscopic Complete Mesocolic Excision (CME) and Central Vascular Ligation (CVL) in right-sided colon cancer: Is it really useful? A prospective clinical study

BACKGROUND

The concept of complete mesocolic excision (CME) and central vascular ligation (CVL) in right colonic resections appears to improve the oncological outcomes. The highest rate of complications reported in the literature in patients undergoing CME is related to difficult surgical manuevers and intraoperative bleeding due to the central vascular dissection.

METHODS

We used preoperative findings obtained with the CT angiography, multiplanar reformation (MPR), maximum intesity projection (MIP) and 3D volume rendering (VR) technique to verify if this preoperative radiological assessment had significant benefits regarding the difficulty of dissection of the embryological planes, the identification of vascular structures and central lymph nodes with reduction in mean operative time, intraoperative complications and better short-term outcomes versus standard contrast enhanced CT scan. We also have administered a questionnaire to investigate the subjective responses on the degree of difficulty of the surgical procedure both by the surgical team expert in CME and by a group of young surgeons.

RESULTS

Statistical analysis showed that overall operative time was significant shorter in patients underwent to radiological assessment (224,5 min; range 160-300 versus 252,6 min; range 200-340; p-value 0.023) with a significant lower rate of intraoperative complication (2.7% versus 4.2%; p-value 0.043). No differences were reported with respect to blood loss, conversion rate, anastomotic leakage or other surgical results. Analysis of the questionnaire underlined a progressive awareness of the correspondence between the radiological imaging and the surgical field.

CONCLUSION

The possibility of identifying the characteristics and course of the vascular structures along the axis of the superior mesenteric vessels certainly increases the surgeon's knowledge of the operating field, making him more confident with surgical maneuvers and significantly reducing the duration of the operating time and intraoperative complications.

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.

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.

Pattern of recurrence and survival after D2 right colectomy for cancer: is there place for a routine more extended lymphadenectomy?

BACKGROUND

Conventional Right Colectomy with D2 lymphadenectomy (RC-D2) currently represent the most common surgical treatment of right-sided colon cancer (RCC). However, whether it should be still considered a standard of care, or replaced by a routine more extended D3 lymphadenectomy remains unclear. In the present study, we aim to critically review the patterns of relapse and the survival outcomes obtained from our 11-year experience of RC-D2.

METHODS

Clinical data of 489 patients who underwent RC-D2 for RCC at two centres, from January 2009 to January 2020, were retrospectively reviewed. Patients with synchronous distant metastases and/or widespread nodal involvement at diagnosis were excluded. Post-operative clinical-pathological characteristics and survival outcomes were evaluated including the pattern of disease relapse.

RESULTS

We enrolled a total of 400 patients with information follow-up. Postoperative morbidity was 14%. The median follow-up was 62 months. Cancer recurrence was observed in 55 patients (13.8%). Among them, 40 patients (72.7%) developed systemic metastases, and lymph-node involvement was found in 7 cases (12.8%). None developed isolated central lymph-node metastasis (CLM), in the D3 site. The estimated 3- and 5-year relapse-free survival were 86.1% and 84.4%, respectively. The estimated 3- and 5-year cancer-specific OS were 94.5% and 92.2%, respectively.

CONCLUSIONS

The absence of isolated CLM, as well as the cancer-specific OS reported in our series, support the routine use of RC-D2 for RCC. However, D3 lymphadenectomy may be recommended in selected patients, such as those with pre-operatively known CLM, or with lymph-node metastases close to the origin of the ileocolic vessels.

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.

Surgical anatomy applied to transperitoneal approaches of the abdominal aorta and visceral trunks. Dynamic article

Access to the abdominal aorta and its visceral trunks is possible through several approaches. Dissections of five cadavers performed during three National Surgical Anatomy courses applied to Aorta, Hepatobiliopancreatic and Digestive Surgery. Videos and pictures were taken throughout the dissections and showed different abdominal aorta approaches. Abdominal aorta and visceral trunks approaches: longitudinal inframesocolic access, supraceliac clamping, celiac trunk dissection, superior mesenteric artery approaches (retroperitoneal after Kocher menoeuvre, supramesocolic or inframesocolic), Cattell-Braasch manoeuvre and mattox manoeuvre: retrorenal and prerenal. Correct knowledge of the intraabdominal anatomy is necessary to perform all the abdominal aorta surgical approaches. Cadaveric dissection could help to achieve this objective. Cardiovascular and digestive surgeons need to know the possible strategies in order to choose the one which is best suited for each patient.

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

Since the 19^th 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.

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.

Central vascular ligation and mesentery based abdominal surgery

In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.

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 D3 lymphadenectomy with central vascular ligation in right-sided colon cancer: a systematic review of postoperative outcomes, tumor recurrence and overall survival

BACKGROUND

In right-sided colon cancer surgery, currently there is a great deal of discussion and debate regarding complete mesocolic excision (CME) versus conventional right hemicolectomy (CRH) on postoperative outcomes and oncological results. Our aim was to perform a systematic review of the short- and long-term outcomes of CME to standardize surgical approach in patients with right-sided colon cancer.

