A New Medial-to-Lateral Approach for Laparoscopic D3 Lymphadenectomy plus Complete Mesocolic Excision (D3 + CME) for Right-Sided Colon Cancer.

Background: D3 lymphadenectomy is important for accurate staging and provides long-term benefits, especially for T3-4/N + tumors.1,2 Both D3 lymphadenectomy as well as complete mesocolic excision (CME) require central ligation of vessels at their origins to ensure radical resection.3 Currently, superior mesentery vein (SMV) is navigated by ileocolic vessels while its sheath is dissected stepwise from caudal to cranial.4-6 This report describes a new medial-to-lateral approach for laparoscopic right hemicolectomy with D3 + CME.

Methods: The patient was a 47-year-old man with diagnosis of hepatic flexure cancer (cT4N1M0). First, the pedicle of the middle colic vessels and ileocolic vessels were both grasped, then the sheath of SMV was dissected at its left side as there are fewer blood vessels entering here compared with its right side. Second, after identification of middle colic artery (MCA), SMV was skeletonized from medial to lateral and no. 213 and no. 203 lymph nodes were dissected. Third, MCA and ileocolic vein and artery (ICV and ICA) were ligated at their roots. After separating the transverse mesocolon from the duodenum, the branches of the Henle trunk were exposed and no. 223 lymph nodes were dissected. Accessory right colic vein, right colic vein, and middle colic vein were ligated respectively. Fourth, the ascending mesocolon was separated from the retroperitoneal tissues through the front side of Toldt's fascia, the mesocolon was mobilized completely, and the tumor was removed en bloc.

Results: The operation time was 175 min, with estimated blood loss of 50 ml. The patient recovered well without bleeding complications and was discharged on postoperative day 7. Histology revealed moderately differentiated adenocarcinoma with 5 of 24 lymph nodes involved (pT3N2M0).

Conclusions: The medial-to-lateral approach presented in the video might be helpful for standardization of laparoscopic D3 + CME for right-sided colon cancer.