METHODS

A systematic review was performed examining available data on randomized and non-randomized studies evaluating the role of CME and D3 lymphadenectomy in the treatment of right-sided colon cancer, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards.

RESULTS

After literature search, 919 studies have been recorded, 110 studies underwent full-text reviews and 30 studies met inclusion criteria. The total number of CME procedures was 5931. Postoperative complications was reported in 28 studies with pooled overall complications of 1.88% for CME surgery. Six studies reported 0% of overall postoperative complications and they demonstrated a low incidence of complications following CME procedure. Anastomotic leak was reported in 27 studies with pooled proportion of 0.92% after CME resections. There were 16 papers reporting overall survival following CME procedure, with a mean of 85% of patients survived at 5 years. Mean 5-year overall survival was 93.05% in stage I patients, 89.76% in stage II patients and 79.65% in stage III patients. Local and distant recurrence were included in 21 studies, reporting tumor recurrence rate of 12.25% following CME. 5-year tumor recurrence was 5.8% in stage I patients, 7.68% in stage II patients and 15.69% in stage III patients.

CONCLUSIONS

CME does not increase the risk of postoperative complications and significantly improves the long-term oncological impact. Prospective multicentre studies results are needed to verify if CME could be considered standard surgery for right colon cancer.

Short-term outcomes of pure transvaginal laparoscopic right colectomy: A novel surgery approach based on an Idea, Development, Exploration, Assessment, Long-term framework stage IIa study

BACKGROUND AND OBJECTIVES

The application of pure natural orifice translumenal endoscopic surgery (NOTES) to intra-abdominal visceral resections remains limited due to the complexity of the dissection. This study aimed to assess the safety and feasibility of laparoscopic right colectomy using a purely transvaginal approach.

METHODS

The data of 12 continuous patients with colon neoplasia who underwent transvaginal right colectomy from November 2018 to July 2020 were prospectively collected, and their perioperative events were recorded.

RESULTS

The patients' median age was 70.4 years. Four were diagnosed with colon adenoma and eight with adenocarcinoma. The median operative time was 185 min, with a median blood loss of 25 ml. The median time to gas passing was 32.5 h after surgery. The median postoperative hospital stay was 6 days. One operation was converted to hybrid NOTES due to difficulty with the anastomosis, and one was converted to laparoscopic surgery because of vascular injury. Three cases were grades I, II, and III according to the Clavien-Dindo classification.

CONCLUSION

Pure NOTES right colectomy using the transvaginal approach is feasible and safe with good short-term outcomes. We recommend this novel technique for highly-selected patients with no more than a D2 dissection performed by experienced colorectal surgeons.

Gastric equivalent of the 'Holy Plane' to standardize the surgical concept of stomach cancer to mesogastric excision: updating Jamieson and Dobson's historic schema

BACKGROUND

Surgery for curable gastric cancer has historically involved dissection of lymph nodes, depending on the risk of metastasis. By establishing the concept of mesogastric excision (MGE), we aim to make this approach compatible with that for colorectal cancer, where the standard is excision of the mesentery.

METHODS

Current advances in molecular embryology, visceral anatomy, and surgical techniques were integrated to update Jamieson and Dobson's schema, a historical reference for the mesogastrium.

RESULTS

The mesogastrium develops with a three-dimensional movement, involving multiple fusions with surrounding structures (retroperitoneum or other mesenteries) and imbedding parenchymal organs (pancreas, liver, and spleen) that grow within the mesentery. Meanwhile, the fusion fascia and the investing fascia interface with adjacent structures of different embryological origin, which we consider to be equivalent to the 'Holy Plane' in rectal surgery emphasized by Heald in the concept of total mesorectal excision. Dissecting these fasciae allows for oncologic MGE, consisting of removing lymph node-containing mesenteric adipose tissue with an intact fascial package. MGE is theoretically compatible with its colorectal counterpart, although complete removal of the mesogastrium is not possible due to the need to spare imbedded vital organs. The celiac axis is treated as the central artery of the mesogastrium, but is peripherally ligated by tributaries flowing into the stomach to feed the spared organs.

CONCLUSION

The obscure contour of the mesogastrium can be clarified by thinking of it as the gastric equivalent of the 'Holy Plane'. MGE could be a standard concept for surgical treatment of stomach cancer.

D3-lymphadenectomy enhances oncological clearance in patients with right colon cancer. Results of a meta-analysis

BACKGROUND

D3-Lymphadenectomy, together with complete mesocolic excision (CME), were introduced to provide oncological results after right colon cancer. The aim of this systematic review with meta-analysis was to assess the short and long-term outcomes of right-sided hemicolectomy with CME + D3 as compared with classic right hemicolectomy. Secondary aims included the prevalence of D3-metastasis and skip metastasis when performing CME + D3.

MATERIAL AND METHODS

A systematic review with meta-analysis was conducted, according to PRISMA methodology.

RESULTS

29 studies were enrolled (2592 patients). No differences were accounted in morbidity variables associated with the measured techniques. CME + D3 was significantly associated with a greater distance between the tumour and the closest vascular tie, a longer colonic resection, a wider resection of mesentery and an increased number of harvested lymph nodes. Regarding to long-terms outcomes, we found a significant decrease in local recurrence in patients undergoing CME + D3 (HR:0.17) and a significant improvement in 3-year and 5-year overall survival rates (HR:0.53 vs. HR:0.57, respectively), as well as an improving survival in patients with stage II and III disease. Overall prevalence of patients with lymphatic metastases in D3-territory was of 8.6% and 2.2% of skip metastases.

CONCLUSIONS

CME + D3 is a feasible surgical procedure that allows to obtain specimens with higher quality oncological resection, without greater associated morbidity, thus improving survival in patients with stage II and III right colon cancer.

Surgical anatomy applied to transperitoneal approaches of the abdominal aorta and visceral trunks. Dynamic article

Access to the abdominal aorta and its visceral trunks is possible through several approaches. Dissections of five cadavers performed during three National Surgical Anatomy courses applied to Aorta, Hepatobiliopancreatic and Digestive Surgery. Videos and pictures were taken throughout the dissections and showed different abdominal aorta approaches. Abdominal aorta and visceral trunks approaches: longitudinal inframesocolic access, supraceliac clamping, celiac trunk dissection, superior mesenteric artery approaches (retroperitoneal after Kocher menoeuvre, supramesocolic or inframesocolic), Cattell-Braasch manoeuvre and mattox manoeuvre: retrorenal and prerenal. Correct knowledge of the intraabdominal anatomy is necessary to perform all the abdominal aorta surgical approaches. Cadaveric dissection could help to achieve this objective. Cardiovascular and digestive surgeons need to know the possible strategies in order to choose the one which is best suited for each patient.

Re-interpreting mesenteric vascular anatomy on 3D virtual and/or physical models: positioning the middle colic artery bifurcation and its relevance to surgeons operating colon cancer

Background

The impact of the position of the middle colic artery (MCA) bifurcation and the trajectory of the accessory MCA (aMCA) on adequate lymphadenectomy when operating colon cancer have as of yet not been described and/or analysed in the literature. The aim of this study was to determine the MCA bifurcation position to anatomical landmarks and to assess the trajectory of aMCA.

Methods

The colonic vascular anatomy was manually reconstructed in 3D from high-resolution CT datasets using Osirix MD and 3-matic Medical and analysed. CT datasets were exported as STL files and supplemented with 3D printed models when required.

Results

Thirty-two datasets were analysed. The MCA bifurcation was left to the superior mesenteric vein (SMV) in 4 (12.1%), in front of SMV in 17 (53.1%) and right to SMV in 11 (34.4%) models. Median distances from the MCA origin to bifurcation were 3.21 (1.18–15.60) cm. A longer MCA bifurcated over or right to SMV, while a shorter bifurcated left to SMV (r = 0.457, p = 0.009). The main MCA direction was towards right in 19 (59.4%) models. When initial directions included left, the bifurcation occurred left to or anterior to SMV in all models. When the initial directions included right, the bifurcation occurred anterior or right to SMV in all models. The aMCA was found in 10 (31.3%) models, following the inferior mesenteric vein (IMV) in 5 near the lower pancreatic border. The IMV confluence was into SMV in 18 (56.3%), splenic vein in 11 (34.4%) and jejunal vein in 3 (9.4%) models.

Conclusion

Awareness of the wide range of MCA bifurcation positions reported is crucial for the quality of lymphadenectomy performed. The aMCA occurs in 31.3% models and its trajectory is in proximity to the lower pancreatic border in one half of models, indicating that it needs to be considered when operating splenic flexure cancer.

Supplementary information

The online version of this article (10.1007/s00464-020-08242-8) contains supplementary material, which is available to authorized users.

Current status and trend of laparoscopic right hemicolectomy for colon cancer

Laparoscopic right hemicolectomy (LRH) is utilized worldwide as one of the standard surgical treatments for right-sided colon cancer. However, there have been issues concerning its applicability, techniques, and trend. The present study aimed to elucidate the current status and trend of LRH by reviewing literature focusing on important issues associated with this surgery. Based on previous studies, LRH most likely provides better short-term outcomes and similar oncological outcomes compared to open surgery. Despite the increasing use of robotic approach in this surgery, it seems to have always been associated with longer operative times and greater hospital cost with limited advantage. Intracorporeal anastomosis seems to improve short-term outcomes, such as quicker recovery of bowel function, compared to extracorporeal anastomosis. However, it does not contribute to shorter hospital stay. With regard to dissection technique, various approaches, and landmarks have been advocated to overcome the technical difficulty in LRH. This difficulty is likely to be caused by anatomical variation, especially in venous structures. The superiority of one approach or landmark over another is still argued about due to the lack of large-scale prospective studies. However, deep understanding both of anatomical variation and characteristics of each approach would be of extreme importance to minimize adverse effects and maximize patient benefit after LRH.